A multi-modal relative spatial access assessment approach to measure spatial accessibility to primary care providers

What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020

Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term "resolvability", commonly used in Brazil, for "effectiveness".

Spatial accessibility to HIV testing, treatment, and prevention services in Illinois and Chicago, USA

Accomplishing the goals outlined in “Ending the HIV (Human Immunodeficiency Virus) Epidemic: A Plan for America Initiative” will require properly estimating and increasing access to HIV testing, treatment, and prevention services. In this research, a computational spatial method for estimating access was applied to measure distance to services from all points of a city or state while considering the size of the population in need for services as well as both driving and public transportation. Specifically, this study employed the enhanced two-step floating catchment area (E2SFCA) method to measure spatial accessibility to HIV testing, treatment (i.e., Ryan White HIV/AIDS program), and prevention (i.e., Pre-Exposure Prophylaxis [PrEP]) services. The method considered the spatial location of MSM (Men Who have Sex with Men), PLWH (People Living with HIV), and the general adult population 15–64 depending on what HIV services the U.S. Centers for Disease Control (CDC) recommends for each group. The study delineated service- and population-specific accessibility maps, demonstrating the method’s utility by analyzing data corresponding to the city of Chicago and the state of Illinois. Findings indicated health disparities in the south and the northwest of Chicago and particular areas in Illinois, as well as unique health disparities for public transportation compared to driving. The methodology details and computer code are shared for use in research and public policy.

Combining Temporal and Multi-Modal Approaches to Better Measure Accessibility to Banking Services

The UK, as elsewhere, has seen an accelerating trend of bank branch closures and reduced opening hours since the early 2000s. The reasons given by the banks are well rehearsed, but the impact assessments they provide to justify such programs and signpost alternatives have been widely criticized as being inadequate. This is particularly so for vulnerable customers dependent on financial services who may face difficulties in accessing remaining branches. There is a need whilst analyzing spatial patterns of access to also include temporal availability in relation to transport opportunities. Drawing on a case study of potential multi-modal accessibility to banks in Wales, we demonstrate how open-source tools can be used to examine patterns of access whilst considering the business operating hours of branches in relation to public transport schedules. The inclusion of public and private travel modes provides insights into access that are often overlooked by a consideration of service-side measures alone. Furthermore, findings from the types of tools developed in this study are illustrative of the additional information that could be included in holistic impact assessments, allowing the consequences of decisions being taken to close or reduce the operating hours of bank branches to be more clearly communicated to customers.

Using GIS to Understand the Influence of Hurricane Harvey on Spatial Access to Primary Care

Hurricanes can have a significant impact on the functioning and capacity of healthcare systems. However, little work has been done to understand the extent to which hurricanes influence local residents' spatial access to healthcare. Our study evaluates the change in spatial access to primary care physicians (PCPs) between 2016 and 2018 (i.e., before and after Hurricane Harvey) in Harris County, Texas. We used an enhanced 2-step floating catchment area (E2SFCA) method to measure spatial access to PCPs at the census tract level. The results show that, despite an increased supply of PCPs across the county, most census tracts, especially those in the northern and eastern fringe areas, experienced decreased access during this period as measured by the spatial access ratio (SPAR). We explain this decline in SPAR by the shift in the spatial distribution of PCPs to the central areas of Harris County from the fringe areas after Harvey. We also examined the socio-demographic impact in the SPAR change and found little variation in change among different socio-demographic groups. Therefore, public health professionals and disaster managers may use our spatial access measure to highlight the geographic disparities in healthcare systems. In addition, we recommend considering other social and institutional dimensions of access, such as users' needs, preferences, resource capacity, mobility options, and quality of healthcare services, in building a resilient and inclusive post-hurricane healthcare system.

General Practitioner Time Availability Per Inhabitant Per Year: A New Indicator to Measure Access to Primary Care

Introduction

The number of general practitioners (GPs) per inhabitant, used commonly as an indicator of primary care (PC) access, reports only imprecisely on the true availability of GPs. The aim of this study is to develop a new PC access indicator that better reflects the availability of GPs to take care of patients at the population level, the average GP time availability per inhabitant per year.

Methods

We extracted the data from the Commonwealth Fund International Health Policy Survey of Primary Care Physicians conducted in 2015, including 11 Western countries and 12,049 randomly drawn GPs. We built the indicator by combining two questions about weekly workload in hours and percentage of time spent on face-to-face contact with patients. The indicator was then adjusted regarding the number of GPs, the weeks worked per year and the country's population size.

Results

On average, GPs worked 43 h a week. The average time spent on face-to-face contact with patients was 30.5 h/week (35 h including emails and telephone contact), ranging from 22 h in Sweden and 38 h in France. The mean time available of GPs for face-to-face contact was 69 min/inhabitant/year, ranging from 38 min in Sweden to 118 min in Australia. Including email and telephone contact, the mean contact time rose to 79 min/inhabitant/year, ranging from 48 min in Sweden to 127 min in Australia.

Conclusion

The new indicator provides an accurate and sensitive estimate of a GP's true time availability at the population level. Results should be interpreted in the context of PC workforce organization, which may help guide GP workforce development.

Medically underserved areas: are primary care teams efficient at attracting and retaining general practitioners?

The geographical imbalances of General Practitioners (GPs) may affect their accessibility for populations, especially in medically underserved areas. We investigate the effect of the dramatic and recent diffusion of Primary Care Teams (PCTs), especially in medically underserved areas, in order to attract and retain GPs through an improvement of their working conditions. We analyze the evolution of GPs and young GPs density between 2004 and 2017 according to a spatial taxonomy of French living areas in 6 clusters. Based on a quasi-experimental design comparing living areas, depending on the clusters, with PCTs (treated) and without PCTs (control), we used difference-in-differences models to estimate the impact of PCT new settlements on the evolution of both attraction and retention of GPs. Our results show that PCT settlements are efficient to attract young GPs and that the magnitude of the effects depends on the living area clusters. Results call for specific policies to address geographical inequalities of GPs that consider the type of place and also, in France, for new measures to attract and retain GPs in rural fringes.

Impact of travel time uncertainties on modeling of spatial accessibility: a comparison of street data sources

GIS-based spatial access measures have been used extensively to monitor social equity and to help develop policy. However, inherent uncertainties in the road datasets used in spatial access estimates remain largely underreported. These uncertainties might result in unrecognized biases within visualization products and decision-making outcomes that strive to improve social equity based on seemingly egalitarian accessibility metrics. To better understand and address these uncertainties, we evaluated variations in travel impedance for car and bus transportation using proprietary, volunteer-information-based, and free (non-volunteer-information-based) street networks. We then interpreted the measured variations through the lens of street data uncertainty and its propagation in a common E2SFCA model of spatial accessibility. Results indicated that travel impedance disagreement propagates through the modeling process to effect agreement of spatial access index (SPAI) estimates among different street sources, with larger uncertainties observed for bus travel than car travel. Higher impedance coefficients (β), a model parameter, reduced the impact of street-source variations on estimates. Less urbanized regions were found to experience higher street-source variations when compared with the core-metropolitan area. We also demonstrated that a relative spatial access measure - the spatial access ratio (SPAR) - reduced uncertainties introduced by the choice of street datasets. Careful selection of reliable street sources and model parameters (e.g., higher β), as well as consideration of the potential for bias, particularly for less urbanized areas and areas reliant on public transportation, is warranted when leveraging SPAI to inform policy. When reliable/accurate road network data is not accessible or data quality information is not available, the SPAR is a suitable alternative or supplement to SPAI for visualization and analyses.

A Review of Recent Spatial Accessibility Studies That Benefitted from Advanced Geospatial Information: Multimodal Transportation and Spatiotemporal Disaggregation

Spatial accessibility provides significant policy implications, describing the spatial disparity of access and supporting the decision-making process for placing additional infrastructure at adequate locations. Several previous reviews have covered spatial accessibility literature, focusing on empirical findings, distance decay functions, and threshold travel times. However, researchers have underexamined how spatial accessibility studies benefitted from the recently enhanced availability of dynamic variables, such as various travel times via different transportation modes and the finer temporal granularity of geospatial data in these studies. Therefore, in our review, we investigated methodological advancements in place-based accessibility measures and scrutinized two recent trends in spatial accessibility studies: multimodal spatial accessibility and temporal changes in spatial accessibility. Based on the critical review, we propose two research agendas: improving the accuracy of measurements with dynamic variable implementation and furnishing policy implications granted from the enhanced accuracy. These agendas particularly call for the action of geographers on the full implementation of dynamic variables and the strong linkage between accessibility and policymaking.

A comparison of methods for measuring spatial access to health care

OBJECTIVE

To compare measures of spatial access to care commonly used by policy makers and researchers with the more comprehensive enhanced two-step floating catchment area (E2SFCA) method.

STUDY SETTING

Fourteen southwestern Pennsylvania counties.

STUDY DESIGN

We estimated spatial access to buprenorphine-waivered prescribers using three commonly used measures-Euclidean travel distance to the closest prescriber, travel time to the closest provider, and provider-to-population ratios-and the E2SFCA. Unlike other measures, the E2SFCA captures provider capacity, potential patient volume, and travel time to prescribers.

DATA COLLECTION/EXTRACTION METHODS

We measured provider capacity as the number of buprenorphine prescribers listed at a given address in the Drug Enforcement Agency's 2020 Controlled Substances Act Registrants Database, and we measured potential patient volume as the number of nonelderly adults in a given census tract as reported by the 2018 American Community Survey. We estimated travel times between potential patients and prescribers with Bing Maps and Mapbox application programming interfaces. We then calculated each spatial access measure using the R programming language. We used each measure of spatial access to identify census tracts in the lowest quintile of spatial access to prescribers.

PRINCIPAL FINDINGS

The Euclidean distance, travel time, and provider-to-population ratio measures identified 48.3%, 47.2%, and 69.9% of the census tracts that the E2SFCA measure identified as being in the lowest quintile of spatial access to care, meaning that these measures misclassify 30%-52% of study area census tracts as having sufficient spatial access to buprenorphine prescribers.

CONCLUSIONS

Measures of spatial access commonly used by policy makers do not sufficiently accurately identify geographic areas with relatively low access to prescribers of buprenorphine. Using the E2SFCA in addition to the commonly used measures would allow policy makers to precisely target interventions to increase spatial access to opioid use disorder treatment and other types of health care services.

A model for measuring healthcare accessibility using the behavior of demand: a conditional logit model-based floating catchment area method

BACKGROUND

Estimating realistic access to health services is essential for designing support policies for healthcare delivery systems. Many studies have proposed a metric to calculate accessibility. However, patients' realistic willingness to use a hospital was not explicitly considered. This study aims to derive a new type of potential accessibility that incorporates a patient's realistic preference in selecting a hospital.

METHODS

This study proposes a floating catchment area (FCA)-type metric combined with a discrete choice model. Specifically, a new FCA-type metric (clmFCA) was proposed using a conditional logit model. Such a model estimates patients' realistic willingness to use health services. The proposed metric was then applied to calculate the accessibility of obstetric care services in Korea.

RESULTS

The clmFCA takes advantage of patients' realistic preferences. Specifically, it can represent each patient's heterogeneous characteristics regarding hospital choice. Such characteristics include bypassing behavior, which could not be considered using prior FCA metrics. Empirical analysis reveals that the clmFCA avoids the misestimation of accessibility to health services to an extent.

CONCLUSIONS

The clmFCA offers a new framework that more realistically estimates patients' accessibility to health services. This is achieved by accurately estimating the potential demand for a service. The proposed method's effectiveness was verified through a case study using nationwide data.

Use of the spatial access ratio to measure geospatial access to emergency general surgery services in California

BACKGROUND

Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities.

METHODS

We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR.

RESULTS

A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold.

CONCLUSION

While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services.

LEVEL OF EVIDENCE

Cross-sectional study, level VI.

Facility Attractiveness and Social Vulnerability Impacts on Spatial Accessibility to Opioid Treatment Programs in South Carolina

Opioid dependence and opioid-related mortality have been increasing in recent years in the United States. Available and accessible treatments may result in a reduction of opioid-related mortality. This work describes the geographic variation of spatial accessibility to opioid treatment programs (OTPs) and identifies areas with poor access to care in South Carolina. The study develops a new index of access that builds on the two-step floating catchment area (2SFCA) method, and has three dimensions: a facility attractiveness index, defined by services rendered incorporated into the Huff Model; a facility catchment area, defined as a function of facility attractiveness to account for variable catchment size; and a Social Vulnerability Index (SVI) to account for nonspatial factors that mitigate or compound the impacts of spatial access to care. Results of the study indicate a significant variation in access to OTPs statewide. Spatial access to OTPs is low across the entire state except for in a limited number of metropolitan areas. The majority of the population with low access (85%) live in areas with a moderate-to-high levels of social vulnerability. This research provides more realistic estimates of access to care and aims to assist policymakers in better targeting disadvantaged areas for OTP program expansion and resource allocation.

Accessibility to delivery care in Hubei Province, China

Accessibility to delivery care is crucial for improving maternal health, which is an important policy goal to ensure healthy lives and promote well-being in China and worldwide, especially with the change of the family planning policy in China in 2016. This study develops a set of methods to project the population of women of child-bearing age and birth population and assess the accessibility to delivery care services in Hubei Province. The Cohort-Component projection method with various scenarios was applied to project the population of women of children-bearing age in 2030. A Gravity-based Variable Two-Step Floating Catchment Area (GV2SFCA) method is developed, which takes into account the heterogeneous catchment areas and distance decay effects for different regions and various levels of delivery care services. The parameters are calibrated by using medical records with patients' addresses. The traditional Supply-Demand Ratio method is also applied. The results demonstrate an overall decreasing trend of birth population in Hubei in all scenarios, but with significant disparities across regions. In 2016, 28% of districts fail to reach the policy goal with 17 beds per thousand births. In 2030, accessibility to delivery care is projected to increase in 98% of districts, while there are still 22% of districts that fail to reach the policy goal. The accessibility scores are further combined with the densities of birth population to identify shortage areas of delivery care. 7% and 6% of districts are classified as Major Shortage Areas in 2016 and 2030, respectively. The findings shed lights on the distributions and future changes of accessibility to and shortage areas of delivery care in Hubei, which can provide evidence-based recommendations for planning and policymaking. It also provides innovative methods for more accurately assessing accessibility to delivery care.

Two-Step Floating Catchment Area Model-Based Evaluation of Community Care Facilities' Spatial Accessibility in Xi'an, China

Due to the rapid increase in the number of elderly people in Chinese cities, the development and planning of aged care facilities, and particularly community care facilities, which will gradually become the mainstream choice for the elderly in China, is becoming an important topic for urban sustainability. Previous studies have shown that the number and scale of aged care facilities in many cities are far from meeting the needs of the elderly and the overall occupation rate is low. Some of these cities are still expanding and some are undergoing urban renovation. In this process, the scientific planning of community care facilities to promote efficient use of facility resources has become an urgent problem that needs to be solved. In this study, the two-step floating catchment area (2SFCA) method and a potential model based on the Geographic Information System (GIS) were used to carry out a scientific evaluation of the spatial accessibility of community care facilities in the Beilin district of Xi'an. The aims were to explore the best quantitative research methods for assessing the distribution of Xi'an community care facilities' spatial accessibility, provide ideas for similar studies in the future, and further the understanding of spatial allocation of urban community care facilities resources.

Measuring Accessibility of Healthcare Facilities for Populations with Multiple Transportation Modes Considering Residential Transportation Mode Choice

Accessibility research of healthcare facilities is developing towards multiple transportation modes (MTM), which are influenced by residential transportation choices and preferences. Due to differences in travel impact factors such as traffic conditions, origin location, distance to the destination, and economic cost, residents’ daily travel presents different residential transportation mode choices (RTMC). The purpose of our study was to measure the spatial accessibility of healthcare facilities based on MTM considering RTMC (MTM-RTMC). We selected the gravity two-step floating catchment area method (G2SFCA) as a fundamental model. Through the single transportation mode (STM), MTM, and MTM-RTMC, three aspects used to illustrate and redesign the G2SFCA, we obtained the MTM-RTMC G2SFCA model that integrates RTMC probabilities and the travel friction coefficient. We selected Nanjing as the experimental area, used route planning data of four modes (including driving, walking, public transportation, and bicycling) from a web mapping platform, and applied the three models to pediatric clinic services to measure accessibility. The results show that the MTM-RTMC mechanism is to make up for the traditional estimation of accessibility, which loses sight of the influence of residential transportation choices. The MTM-RTMC mechanism that provides a more realistic and reliable way can generalize to major accessibility models and offers preferable guidance for policymakers.

A spatial analysis to evaluate the impact of deregulation policies in the pharmacy sector: Evidence from the case of Navarre

Community pharmacies represent unusual enterprises as their main function is intrinsically related to the provision of healthcare services. Hence, market competition in this sector needs to be regulated, in order to ensure equitable accessibility, efficiency and quality of services. However, recently a general deregulation trend may be observed in Europe. In this paper, we focus on location restrictions, i.e. on demographic and geographic constraints to open new pharmacies, and we evaluate the impact of their relaxation. In particular, we analyze the case of the city of Pamplona (ES), where a striking increase in the number of pharmacies occurred, after the introduction of a new regulatory system in 2000. We evaluate, thanks to an in-depth spatial analysis, the evolution of the system to date and the effects produced on the consumers, in terms of accessibility, and on the competitors, in terms of market shares distribution. By comparing the obtained results with the ones related to the case of a second Spanish city, characterized by more strict restrictions, it emerges that the deregulation risks to produce a limited improvement in terms of accessibility and to exacerbate differences among consumers. Moreover, an increasing number of competitors does not necessarily imply a more equitable distribution of market shares, thus putting at risk the desired effects in terms of cost reduction and service quality improvement.