Is there an association between spatial accessibility of outpatient care and utilization? Analysis of gynecological and general care

Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data

BACKGROUND

Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities.

METHODS

Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates.

RESULTS

Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified.

CONCLUSIONS

The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Healthcare service use in paediatric inflammatory bowel disease: a questionnaire on patient and parent care experiences in Germany

BACKGROUND

Paediatric inflammatory bowel disease (PIBD) patients require chronic care over the lifespan. Care for these patients is complex, as it is adapted for childrens' life stages and changing disease activity. Guideline based care for this patient group recommends a multidisciplinary approach, which includes in addition to paediatric gastroenterologists, nutritional and psychological care services. For PIBD patients, a discrepancy between available guideline-based multidisciplinary care and actual care has been found from the provider side, but to what extent patients experience this is unclear.

OBJECTIVES

To identify which healthcare services were used and whether socio-demographic, geographic or disease related factors have an influence on health service utilisation.

METHODS

A standardised questionnaire (CEDNA) was distributed amongst parents of children aged 0-17 diagnosed with PIBD and adolescents (aged 12-17) with a PIBD. Items related to health service use were analysed, these included specialist care, additional care services, reachability of services and satisfaction with care. Logistic regression models on additional service use were calculated. Service availability and reachability maps were made.

RESULTS

Data was analysed for 583 parent and 359 adolescent questionnaires. Over half of the respondents had Crohn's Disease (CD, patients n = 186 parents n = 297). Most patients and parents reported their paediatric gastroenterologist as their main care contact (patients 90.5%; parents 93%). Frequently reported additional services were nutritional counselling (patients 48.6%; parents 42.2%) and psychological support (patients 28.1%; parents 25.1%). Nutritional counselling was more frequently reported by CD patients in both the patient (OR 2.86; 95%CI 1.73-4.70) and parent (OR 3.1; 95%CI 1.42-6.71) sample. Of the patients, 32% reported not using any additional services, which was more likely for patients with an illness duration of less than one year (OR 3.42; 95%CI 1.26-9.24). This was also observed for the parent population (OR 2.23; 95%CI 1.13-4.4). The population-based density of specialised paediatric gastroenterologists was not proportionate to the spatial distribution of patients in Germany, which may have an influence on access.

CONCLUSIONS

Parents and children reported highly specialised medical care. Multidisciplinary care offers do not reach the entire patient population. Access to multidisciplinary services needs to be ensured for all affected children.

[Tandem Practices: Pediatric Consultation Hours in General Practitioners' Practices in Rural Areas in Germany - a Collaborative Project]

BACKGROUND

In Germany, patients under the age of 18 receive medical care from pediatricians. In sparsely populated regions, general practitioners often have to do the job of pediatricians and offer medical care to children, which in most cases is adequate. However, it does not meet the goal of demand planning namely, every patient should have equal access to care regardless of their place of residence. One option to help achieve this is the implementation of consultation hours with pediatricians in general practitioners' practices (tandem practices). The aim of this study was to investigate the feasibility and acceptance of this cooperation and whether this improved access to pediatric care.

METHODS

First, general practitioners willing to participate were identified, where the nearest pediatrician's practice was more than 20 kilometers away. The second step was to find suitable pediatricians willing to offer regular weekly pediatric consultations in the practice of a general practitioner. For the evaluation, various data collection methods were used: one-off parent questionnaires at the time of study inclusion, questionnaires filled out by the pediatricians for each consultation, and data from the practice information systems in the participating practices. The distance between the patients' place of residence and the next regular outpatient pediatrician's practice were calculated and compared to the distance to a tandem practice.

RESULTS

In April 2019, in two practices tandem consultation hours were implemented. During 12 months, 192 children and adolescents (50.2% female) were included. They attended the consultation hours a total of 387 times. Of 482 reasons given in the doctor's questionnaire, 36.9% were vaccinations (n=178), 14.9% were preventive examinations (n=72), the most frequently coded ICD-10 diagnostic groups were diseases of the respiratory system (J00-J99: 8.5%, n=41) and mental/behavioral disorders (F00-F99: 7.7%, n=37). Before the project, the patients had an average of 20.2 kilometers (min 0.3; max 34.8) to the next regular outpatient pediatrician's practice; within the project, the distance decreased to 5.1 kilometers (min 0.1; max 26.7).

CONCLUSION

All doctors involved wanted to continue the tandem consultations after the end of the test phase. The project results showed the feasibility and a high level of acceptance of tandem practices, both for the doctors involved and for the patients and their parents.

Impacts of seasonal flooding on geographical access to maternal healthcare in the Barotse Floodplain, Zambia

BACKGROUND

Seasonal floods pose a commonly-recognised barrier to women's access to maternal services, resulting in increased morbidity and mortality. Despite their importance, previous GIS models of healthcare access have not adequately accounted for floods. This study developed new methodologies for incorporating flood depths, velocities, and extents produced with a flood model into network- and raster-based health access models. The methodologies were applied to the Barotse Floodplain to assess flood impact on women's walking access to maternal services and vehicular emergency referrals for a monthly basis between October 2017 and October 2018.

METHODS

Information on health facilities were acquired from the Ministry of Health. Population density data on women of reproductive age were obtained from the High Resolution Settlement Layer. Roads were a fusion of OpenStreetMap and data manually delineated from satellite imagery. Monthly information on floodwater depth and velocity were obtained from a flood model for 13-months. Referral driving times between delivery sites and EmOC were calculated with network analysis. Walking times to the nearest maternal services were calculated using a cost-distance algorithm.

RESULTS

The changing distribution of floodwaters impacted the ability of women to reach maternal services. At the peak of the dry season (October 2017), 55%, 19%, and 24% of women had walking access within 2-hrs to their nearest delivery site, EmOC location, and maternity waiting shelter (MWS) respectively. By the flood peak, this dropped to 29%, 14%, and 16%. Complete inaccessibility became stark with 65%, 76%, and 74% unable to access any delivery site, EmOC, and MWS respectively. The percentage of women that could be referred by vehicle to EmOC from a delivery site within an hour also declined from 65% in October 2017 to 23% in March 2018.

CONCLUSIONS

Flooding greatly impacted health access, with impacts varying monthly as the floodwave progressed. Additional validation and application to other regions is still needed, however our first results suggest the use of a hydrodynamic model permits a more detailed representation of floodwater impact and there is great potential for generating predictive models which will be necessary to consider climate change impacts on future health access.

Population-Based, Spatial Analysis of Specialised Ambulatory Palliative Care in Mecklenburg-Western Pomerania, Germany, on the Basis of Reimbursement Data

In rural areas, healthcare providers, patients and relatives have to cover long distances. For specialised ambulatory palliative care (SAPV), a supply radius of max. 30 km is recommended. The aim of this study was to analyse whether there are regional disparities in the supply of SAPV and whether it is associated with the distance between the SAPV team's site and the patient's location. Therefore, anonymised data of the Association of Statutory Health Insurance Physicians of the Federal State of Mecklenburg-Western Pomerania (M-V) were retrospectively analysed for the period of 2014-2017. Identification as a palliative patient was based on palliative-specific items from the ambulatory reimbursement catalogue. In total, 6940 SAPV patients were identified; thereof, 48.9% female. The mean age was 73.3 years. For 28.3% of the identified SAPV patients (n = 1961), the SAPV teams had a travel distance of >30 km. With increasing distance, the average number of treatment days per patient increased. It was found that there are regional disparities in the provision of SAPV services in M-V and that local structures have an important impact on regional supply patterns. The distance between the SAPV team's site and the patient's location is not the only determining factor; other causes must be considered.

Investigating Accessibility of Hospitals in Cold Regions: A Case Study of Harbin in China

OBJECTIVE

The objective of this study is to explore healthcare resource accessibility in Harbin, a typical city in a cold region in China.

BACKGROUND

Recently, investments in the construction of medical resources have been increasing annually in China, and consequently, the allocation of these resources has improved. Snow and ice on surfaces in China's cold regions have certain effects on the traffic capacity of urban roads, leading to a great difference in the accessibility of medical resources in winter and summer.

METHODS

The basic spatial data, including spatial road data, medical facility data, and population distribution data, are analyzed using geographic information system. Then, a spatial barrier model is used to measure healthcare accessibility based on geographic and population weighting; we explore the accessibility of hospitals under the influence of weather by defining a novel distance attenuation function. Finally, the accessibility of medical institutions in the study area is explored by analyzing data about the related separation factors.

RESULTS

It was found that the spatial distribution of medical resources was not equal, and the dominant resources were concentrated in the city center. Some regions are always in an advantageous position regardless of traffic conditions. In contrast, in areas far from the city center, the accessibility of medical resources significantly decreases in winter.

CONCLUSIONS

These results will help optimize the layout of medical institutions and improve medical equality and propose strategies for the optimization of the accessibility of urban medical institutions in cold regions of China.

Spatial Accessibility Analysis of Medical Facilities Based on Public Transportation Networks

Aiming to look at the problems of the unreasonable layout of medical facilities and low coverage of primary medical services. This paper selects tertiary grade A hospitals, general hospitals, specialized hospitals, community-level hospitals, clinics, and pharmacies in the main urban areas of Chongqing as research objects. The nearest analysis, kernel density, mean center, and standard deviational ellipse method were used to analyze the spatial differentiation characteristics of medical facilities and public transportation stations. Spatial accessibility was assessed from the perspective of service area ratios and service population ratios by constructing multiple modes of transportation (pedestrian systems, bus lines, rail lines). The results show that (1) the spatial layout of medical facilities in the main urban area of Chongqing is unbalanced; and the spatial distribution of medical facilities is characterized by "large agglomeration, small dispersion" and "multi-center group"; (2) the sub-core circle is centered on the Southwest University Area in Beibei District, the University Town Area in Shapingba, the Yudong Area and Lijiatuo Area in Banan District, the Pingan Light Rail Station Area in Dadukou District, the Chongqing No. 8 Middle School Area in Jiulongpo District, the Tea Garden Area in Nanan District, and the Jiangbei Airport Area in Yubei District; (3) the medical facilities with the weakest average accessibility are tertiary grade A hospitals, and the strongest are pharmacies; (4) the areas with vital average accessibility are Yuzhong District, Shapingba District, Dadukou District, and Nanan District.

Regional variation in travel to health services following transport-related major trauma

INTRODUCTION

Post-discharge healthcare needs are complex and persistent for people following major trauma. A number of geographic barriers to accessing healthcare exist, particularly for people in regional areas. The aim of this study was to explore regional variation in the distances travelled to access health services and identify patterns of health service use in the first three years following transport-related major trauma.

METHODS

This registry-based cohort study used linked data from the Victorian State Trauma Registry (VSTR) and the Transport Accident Commission (TAC). Victorians who sustained major trauma from a transport-related event between January 1 2006 and December 31 2016, with at least three years of follow-up TAC claims data were included in the study. Geospatial mapping of the median distance travelled to medical and allied health services was conducted for each Victorian Local Government Area.

RESULTS

In the first three years post-discharge, 4,964 people (75.6%) visited a general practitioner, 5058 (77.0%) saw other medical professionals, 2269 (34.6%) accessed mental health services, 2154 (32.8%) saw an occupational therapist and 4404 (67.0%) attended a physical therapy service. Geospatial mapping revealed that people in regional Local Government Area travelled further distances to access health services. Specific clustering of increased travel distances was observed in regional areas of the far west and north-east of Victoria. The number of people using services declined with each subsequent year beyond hospital discharge. However, the number of trips were consistent over time for those still engaged in services.

CONCLUSIONS

Distances travelled to access health services vary across geographic regions and may result in an increased travel burden for those in some regional Local Government Area. Understanding gaps in health services by geographic region can assist to improve service availability. Alternate service delivery methods, such as telehealth, may assist to reduce the associated burden of travel for those in regional areas.

A multicriteria decision analysis framework to measure equitable healthcare access during COVID-19

The ongoing novel coronavirus (COVID-19) pandemic has highlighted the need for individuals to have easy access to healthcare facilities for treatment as well as vaccinations. The surge in COVID-19 hospitalizations during 2020 also underscored the fact that accessibility to nearby hospitals for testing, treatment and vaccination sites is crucial for patients with fever or respiratory symptoms. Although necessary, quantifying healthcare access is challenging as it depends on a complex interaction between underlying socioeconomic and physical factors. In this case study, we deployed a Multi Criteria Decision Analysis (MCDA) approach to uncover the barriers and their effect on healthcare access. Using a least cost path (LCP) analysis we quantified the costs associated with healthcare access from each census block group in the Los Angeles metropolitan area (LA Metro) to the nearest hospital. Social vulnerability reported by the Centers for Disease Control and Prevention (CDC), the daily number of COVID-19 cases from the Los Angeles open data portal and built environment characteristics (slope of the street, car ownership, population density distribution, walkability, traffic collision density, and speed limit) were used to quantify overall accessibility index for the entire study area. Our results showed that the census block groups with a social vulnerability index above 0.75 (high vulnerability) had low accessibility owing to the higher cost of access to nearby hospitals. These areas were also coincident with the hotspots for COVID-19 cases and deaths which highlighted the inequitable exposure of socially disadvantaged populations to COVID-19 infections and how the pandemic impacts were exacerbated by the synergistic effect of socioeconomic status and built environment characteristics of the locations where the disadvantaged populations resided. The framework proposed herein could be adapted to geo-target testing/vaccination sites and improve accessibility to healthcare facilities in general and more specifically among the socially vulnerable populations residing in urban areas to reduce their overall health risks during future pandemic outbreaks.

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay

Background

Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS).

Methods

Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models.

Results

The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility.

Conclusions

This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population’s healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

Does the Direct Settlement Policy of Trans-Provincial Outpatient Expenses Aggravate the Siphoning Effect? An Empirical Study on Yangtze River Delta, China

To solve the problem of reimbursing trans-regional medical expenses, using only cross-regional manual reimbursement but not direct medical insurance card settlement, China implemented a pilot policy of direct settlement of trans-provincial outpatient expenses (DSTOE) in the Yangtze River Delta region. Due to the differences in inter-regional medical development, patients often migrate from areas with low-level medical resources to the high-level areas, a phenomenon that we define as the “siphoning” of trans-regional patients, which can cause a variety of problems. To study whether DSTOE aggravates the siphoning effect, we analyzed the changes in the volume of trans-provincial outpatient visits and conducted a questionnaire survey and factor analysis on the willingness of trans-provincial medical treatment under DSTOE. Results showed that manual reimbursement was gradually replaced by direct settlement, while the total volume was not increased significantly, and the ratio of outpatient visits flowing into and out from Shanghai decreased. The majority of questionnaire respondents confessed that their willingness toward trans-regional medical treatment increased, while their first choice of medical location was still mainly local, with only a few indicating that they would directly choose a cross-regional, higher-level medical institution. Spatial accessibility significantly restricted the seeking of trans-regional medical treatment, whereas age, education level, and policy awareness served as significant protective factors for the choice of medical location. In conclusion, due to space accessibility constraints, insufficient policy coverage, and the rationale for choice of location, DSTOE did not aggravate the siphoning effect of trans-regional patients.

Massive uterine fibroid: a diagnostic dilemma: a case report and review of the literature

Background

Fibroids of the uterus are the most common benign pelvic tumors in women worldwide. Their diagnosis is usually not missed because of the widespread and well-established use of ultrasound in gynecological clinics. Hence, the development of an unusually large myoma is a rare event, particularly in first-world countries such as Germany. It is even more uncommon that a myoma is misdiagnosed as a dietary failure.

Case presentation

Herein, we report the case of a Caucasian woman with a giant fibroid that reached a size of over 50 cm, growing slowly over the past 15 years, and was misdiagnosed as abdominal fat due to weight gain. We aim to discuss the factors that lead to the growth of such a huge tumoral mass, including misdiagnosis and treatment, and the psychological impact. Through this case, we intend to increase the awareness among general physicians and gynecologists. Although menstrual disorders incorporate several pathologies, adequate assessment remains the primary responsibility of health care providers. A literature review revealed approximately 60 cases of giant uterine fibroids.

Conclusion

The use of clinical and diagnostic devices, especially ultrasound, in this case, is indispensable. In conclusion, the growth of a giant fibroid can have disastrous effects on a woman’s health, including surgical trauma and psychological issues.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Disparities in accessibility to evidence-based breast cancer care facilities by rural and urban areas in Bavaria, Germany

BACKGROUND

Breast cancer (BC), which is most common in elderly women, requires a multidisciplinary and continuous approach to care. With demographic changes, the number of patients with chronic diseases such as BC will increase. This trend will especially hit rural areas, where the majority of the elderly live, in terms of comprehensive health care.

METHODS

Accessibility to several cancer facilities in Bavaria, Germany, was analyzed with a geographic information system. Facilities were identified from the national BC guideline and from 31 participants in a proof-of-concept study from the Breast Cancer Care for Patients With Metastatic Disease registry. The timeframe for accessibility was defined as 30 or 60 minutes for all population points. The collection of address information was performed with different sources (eg, a physician registry). Routine data from the German Census 2011 and the population-based Cancer Registry of Bavaria were linked at the district level.

RESULTS

Females from urban areas (n = 2,938,991 [ie, total of females living in urban areas]) had a higher chance for predefined accessibility to the majority of analyzed facilities in comparison with females from rural areas (n = 3,385,813 [ie, total number of females living in rural areas]) with an odds ratio (OR) of 9.0 for cancer information counselling, an OR of 17.2 for a university hospital, and an OR of 7.2 for a psycho-oncologist. For (inpatient) rehabilitation centers (OR, 0.2) and genetic counselling (OR, 0.3), women from urban areas had lower odds of accessibility within 30 or 60 minutes.

CONCLUSIONS

Disparities in accessibility between rural and urban areas exist in Bavaria. The identification of underserved areas can help to inform policymakers about disparities in comprehensive health care. Future strategies are needed to deliver high-quality health care to all inhabitants, regardless of residence.

[Attitude of Parents Towards Pediatric Care and Interprofessional Task-Sharing in Regions Distant Versus Close to Care Facilities: Results of a Standardized Survey]

AIM

The aim of the study was to determine parents' views in regions distant to medical care (dtmc) vs. close to medical care (ctmc) on (1) the assessment of situation in pediatric care and (2) on delegation of medical tasks to qualified members of non-medical health professions.

METHOD

A self-developed questionnaire was sent to parents in kindergartens, who are either nearby (=close to the medical care provider, ctmc) or more than 20 km away from the nearest pediatric practice and a pediatrics department (=distant to the medical care provider, dtmc). The questions covered socio-demographic, pediatric-care-related aspects and attitudes to delegation of defined medical tasks to non-medical health professionals.

RESULTS

Of the n=407 evaluable questionnaires (response rate: 18%), 49% came from parents in ctmc-kindergartens and 51% from parents in dtmc-kindergartens. Significant differences were found in the number of children living in the household (ctmc: 21% with 3 or more children vs. dtmc:13%; p-value 0,044), years of education of parents (ctmc: 50% had more than 10 years vs. dtmc: 39%; p-value 0.026), the number of visits to doctor (ctmc: 50% presented her child 4 or more times to a doctor in the last 12 months vs. dtmc: 32%; p-value <0.001) and the kind of medical doctor present (dtmc: in 51% a pediatrician vs. ctmc: 87%; p-value <0.001). The distance to the doctor was significantly different (p-value <0.001) and parents in dtmc-kindergartens perceived more often problems in pediatric health care (dtmc: 61% confirmed problems vs. ctmc: 47%; p-value 0.032). Dtmc-kindergarten-parents more often approved delegation for all of the defined and proposed medical tasks.

CONCLUSIONS

The results show clear differences between the survey regions. To support pediatric care in regions distant to medical care facilities, innovative care concepts are needed. The positive attitude of the majority of parents on the subject of delegation forms a good basis for the development of concrete concepts and their practical testing in pilot projects.

The impact of accessibility and service quality on the frequency of patient visits to the primary diabetes care provider: results from a cross-sectional survey performed in six European countries

Background

Visits to the primary diabetes care provider play a central role in diabetes care. Therefore, patients should attend their primary diabetes care providers whenever a visit is necessary. Parameters that might affect whether this condition is fulfilled include accessibility (in terms of travel distance and travel time to the practice), as well as aspects of service quality (for example in-practice waiting time and quality of the provider’s communication with the patient). The relationships of these variables with the frequency of visits to the primary diabetes care provider are investigated.

Methods

The investigation is performed with questionnaire data of 1086 type 2 diabetes patients from study regions in England (213), Finland (135), Germany (218), Greece (153), the Netherlands (296) and Spain (71). Data were collected between October 2011 and March 2012. Data were analysed using log-linear Poisson regression models with self-reported numbers of visits in a year to the primary diabetes care provider as the criterion variable. Predictor variables of the core model were: country; gender; age; education; stage of diabetes; heart problems; previous stroke; problems with lower extremities; problems with sight; kidney problems; travel distance and travel time; in-practice waiting time; and quality of communication. To test region-specific characteristics, the interaction between the latter four predictor variables and study region was also investigated.

Results

When study regions are merged, travel distance and in-practice waiting time have a negative effect, travel time no effect and quality of communication a positive effect on visit frequency (with the latter effect being by far largest). When region specific effects are considered, there are strong interaction effects shown for travel distance, in-practice waiting time and quality of communication. For travel distance, as well as for in-practice waiting time, there are region-specific effects in opposite directions. For quality of communication, there are only differences in the strength with which visit frequency increases with this variable.

Conclusions

The impact of quality of communication on visit frequency is the largest and is stable across all study regions. Hence, increasing quality of communication seems to be the best approach for increasing visit frequency.

Gynaecology and general practitioner services utilisation by women in the age group 50 years and older

There are relatively few representative data on the utilisation of physician services in Germany and its influencing. Based on data from the German Health Interview and Examination Survey for Adults (DEGS1, 2008-2011), we analyse the utilisation of gynaecology and general practitioner (GP) services, with a focus on women aged 50 years and older. We compare these findings with data from the German National Health Interview and Examination Survey 1998 (GNHIES98) and, based on this and further data, discuss possible developments. Figures for seeking GP services (over 80%) are constantly high across the entire lifespan, whereas figures for gynaecology services drop with age. Around 60% of women aged 50 years and older go to a gynaecological practice at least once a year. Socioeconomic status and place of residence are important determinants for the utilisation of services. Around half of all women aged 50 years and older sought both gynaecology and GP services at least once over a one-year period. Under 10% had only been to a gynaecologist, and around one third sought GP services only. Compared to GNHIES98, figures for GP and gynaecology services were considerably higher in DEGS1, health insurance data, however, shows no increase in the use of gynaecology services between 2008 and 2018. The results highlight the need to increase awareness among GPs of the needs of middle-aged and older women for gynaecological consultation and treatment.

Assessment of Spatial Accessibility to Residential Care Facilities in 2020 in Guangzhou by Small-Scale Residential Community Data

Population aging has increasingly challenged socio-economic development worldwide, highlighting the significance of relevant research such as accessibility to residential care facilities (RCFs). However, a number of previous studies are carried out only on street (town)-to-district scales, which could cause errors of the accessibility to RCFs for a family. In order to improve the resolution to individual families, we measure and compare the accessibilities to RCFs based on 3494 residential communities and 169 streets of Guangzhou in 2020 through the two-step floating catchment area (2SFCA) method. It was found that the distributions of the elderly and the service-dense blobs of the RCFs show patterns of a three-level spatial distribution, with a characteristic clustering at the center with peripheral dispersion. The resultant accessibility to RCFs in Guangzhou, ranging from 2.5 to 3.45, is generally consistent with the studies focusing on street scales. However, the maximum difference in the accessibility of two residential communities on the same street ranges from less than 0.02 to 0.94 in Guangzhou, indicating large variations. Although the relative errors of the accessibility results based on bi-scale data are relatively low, the cumulative errors can be high, e.g., over 25% in many streets of large cities. Consequently, hundreds of elderly persons per street can be adversely affected by those errors, with six streets over 1000. Therefore, this study focusing on the smaller-scale residential community data may provide more accurate reference to individual households. For the spatial allocation and optimal layout of Guangzhou and similar cities with population aging, we suggest maximizing RCFs in metropolises by taking full advantage of existing residential care facilities with necessary restructuring, improvements, and expansions on service capability. While for less connected cities, we encourage building new RCFs in situ.

Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China

BACKGROUND

This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors.

METHODS

A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity.

RESULTS

Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs.

CONCLUSION

Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.

Economic efficiency versus accessibility: Planning of the hospital landscape in rural regions using a linear model on the example of paediatric and obstetric wards in the northeast of Germany

BACKGROUND

Costs for the provision of regional hospital care depend, among other things, on the population density and the maximum reasonable distance to the nearest hospital. In regions with a low population density, it is a challenge to plan the number and location of hospitals with respect both to economic efficiency and to the availability of hospital care close to residential areas. We examined whether the hospital landscape in rural regions can be planned on the basis of a regional economic model using the example which number of paediatric and obstetric wards in a region in the Northeast of Germany is economically efficient and what would be the consequences for the accessibility when one or more of the three current locations would be closed.

METHODS

A model of linear programming was developed to estimate the costs and revenues under different scenarios with up to three hospitals with both a paediatric and an obstetric ward in the investigation region. To calculate accessibility of the wards, geographic analyses were conducted.

RESULTS

With three hospitals in the study region, there is a financial gap of €3.6 million. To get a positive contribution margin for all three hospitals, more cases have to be treated than the region can deliver. Closing hospitals in the parts of the region with the smallest population density would lead to reduced accessibility for about 8% of the population under risk.

CONCLUSIONS

Quantitative modelling of the costs of regional hospital care provides a basis for planning. A qualitative discussion to the locations of the remaining departments and the implementation of alternative healthcare concepts should follow.