Measuring Spatial Accessibility of Health Care Providers - Introduction of a Variable Distance Decay Function within the Floating Catchment Area (FCA) Method

Analysing the intra and interregional components of spatial accessibility gravity model to capture the level of equity in the distribution of hospital services in Italy: do they influence patient mobility?

BACKGROUND

An equal distribution of hospital structures represents an important factor to achieve Universal Health Coverage. Generally, the most diffused approach to measure the potential availability to healthcare is the provider-to-population ratio based on the number of beds or professionals. However, this approach considers only the availability of resources provided at regional or local level ignoring the spatial accessibility of interregional facilities that are particularly accessed by patients living at the borders. Aim of this study is to outline the distribution of the intra and interregional services in Italy to capture the level of equity across the country. Moreover, it explores the impact of the accessibility to these resources on interregional patient's mobility to receive care.

METHODS

To compute spatial accessibility, we propose an alternative approach that applies the enhanced two-step floating catchment area (ESFCA) to capture the level of attraction of intra and interregional hospitals to a given population. Moreover, the adoption of process and outcome indices captured to what extent the quality of structures influenced patients in choosing services located inside or outside their region of residence.

RESULTS

The study confirms that there is an unequal distribution of high-quality resources at regional and national level with a high level of inequality in the availability and accessibility of quality resources between the north and south part of Italy. This is particularly true considering the accessibility of intraregional resources in the southern part of the country that clearly influences patient choice and contribute to a significant cross border passive mobility to northern regions. This is confirmed by an econometric model that showed a significant effect of spatial accessibility with the propensity of patients of travel from the region of residence to receive care.

CONCLUSIONS

The analysis of intra and interregional components of spatial accessibility may contribute to identify to what extent patients are willing to travel outside their region of residence to access to care services. Moreover, it can contribute to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility in order to contain patient mobility.

Patterns and determinants of health care utilization among people with Parkinson's disease: A population-based analysis in Ontario, Canada

In Ontario, despite the increasing prevalence of Parkinson's disease (PD), barriers to access-to-care for people with Parkinson's disease (PwP) and their caregivers are not well understood. The objective of this study is to examine spatial patterns of health care utilization among PwP and identify factors associated with PD-related health care utilization of individuals in Ontario. We employed a retrospective, population-based study design involving administrative health data to identify PwP as of March 31, 2018 (N = 35,482) using a previously validated case definition. An enhanced 2-step floating catchment area method was used to measure spatial accessibility to PD care and a descriptive spatial analysis was conducted to describe health service utilization by geographic area and specialty type. Negative binomial regression models were then conducted to identify associated geographic, socioeconomic, comorbidity and demographic factors. There was marked spatial variability in PD-related service utilization, with neurology and all provider visits being significantly higher in urban areas (CMF>1.20; p<0.05) and family physician visits being significantly higher (CMF >1.20; p<0.05) in more rural areas and remote areas. More frequent visits to family physicians were associated with living in rural areas, while less frequent visitation was associated with living in areas of low spatial accessibility with high ethnic concentration. Visits to neurologists were positively associated with living in areas of high spatial accessibility and with high ethnic concentration. Visits to all providers were also positively associated with areas of high spatial accessibility. For all outcomes, less frequent visits were found in women, older people, and those living in more deprived areas as years living with PD increased. This study demonstrates the importance of geographic, socioeconomic and individual factors in determining PwP's likelihood of accessing care and type of care provided. Our results can be expected to inform the development of policies and patient care models aimed at improving accessibility among diverse populations of PwP.

Gravity models for potential spatial healthcare access measurement: a systematic methodological review

BACKGROUND

Quantifying spatial access to care-the interplay of accessibility and availability-is vital for healthcare planning and understanding implications of services (mal-)distribution. A plethora of methods aims to measure potential spatial access to healthcare services. The current study conducts a systematic review to identify and assess gravity model-type methods for spatial healthcare access measurement and to summarize the use of these measures in empirical research.

METHODS

A two-step approach was used to identify (1) methodological studies that presented a novel gravity model for measuring spatial access to healthcare and (2) empirical studies that applied one of these methods in a healthcare context. The review was conducted according to the PRISMA guidelines. EMBASE, CINAHL, Web of Science, and Scopus were searched in the first step. Forward citation search was used in the second step.

RESULTS

We identified 43 studies presenting a methodological development and 346 empirical application cases of those methods in 309 studies. Two major conceptual developments emerged: The Two-Step Floating Catchment Area (2SFCA) method and the Kernel Density (KD) method. Virtually all other methodological developments evolved from the 2SFCA method, forming the 2SFCA method family. Novel methodologies within the 2SFCA family introduced developments regarding distance decay within the catchment area, variable catchment area sizes, outcome unit, provider competition, local and global distance decay, subgroup-specific access, multiple transportation modes, and time-dependent access. Methodological developments aimed to either approximate reality, fit a specific context, or correct methodology. Empirical studies almost exclusively applied methods from the 2SFCA family while other gravity model types were applied rarely. Distance decay within catchment areas was frequently implemented in application studies, however, the initial 2SFCA method remains common in empirical research. Most empirical studies used the spatial access measure for descriptive purposes. Increasingly, gravity model measures also served as potential explanatory factor for health outcomes.

CONCLUSIONS

Gravity models for measuring potential spatial healthcare access are almost exclusively dominated by the family of 2SFCA methods-both for methodological developments and applications in empirical research. While methodological developments incorporate increasing methodological complexity, research practice largely applies gravity models with straightforward intuition and moderate data and computational requirements.

Location selection of field hospitals amid COVID-19 considering effectiveness and fairness: A case study of Florida

The world has experienced an unprecedented global health crisis since 2020, the COVID-19 pandemic, which inflicted massive burdens on countries' healthcare systems. During the peaks of the pandemic, the shortages of intensive care unit (ICU) beds illustrated a critical vulnerability in the fight. Many individuals suffering the effects of COVID-19 had difficulty accessing ICU beds due to insufficient capacity. Unfortunately, it has been observed that many hospitals do not have enough ICU beds, and the ones with ICU capacity might not be accessible to all population strata. To remedy this going forward, field hospitals could be established to provide additional capacity in helping emergency health situations such as pandemics; however, location selection is a crucial decision ultimately for this purpose. As such, we consider finding new field hospital locations to serve the demand within certain travel-time thresholds, while accounting for the presence of vulnerable populations. A multi-objective mathematical model is proposed in this paper that maximizes the minimum accessibility and minimizes the travel time by integrating the Enhanced 2-Step Floating Catchment Area (E2SFCA) method and travel-time-constrained capacitated p-median model. This is performed to decide on the locations of field hospitals, while a sensitivity analysis addresses hospital capacity, demand level, and the number of field hospital locations. Four counties in Florida are selected to implement the proposed approach. Findings can be used to identify the ideal location(s) of capacity expansions concerning the fair distribution of field hospitals in terms of accessibility with a specific focus on vulnerable strata of the population.

Geographic accessibility and hospital competition for emergency blood transfusion services in Bungoma, Western Kenya

BACKGROUND

Estimating accessibility gaps to essential health interventions helps to allocate and prioritize health resources. Access to blood transfusion represents an important emergency health requirement. Here, we develop geo-spatial models of accessibility and competition to blood transfusion services in Bungoma County, Western Kenya.

METHODS

Hospitals providing blood transfusion services in Bungoma were identified from an up-dated geo-coded facility database. AccessMod was used to define care-seeker's travel times to the nearest blood transfusion service. A spatial accessibility index for each enumeration area (EA) was defined using modelled travel time, population demand, and supply available at the hospital, assuming a uniform risk of emergency occurrence in the county. To identify populations marginalized from transfusion services, the number of people outside 1-h travel time and those residing in EAs with low accessibility indexes were computed at the sub-county level. Competition between the transfusing hospitals was estimated using a spatial competition index which provided a measure of the level of attractiveness of each hospital. To understand whether highly competitive facilities had better capacity for blood transfusion services, a correlation test between the computed competition metric and the blood units received and transfused at the hospital was done.

RESULTS

15 hospitals in Bungoma county provide transfusion services, however these are unevenly distributed across the sub-counties. Average travel time to a blood transfusion centre in the county was 33 min and 5% of the population resided outside 1-h travel time. Based on the accessibility index, 38% of the EAs were classified to have low accessibility, representing 34% of the population, with one sub-county having the highest marginalized population. The computed competition index showed that hospitals in the urban areas had a spatial competitive advantage over those in rural areas.

CONCLUSION

The modelled spatial accessibility has provided an improved understanding of health care gaps essential for health planning. Hospital competition has been illustrated to have some degree of influence in provision of health services hence should be considered as a significant external factor impacting the delivery, and re-design of available services.

MHV3SFCA: A new measure to capture the spatial accessibility of health care systems

Good accessibility of health care services is essential to meet the needs of the population and ensure adequate health care coverage. It usually refers to two spatial dimensions: availability (competition between populations for the same medical supply) and reachability (distance between population and medical supply). Traditional indicators of health care accessibility usually fail to consider both of these components simultaneously. Floating-Catchment-Area (FCA) methods were developed to address these shortcomings. This study reviews the existing FCA methods and proposes the Modified Huff-based Variable 3 Steps Floating Catchment Area (MHV3SFCA) method as a new approach. The MHV3SFCA method integrates the strengths of several existing FCA methods into a single method, such as supply competition through the Huff model, and the integration of variable effective catchment sizes. In addition, and as a novelty, the MHV3SFCA relies on the assumption of a constant overall population demand, independent of the distances between population units and supply sites. It also accounts for absolute difference in distances without overestimating distance effects. Based on the results of a simulation study the paper discusses the strengths of the MHV3SFCA method capturing spatial differences in access to health care services.

Use of an E2SFCA method to assess healthcare resources in Jordan during COVID-19 pandemic

Healthcare spatial accessibility requires a better understanding and evaluation, especially during pandemic outbreaks like the recent COVID-19 pandemic. The main goal of this study is to measure and assess community-level spatial accessibility in Amman city to various COVID-19 related healthcare resources that could provide any urgent medical care for suspected or confirmed COVID-19 cases. To address this aim, the Enhanced 2-step floating catchment area (E2SFCA) method combined with several geospatial techniques were performed. The main E2SFCA results show the differences in the capacities and spatial accessibility of health facilities within Amman city, as well as how the variations are captured at different regions. The resulted spatial accessibility scores were presented in interactive Geo-spatial maps, analyzed, and compared for several health resources in public, private, and educational hospitals. The current research findings stated that although there are enough healthcare facilities to service almost the entire city, inappropriate health facility distribution, rather than a lack of resources, has resulted in coverage gaps in some areas. The center zones had been fully serviced, or perhaps over-served, by a large number of facilities. The other zones, on the contrary, were partially served or were even underserved by a certain number of resources.

Rural–Urban Disparities in Realized Spatial Access to General Practitioners, Orthopedic Surgeons, and Physiotherapists among People with Osteoarthritis in Alberta, Canada

Rural Canadians have high health care needs due to high prevalence of osteoarthritis (OA) but lack access to care. Examining realized access to three types of providers (general practitioners (GPs), orthopedic surgeons (Ortho), and physiotherapists (PTs)) simultaneously helps identify gaps in access to needed OA care, inform accessibility assessment, and support health care resource allocation. Travel time from a patient’s postal code to the physician’s postal code was calculated using origin–destination network analysis. We applied descriptive statistics to summarize differences in travel time, hotspot analysis to explore geospatial patterns, and distance decay function to examine the travel pattern of health care utilization by urbanicity. The median travel time in Alberta was 11.6 min (IQR = 4.3–25.7) to GPs, 28.9 (IQR = 14.8–65.0) to Ortho, and 33.7 (IQR = 23.1–47.3) to PTs. We observed significant rural–urban disparities in realized access to GPs (2.9 and IQR = 0.0–92.1 in rural remote areas vs. 12.6 and IQR = 6.4–21.0 in metropolitan areas), Ortho (233.3 and IQR = 171.3–363.7 in rural remote areas vs. 21.3 and IQR = 14.0–29.3 in metropolitan areas), and PTs (62.4 and IQR = 0.0–232.1 in rural remote areas vs. 32.1 and IQR = 25.2–39.9 in metropolitan areas). We identified hotspots of realized access to all three types of providers in rural remote areas, where patients with OA tend to travel longer for health care. This study may provide insight on the choice of catchment size and the distance decay pattern of health care utilization for further studies on spatial accessibility.

Measuring spatial accessibility to urban services for older adults: an application to healthcare facilities in Milan

This study proposes a Geographic Information Systems-based methodology to measure accessibility to urban services from the elderly perspective to support urban planning processes. Specifically, it seeks to understand and clarify how the urban environment can influence the quality of life for older adults, mostly through pedestrian and public transport networks, locations of essential urban services, and the organisation of their resources. In light of a significant demographic change, policymakers will have to promote age-friendly urban planning approaches to guarantee equal access to services and activities. We propose a methodology to measure accessibility to healthcare provision services that considers land-use and mobility features and older adults' behavioural traits. The method belongs to the family of 2SFCA-2 steps floating catchment area-which evaluate accessibility as the combination of both supply and demand of urban services. Therefore, we have introduced innovative elements to shape actual mobility opportunities for the elderly and their travel choices. The methodology was applied to Milan's city to measure accessibility to the Health Protection Agency (ATS) services, which is responsible for healthcare assistance to the elderly dwelling in the city. The outputs show that a significant share of older people (almost 40%) suffer from poor accessibility to primary health services and that they mostly live in the city periphery. Moreover, the application to a case study has shown that the methodology could identify the critical aspects needed to aid urban planning to achieve a high quality of life for elderly people.

Spatial Pattern of the Walkability Index, Walk Score and Walk Score Modification for Elderly

Contemporary cities require excellent walking conditions to support human physical activity, increase humans’ well-being, reduce traffic, and create a healthy urban environment. Various indicators and metrics exist to evaluate walking conditions. To evaluate the spatial pattern of objective-based indicators, two popular indices were selected—the Walkability Index (WAI), representing environmental-based indicators, and Walk Score (WS), which applies an accessibility-based approach. Both indicators were evaluated using adequate spatial units (circle buffers with radii from 400 m to 2414 m) in two Czech cities. A new software tool was developed for the calculation of WS using OSM data and freely available network services. The new variant of WS was specifically designed for the elderly. Differing gait speeds, and variable settings of targets and their weights enabled the adaptation of WS to local conditions and personal needs. WAI and WS demonstrated different spatial pattern where WAI is better used for smaller radii (up to approx. 800 m) and WS for larger radii (starting from 800 m). The assessment of WS for both cities indicates that approx. 40% of inhabitants live in unsatisfactory walking conditions. A sensitivity analysis discovered the major influences of gait speed and the β coefficient on the walkability assessment.

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.

Evaluations of Spatial Accessibility and Equity of Multi-Tiered Medical System: A Case Study of Shenzhen, China

The Chinese government has implemented a medical system reform to improve the equity of healthcare resources since 2009. We selected Shenzhen as our study area and evaluated the accessibility and equity of the multi-tiered medical system in China using a novel multi-tiered two-step floating catchment area (MT2SFCA) method. We proposed the benchmark and applied the independent variables of travel time and facility attractiveness, along with a combination of the two factors, as tolerances to determine the new logistic cumulative distribution decay functions. Community health centers (CHCs) and hospitals were included while integrating their features. Results revealed that the MT2SFCA method was able to determine the particular advantages of CHCs and hospitals in the multi-tiered medical system. The CHCs offset the lower accessibility of hospitals in suburban areas and hospitals balanced the regional inequity caused by the CHC. Travel time is the main consideration of patients who have access to CHCs, whereas facility features are the main considerations of patients who have access to hospitals. Notably, both CHCs and hospitals are crucial for the whole multi-tiered medical system. Finally, we suggested modifications in different travel modes, weights of contributing factors, and the validation of decay functions to improve the MT2SFCA method.

Trap of weights: The reuse of weights in the floating catchment area (FCA) methods to measuring accessibility

Background: Geographic weights are vital in the floating catchment area (FCA) method of accessibility measurements due to their simulation of spatial barriers in various ways. When modelling population demand, geographical weights with different distance decay coefficients can reflect diverse distance tolerances in facility utilization and could lead to erratic accessibility results. Quantifying accessibility as the sum of weighted supply-demand ratios can alleviate the distance decay coefficient's influence and generate stable geographic patterns. However, the effects of weighted ratios on different FCA models and resources have not been investigated. Methods: To identify impacts of weighted ratios on various FCA variants, this study contrasted the accessibility calculated from the sum of ratios (access) and the sum of weighted ratios (access ratios) within three prevalent FCA models: enhanced two-step FCA (E2SFCA), modified two-step FCA (M2SFCA), and three-step FCA (3SFCA). In addition, the accessibilities of various resources evaluate the stability of the weighted ratios' effect. This study therefore examined the accessibilities to primary schools, job opportunities, and major hospitals in Shanghai. Shanghai is a case study that provides lessons on using big data to measure accessibility in metropolitan areas. Results: Geographic weights can not only mitigate the impact of the distance decay coefficients, but can also eliminate model features, which reduces the performance of the M2SFCA's supply decay and the 3SFCA's population demand adjustment in accessibility results. Moreover, weighted ratios tend to overestimate accessibility in marginal communities that lie within fewer catchments, regardless of the resource type. This tendency can lead to an epistemological trap that creates an inaccurate and counter-intuitive perception of resource distribution in a given area. Conclusions: The results identify a gap between the methodological logic and the empirical perception in accessibility measurements. This study concludes that the use of geographic weights needs to be cautious and epistemologically consistent.

Predicting the Travel Distance of Patients to Access Healthcare Using Deep Neural Networks

OBJECTIVE

Improving geographical access remains a key issue in determining the sufficiency of regional medical resources during health policy design. However, patient choices can be the result of the complex interactivity of various factors. The aim of this study is to propose a deep neural network approach to model the complex decision of patient choice in travel distance to access care, which is an important indicator for policymaking in allocating resources.

METHOD

We used the 4-year nationwide insurance data of Taiwan and accumulated the possible features discussed in earlier literature. This study proposes the use of a convolutional neural network (CNN)-based framework to make predictions. The model performance was tested against other machine learning methods. The proposed framework was further interpreted using Integrated Gradients (IG) to analyze the feature weights.

RESULTS

We successfully demonstrated the effectiveness of using a CNN-based framework to predict the travel distance of patients, achieving an accuracy of 0.968, AUC of 0.969, sensitivity of 0.960, and specificity of 0.989. The CNN-based framework outperformed all other methods. In this research, the IG weights are potentially explainable; however, the relationship does not correspond to known indicators in public health.

CONCLUSIONS

Our results demonstrate the feasibility of the deep learning-based travel distance prediction model. It has the potential to guide policymaking in resource allocation. Clinical and Translational Impact Statement- Deep learning technology is feasible in investigating the distance that patients would travel while accessing care. It is a tool that integrates complex interactive variables with highly imbalanced data distributions.

Trap of weights: The reuse of weights in the floating catchment area (FCA) methods to measuring accessibility

Background: Geographic weights are vital in the floating catchment area (FCA) method of accessibility measurements due to their simulation of spatial barriers in various ways. When modelling population demand, geographical weights with different distance decay coefficients can reflect diverse distance tolerances in facility utilization and could lead to erratic accessibility results. Quantifying accessibility as the sum of weighted supply-demand ratios can alleviate the distance decay coefficient's influence and generate stable geographic patterns. However, the effects of weighted ratios on different FCA models and resources have not been investigated. Methods: To identify impacts of weighted ratios on various FCA variants, this study contrasted the accessibility calculated from the sum of ratios (access) and the sum of weighted ratios (access ratios) within three prevalent FCA models: enhanced two-step FCA (E2SFCA), modified two-step FCA (M2SFCA), and three-step FCA (3SFCA). In addition, the accessibilities of various resources evaluate the stability of the weighted ratios' effect. This study therefore examined the accessibilities to primary schools, job opportunities, and major hospitals in Shanghai. Shanghai is a case study that provides lessons on using big data to measure accessibility in metropolitan areas. Results: Geographic weights can not only mitigate the impact of the distance decay coefficients, but can also eliminate model features,  which reduces the performance of the M2SFCA's supply decay and the 3SFCA's population demand adjustment in accessibility results. Moreover, weighted ratios tend to overestimate accessibility in marginal communities that lie within fewer catchments, regardless of the resource type. This tendency can lead to an epistemological trap that creates an inaccurate and counter-intuitive perception of resource distribution in a given area. Conclusions: The results identify a gap between the methodological logic and the empirical perception in accessibility measurements. This study concludes that the use of geographic weights needs to be cautious and epistemologically consistent.

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.

[Smart sensors in pregnancy: Narrative review on the use of smart home technology in routine prenatal care]

INTRODUCTION

Today's routine prenatal care in Germany includes regular in-person appointments of pregnant women with doctors or midwives. Considering an increasing digitalization of the health care sector and in view of the global COVID-19 pandemic, the frequency of in-person visits could be reduced by remote monitoring using smart sensor technology. We aim to give an overview of the current international research on the use of smart sensors in prenatal care and its benefits, costs and resource consumption.

METHODS

For this narrative review, PubMed and Science Direct were searched for clinical trials using smart sensors in prenatal care published in English or German language from 1/2016 to 12/2020. We included studies which addressed the benefits, costs and resource consumption of this innovative technology.

RESULTS

We identified 13 projects using smart sensors in the fields of basic prenatal care, prenatal care for patients with hypertensive disease in pregnancy and prenatal care for women with gestational diabetes. The projects detected positive effects of smart sensors on health care costs and resource consumption and at least equal benefits for the pregnant women.

DISCUSSION AND CONCLUSIONS

The current COVID-19 pandemic underlines the need for the introduction of smart sensor technology into German prenatal care routine. Remote monitoring could easily reduce the frequency of in-person visits by half. Smart sensor concepts could be approved as digital health applications in Germany. In order to increase user acceptance, there should not be any additional costs for pregnant women and health care professionals using modern health care apps. However, health insurance providers need to invest in smart sensor technology in order to eventually benefit from it.

Quality of life in the urban environment and primary health services for the elderly during the Covid-19 pandemic: An application to the city of Milan (Italy)

The outbreak of the Coronavirus during the first months of 2020 completely reshaped urban lives because of the need to limit the spread of the disease and ensure essential services to the most vulnerable city users, such as elderly people. The urban population in European is ageing at unprecedented rate; at the same time, ageing is associated with increased vulnerability and dependence on medical care services. Age-friendly approaches are consequently necessary in urban planning strategies to ensure equal accessibility to essential services, not least in view of coronavirus pandemic. This article aims at defining a methodology for measuring urban accessibility to healthcare services as indicative of quality of life for the elderly within the city of Milan - affected by Covid - both in ordinary working scenarios and during the pandemic. The outputs show that entire neighbourhoods' elderly populations suffer from very poor accessibility to primary health services, especially in the city suburbs, and their condition deteriorates even more because of limited services and activities. The methodology would be effective to suggest policy recommendations to distribution of public services in urban areas and to reduce the potential effects of the Covid-19 pandemic on old people's health and quality of life.

Spatial access to health care: a case study on community health centers in Asmat District, Papua, Indonesia

In recent decades, access to primary health care has become a crucial issue for health policy planners and researchers. One of the fundamental problems is inequitable access to health care due to imbalanced resource distributions between health care providers and population location. Accordingly, this study aims to examine the spatial access to Community Health Centers (CHC) in the Asmat district, one of the most isolated regions in Papua, Indonesia. We conducted the study using a two-step floating catchment area (2SFCA) method to quantify accessibility value to primary health care of each village in the district of Asmat. By taking five distance thresholds ranging from 5 to 25 km with an increment of 5 km, the results indicate that distance has a varying impact on each village. For example, within a 5-km distance threshold, 74% of villages have a zero score or have no access to CHCs, 22% have a score < 100, while only 4% of villages have a score > 100 or meet the minimum score recommended by World Health Organization (WHO). Two major related factors of these geographic disparities are the unequal distribution of CHCs and the high population dispersion. As an attempt to provide equal access to health care services, these results suggest that spatial access should be conscientiously considered by health planners and policy makers.

Quantifying spatial accessibility of general practitioners by applying a modified huff three-step floating catchment area (MH3SFCA) method

BACKGROUND

It is necessary to ensure sufficient healthcare. The use of current, precise and realistic methods to model spatial accessibility to healthcare and thus improved decision-making is helping this process. Generally, these methods-which include the family of floating catchment area (FCA) methods-incorporate a number of criteria that address topics like access, efficiency, budget, equity and the overall system utilization. How can we measure spatial accessibility? This paper investigates a sophisticated approach for quantifying the spatial accessibility of general practitioners. (GPs). Our objective is the investigation and application of a spatial accessibility index by an improved Huff three-step floating catchment area (MH3SFCA) method.

METHODS

We modify and implement the huff model three-step floating catchment area (MH3SFCA) method and exemplary calculation of the spatial accessibility indices for the test study area. The method is extended to incorporate a more realistic way to model the distance decay effect. To that end, instead of a binary approach, a continuous approach is employed. Therefore, each distance between a healthcare site and the population is incorporated individually. The study area includes Swabia and the city of Augsburg, Germany. The data for analysis is obtained from following data sources: (1) Acxiom Deutschland GmbH (2020) provided a test dataset for the locations of general practitioners (GPs); (2) OpenStreetMap (OSM) data is utilized for road networks; and (3) the Statistische Ämter des Bundes und der Länder (German official census 2011) provided a population distribution dataset stemming from the 2011 Census.

RESULTS

The spatial accessibility indices are distributed in an inhomogeneous as well as polycentric pattern for the general practitioners (GPs). Differences in spatial accessibility are found mainly between urban and rural areas. The transitions from lower to higher values of accessibility or vice versa in general are smooth rather than abrupt. The results indicate that the MH3SFCA method is suited for comparing the spatial accessibility of GPs in different regions. The results of the MH3SFCA method can be used to indicate over- and undersupplied areas. However, the absolute values of the indices do not inherently define accessibility to be too low or too high. Instead, the indices compare the spatial relationships between each supply and demand location. As a result, the higher the value of the accessibility indices, the higher the opportunities for the respective population locations. The result for the study area are exemplary as the test input data has a high uncertainty. Depending on the objective, it might be necessary to further analyze the results of the method.

CONCLUSIONS

The application of the MH3SFCA method on small-scale data can provide an overview of accessibility for the whole study area. As many factors have to be taken into account, the outcomes are too complex for a direct and clear interpretation of why indices are low or high. The MH3SFCA method can be used to detect differences in accessibility on a small scale. In order to effectively detect over- or undersupply, further analysis must be conducted and/or different (legal) constraints must be applied. The methodology requires input data of high quality.

Geographic access to COVID-19 healthcare in Brazil using a balanced float catchment area approach

The rapid spread of COVID-19 across the world has raised concerns about the responsiveness of cities and healthcare systems during pandemics. Recent studies try to model how the number of COVID-19 infections will likely grow and impact the demand for hospitalization services at national and regional levels. However, less attention has been paid to the geographic access to COVID-19 healthcare services and to hospitals' response capacity at the local level, particularly in urban areas in the Global South. This paper shows how transport accessibility analysis can provide actionable information to help improve healthcare coverage and responsiveness. It analyzes accessibility to COVID-19 healthcare at high spatial resolution in the 20 largest cities of Brazil. Using network-distance metrics, we estimate the vulnerable population living in areas with poor access to healthcare facilities that could either screen or hospitalize COVID-19 patients. We then use a new balanced floating catchment area (BFCA) indicator to estimate spatial, income, and racial inequalities in access to hospitals with intensive care unit (ICU) beds and mechanical ventilators while taking into account congestion effects. Based on this analysis, we identify substantial social and spatial inequalities in access to health services during the pandemic. The availability of ICU equipment varies considerably between cities, and it is substantially lower among black and poor communities. The study maps territorial inequalities in healthcare access and reflects on different policy lessons that can be learned for other countries based on the Brazilian case.

Spatial accessibility of general inpatient care in Germany: an analysis of surgery, internal medicine and neurology

Improving spatial accessibility to hospitals is a major task for health care systems which can be facilitated using recent methodological improvements of spatial accessibility measures. We used the integrated floating catchment area (iFCA) method to analyze spatial accessibility of general inpatient care (internal medicine, surgery and neurology) on national level in Germany determining an accessibility index (AI) by integrating distances, hospital beds and morbidity data. The analysis of 358 million distances between hospitals and population locations revealed clusters of lower accessibility indices in areas in north east Germany. There was a correlation of urbanity and accessibility up to r = 0.31 (p < 0.001). Furthermore, 10% of the population lived in areas with significant clusters of low spatial accessibility for internal medicine and surgery (neurology: 20%). The analysis revealed the highest accessibility for heart failure (AI = 7.33) and the lowest accessibility for stroke (AI = 0.69). The method applied proofed to reveal important aspects of spatial accessibility i.e. geographic variations that need to be addressed. However, for the majority of the German population, accessibility of general inpatient care was either high or at least not significantly low, which suggests rather adequate allocation of hospital resources for most parts of Germany.

Access to intensive care in 14 European countries: a spatial analysis of intensive care need and capacity in the light of COVID-19

Purpose

The coronavirus disease 2019 (COVID-19) poses major challenges to health-care systems worldwide. This pandemic demonstrates the importance of timely access to intensive care and, therefore, this study aims to explore the accessibility of intensive care beds in 14 European countries and its impact on the COVID-19 case fatality ratio (CFR).

Methods

We examined access to intensive care beds by deriving (1) a regional ratio of intensive care beds to 100,000 population capita (accessibility index, AI) and (2) the distance to the closest intensive care unit. The cross-sectional analysis was performed at a 5-by-5 km spatial resolution and results were summarized nationally for 14 European countries. The relationship between AI and CFR was analyzed at the regional level.

Results

We found national-level differences in the levels of access to intensive care beds. The AI was highest in Germany (AI = 35.3), followed by Estonia (AI = 33.5) and Austria (AI = 26.4), and lowest in Sweden (AI = 5) and Denmark (AI = 6.4). The average travel distance to the closest hospital was highest in Croatia (25.3 min by car) and lowest in Luxembourg (9.1 min). Subnational results illustrate that capacity was associated with population density and national-level inventories. The correlation analysis revealed a negative correlation of ICU accessibility and COVID-19 CFR (r = − 0.57; p < 0.001).

Conclusion

Geographical access to intensive care beds varies significantly across European countries and low ICU accessibility was associated with a higher proportion of COVID-19 deaths to cases (CFR). Important differences in access are due to the sizes of national resource inventories and the distribution of health-care facilities relative to the human population. Our findings provide a resource for officials planning public health responses beyond the current COVID-19 pandemic, such as identifying potential locations suitable for temporary facilities or establishing logistical plans for moving severely ill patients to facilities with available beds.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06229-6) contains supplementary material, which is available to authorized users.

Prediction of hospital visits for the general inpatient care using floating catchment area methods: a reconceptualization of spatial accessibility

Background

The adequate allocation of inpatient care resources requires assumptions about the need for health care and how this need will be met. However, in current practice, these assumptions are often based on outdated methods (e.g. Hill-Burton Formula). This study evaluated floating catchment area (FCA) methods, which have been applied as measures of spatial accessibility, focusing on their ability to predict the need for health care in the inpatient sector in Germany.

Methods

We tested three FCA methods (enhanced (E2SFCA), modified (M2SFCA) and integrated (iFCA)) for their accuracy in predicting hospital visits regarding six medical diagnoses (atrial flutter/fibrillation, heart failure, femoral fracture, gonarthrosis, stroke, and epilepsy) on national level in Germany. We further used the closest provider approach for benchmark purposes. The predicted visits were compared with the actual visits for all six diagnoses using a correlation analysis and a maximum error from the actual visits of ± 5%, ± 10% and ± 15%.

Results

The analysis of 229 million distances between hospitals and population locations revealed a high and significant correlation of predicted with actual visits for all three FCA methods across all six diagnoses up to ρ = 0.79 (p < 0.001). Overall, all FCA methods showed a substantially higher correlation with actual hospital visits compared to the closest provider approach (up to ρ = 0.51; p < 0.001). Allowing a 5% error of the absolute values, the analysis revealed up to 13.4% correctly predicted hospital visits using the FCA methods (15% error: up to 32.5% correctly predicted hospital). Finally, the potential of the FCA methods could be revealed by using the actual hospital visits as the measure of hospital attractiveness, which returned very strong correlations with the actual hospital visits up to ρ = 0.99 (p < 0.001).

Conclusion

We were able to demonstrate the impact of FCA measures regarding the prediction of hospital visits in non-emergency settings, and their superiority over commonly used methods (i.e. closest provider). However, hospital beds were inadequate as the measure of hospital attractiveness resulting in low accuracy of predicted hospital visits. More reliable measures must be integrated within the proposed methods. Still, this study strengthens the possibilities of FCA methods in health care planning beyond their original application in measuring spatial accessibility.

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.

Geosocial Factors Associated With Adherence to Statin Medications

Background:

Individual patient characteristics, social determinants, and geographic access may be associated with patients engaging in appropriate health behaviors.

Objective:

To assess the relationship between statin adherence, geographic accessibility to pharmacies, and neighborhood sociodemographic characteristics in Michigan.

Methods:

The proportion of days covered (PDC) was calculated from pharmacy claims of a large insurer of adults who had prescriptions for statins between July 2009 and June 2010. A PDC ≥0.80 was defined as adherent. The predictor of interest was a ZIP code tabulation area (ZCTA)-level measure of geographic accessibility to pharmacies, measured using a method that integrates availability and access into a single index. We fit unadjusted models as well as adjusted models controlling for age, sex, and ZCTA-level measures of socioeconomic status (SES), racial isolation (RI) of non-Hispanic blacks, and urbanicity.

Results:

More than 174 000 patients’ claims data were analyzed. In adjusted models, pharmacy access was not associated with adherence (0.99; 95% CI: 0.96, 1.03). Greater RI (0.87; 95% CI: 0.85, 0.88) and urban status (0.93; 95% CI: 0.89, 0.96) were associated with lower odds of adherence. Individuals in ZCTAs with higher SES had higher odds of adherence, as were men and older age groups.

Conclusion and Relevance:

Adherence to statin prescriptions was lower for patients living in areas characterized as being racially segregated or lower income. Initiating interventions to enhance adherence, informed by understanding the social and systematic barriers patients face when refilling medication, is an important public health initiative that pharmacists practicing in these areas may undertake.

Multimodal Accessibility to Primary Health Services for the Elderly: A Case Study of Naples, Italy

In Europe, the share of people aged 65 years and above is expected to increase exponentially, and in 2050, for the first time in human history, the number of older people will be larger than the number of children under the age of 15. Aging is associated with increased vulnerability and dependence on medical care services. For these reasons, providing access to health services to people aged 65 years and over is crucial. From the perspective of social equity, everyone should have the opportunity to access healthcare services equally, but due to economic and geographical issues, achieving this level of equity is challenging. The aim of this study was to fill the gap between scientific and actual practices using an accessibility measure to evaluate urban accessibility to primary healthcare services and to support decision-makers to better allocate resources in local restructuring of welfare policies. The accessibility measure was designed considering both the land use and the transportation components, the local healthcare supply system, and a multimodal transportation network. The methodology was applied to the city of Naples considering Local Health Agency (ASL) healthcare services to the elderly. The ASL is the largest health agency in Europe, consisting of 17 buildings serving nearly 200,000 elderly. The results show that the entire elderly neighborhood population suffers from poor accessibility to primary health services, especially in the city suburbs, and that the methodology could be effectively applied to urban planning strategies to achieve a high quality of life for elderly people. Due to poor dialogue between the authorities, this could help to improve the decision-making process through the lens of social equity.

Demand and level of service inflation in Floating Catchment Area (FCA) methods

Floating Catchment Area (FCA) methods are a popular tool to investigate accessibility to public facilities, in particular health care services. FCA approaches are attractive because, unlike other accessibility measures, they take into account the potential for congestion of facilities. This is done by 1) considering the population within the catchment area of a facility to calculate a variable that measures level of service, and then 2) aggregating the level of service by population centers subject to catchment area constraints. In this paper we discuss an effect of FCA approaches, an artifact that we term demand and level of service inflation. These artifacts are present in previous implementations of FCA methods. We argue that inflation makes interpretation of estimates of accessibility difficult, which has possible deleterious consequences for decision making. Next, we propose a simple and intuitive approach to proportionally allocate demandand and level of service in FCA calculations. The approach is based on a standardization of the impedance matrix, similar to approaches popular in the spatial statistics and econometrics literature. The result is a more intiuitive measure of accessibility that 1) provides a local version of the provider-to-population ratio; and 2) preserves the level of demand and the level of supply in a system. We illustrate the relevant issues with some examples, and then empirically by means of a case study of accessibility to family physicians in the Hamilton Census Metropolitan Area (CMA), in Ontario, Canada. Results indicate that demand and supply inflation/deflation affect the interpretation of accessibility analysis using existing FCA methods, and that the proposed adjustment can lead to more intuitive results.

Association between spatial accessibility to fire protection services and unintentional residential fire injuries or deaths: a cross-sectional study in Dallas, Texas

OBJECTIVES

In addition to neighbourhood characteristics encompassing racial composition, socioeconomic status and housing environments, it was unclear if location characteristics relating to the accessibility of fire protection services were risk factors for unintentional residential fire-related injuries in urban areas. This study was aimed to measure spatial accessibility to fire protection services at the census block group level, and examine whether it is associated with unintentional residential fire-related injuries.

DESIGN

A cross-sectional study.

SETTING

Unintentional residential fire incidents between 2012 and 2015 in Dallas City, Texas, USA.

MAIN OUTCOME MEASURES

Using multiple logistic regression, the study analysed association between unintentional residential fire incidents in the city and risk factors, including spatial accessibility to fire protection services, measured by the two-step floating catchment area method.

RESULTS

Compared with incidents without any injuries, fire incidents involving injuries were significantly more likely to include unconfined fire, fire originating in a cooking area, a bedroom for less than five people or a common family area, census block groups with >75% African American residents, >25% elderly single-person households and positive population growth rates <25% or >25%. Incidents involving injuries were significantly less likely to occur in areas with high spatial accessibility, as measured by spatial accessibility score.

CONCLUSIONS

In addition to fire characteristics and neighbourhood demographics, spatial accessibility to fire protection services was significantly associated with unintentional residential fire-related injuries. The findings can be used to help select locations of additional fire stations.

Assessing Spatial Accessibility to Hierarchical Urban Parks by Multi-Types of Travel Distance in Shenzhen, China

Urban green spaces play a critical role in public health and human wellbeing for urban residents. Due to the uneven spatial distribution of urban green spaces in most of cities, the issue of the disparity between supply and demand has aroused public concern. In a case of Shenzhen, a modified Gaussian-based two-step floating catchment area (2SFCA) method is adopted to evaluate the disparity between park provision and the demanders in terms of accessibility at hierarchical levels under four types of distance (e.g., Euclidean distance, walking distance, bicycling distance, and driving distance), which is well aligned with hierarchical systems in urban green spaces in urban planning practice. By contrast and correlation analysis, among the four types of distance, the statistical correlations are relatively high between Euclidean distance and the other three. Nonetheless, the pattern of spatial accessibility under different type of travel distance is apparently variant. Accessibility calculated by Euclidean distance is overestimated relative to that of the other three, while the pattern of walking distance and bicycling distance is similar to each other. The choice of type of distance is worthy of caution when evaluating spatial accessibility by 2SFCA method. Results show that the accessibility to parks at all hierarchical levels is high particularly, particularly at the natural level. However, the disparity between the supply and demand is significant. The percentage of communities that have high population density but low park accessibility is over 40% (equivalent to approximately 55% of the population). The finding may provide implications on access to urban greens paces for urban planners and authorities to develop effective planning strategies.

Using floating catchment area (FCA) metrics to predict health care utilization patterns

BACKGROUND

Floating Catchment Area (FCA) metrics provide a comprehensive measure of potential spatial accessibility to health care services and are often used to identify geographic disparities in health care access. An unexplored aspect of FCA metrics is whether they can be useful in predicting where people actually seek care. This research addresses this question by examining the utility of FCA metrics for predicting patient utilization patterns, the flows of patients from their residences to facilities.

METHODS

Using more than one million inpatient hospital visits in Michigan, we calculated expected utilization patterns from Zip Codes to hospitals using four FCA metrics and two traditional metrics (simple distance and a Huff model) and compared them to observed utilization patterns. Because all of the accessibility metrics rely on the specification of a distance decay function and its associated parameters, we conducted a sensitivity analysis to evaluate their effects on prediction accuracy.

RESULTS

We found that the Three Step FCA (3SFCA) and Modified Two Step FCA (M2SFCA) were the most effective metrics for predicting utilization patterns, correctly predicting the destination hospital for nearly 74% of hospital visits in Michigan. These two metrics were also the least sensitive to changes to the distance decay functions and parameter settings.

CONCLUSIONS

Overall, this research demonstrates that FCA metrics can provide reasonable predictions of patient utilization patterns and FCA utilization models could be considered as a substitute when utilization pattern data are unavailable.

Temporal availability of public health care in developing countries of the Caribbean: An improved two-step floating catchment area method for estimating spatial accessibility to health care

Due to restrictions on personnel availability, the service capacity at a health facility may vary day to day based on an established schedule. This temporal variability influences a user's choice set, modifying their possible choices. As a result, the spatial accessibility of public health care may be constantly reshaped rather than being a relatively static experience as commonly represented in place-based spatial accessibility literature. Building on the latest advances in the two-step floating catchment method, this study presents further advancements through the inclusion of health facility schedules to better represent health care availability in the assessment of accessibility. The results show that the proposed method reveals communities with relatively poor accessibility that are hidden with many existing methods. By exposing the available care within time windows, a more accurate picture of the services available to be accessed is revealed. The findings suggest that improvement in the number of doctor hours at health facilities may reduce the disparities found in accessibility scores for communities. Further, in public health care systems similarly structured, the spatial configuration of facilities with doctors can be considered at the administrative level to ensure adequate levels of access across the jurisdiction.

Use of an E2SFCA Method to Measure and Analyse Spatial Accessibility to Medical Services for Elderly People in Wuhan, China

Current studies on measuring the accessibility of medical services for the elderly (AMSE) have ignored the potential competition among supply and demand and the distance decay laws. Hence, an enhanced two-step floating catchment area (E2SFCA) method (i.e., the road network-based Gaussian 2SFCA method) is proposed to calculate AMSE scores after considering different types of roads, including urban rail transit, freeways, major roads, minor roads and rural roads. Based on the first National Geographic Conditions Monitoring (NGCM) data, this study took Wuhan, China, as a case study and assessed the variation of AMSE using two different threshold times (i.e., Platinum Ten and Golden Hour). Next, global (i.e., sensitivity and hot spot analysis) and local analyses (i.e., three regional area internal comparisons) of AMSE scores were conducted to accurately identify details in the variation of spatial accessibility. It was observed that the E2SFCA method could be easily applied to measure AMSE. The results showed that 48.63% of the elderly population in Wuhan had a higher or the highest level of medical accessibility in "Platinum Ten", while 72.97% had a higher or the highest level in the "Golden Hour", and hot spots of AMSE scores were located in central urban areas and presented an enclosure structure using both threshold travel times, which could provide guidance to governments or planners on issues of spatial planning and identifying elderly medical services shortage areas.

Spatial Accessibility of Primary Care in England: A Cross-Sectional Study Using a Floating Catchment Area Method

OBJECTIVE

To analyze the general practitioners (GPs) with regard to the degree of urbanization, social deprivation, general health, and disability.

DATA SOURCES

Small area population data and GP practice data in England.

STUDY DESIGN

We used a floating catchment area method to measure spatial GP accessibility with regard to the degree of urbanization, social deprivation, general health, and disability.

DATA COLLECTION

Data were collected from the Office for National Statistics and the general practice census and analyzed using a geographic information system.

PRINCIPAL FINDINGS

In all, 25.8 percent of the population in England lived in areas with a significant low GP accessibility (mean z-score: -4.2); 27.6 percent lived in areas with a significant high GP accessibility (mean z-score: 7.7); 97.8 percent of high GP accessibility areas represented urban areas, and 31.1 percent of low GP accessibility areas represented rural areas (correlation of accessibility and urbanity: r = 0.59; p<.001). Furthermore, a minor negative correlation with social deprivation was present (r = -0.19; p<.001). Results were confirmed by a multivariate analysis.

CONCLUSION

This study showed substantially differing GP accessibility throughout England. However, socially deprived areas did not have poorer spatial access to GPs.

Enhancing healthcare accessibility measurements using GIS: A case study in Seoul, Korea

With recent aging demographic trends, the needs for enhancing geo-spatial analysis capabilities and monitoring the status of accessibilities of its citizens with healthcare services have increased. The accessibility to healthcare is determined not only by geographic distances to service locations, but also includes travel time, available modes of transportation, and departure time. Having access to the latest and accurate information regarding the healthcare accessibility allows the municipal government to plan for improvements, including expansion of healthcare infrastructure, effective labor distribution, alternative healthcare options for the regions with low accessibilities, and redesigning the public transportation routes and schedules. This paper proposes a new method named, Seoul Enhanced 2-Step Floating Catchment Area (SE2SFCA), which is customized for the city of Seoul, where population density is higher and the average distance between healthcare-service locations tends to be shorter than the typical North American or European cities. The proposed method of SE2SFCA is found to be realistic and effective in determining the weak accessibility regions. It resolves the over-estimation issues of the past, arising from the assignment of high healthcare accessibility for the regions with large hospitals and high density of population and hospitals.

Accessibility of general and specialized obstetric care providers in Germany and England: an analysis of location and neonatal outcome

BACKGROUND

Health care accessibility is known to differ geographically. With this study we focused on analysing accessibility of general and specialized obstetric units in England and Germany with regard to urbanity, area deprivation and neonatal outcome using routine data.

METHODS

We used a floating catchment area method to measure obstetric care accessibility, the degree of urbanization (DEGURBA) to measure urbanity and the index of multiple deprivation to measure area deprivation.

RESULTS

Accessibility of general obstetric units was significantly higher in Germany compared to England (accessibility index of 16.2 vs. 11.6; p < 0.001), whereas accessibility of specialized obstetric units was higher in England (accessibility index for highest level of care of 0.235 vs. 0.002; p < 0.001). We further demonstrated higher obstetric accessibility for people living in less deprived areas in Germany (r = - 0.31; p < 0.001) whereas no correlation was present in England. There were also urban-rural disparities present, with higher accessibility in urban areas in both countries (r = 0.37-0.39; p < 0.001). The analysis did not show that accessibility affected neonatal outcomes. Finally, our computer generated model for obstetric care provider demand in terms of birth counts showed a very strong correlation with actual birth counts at obstetric units (r = 0.91-0.95; p < 0.001).

CONCLUSION

In Germany the focus of obstetric care seemed to be put on general obstetric units leading to higher accessibility compared to England. Regarding specialized obstetric care the focus in Germany was put on high level units whereas in England obstetric care seems to be more balanced between the different levels of care with larger units on average leading to higher accessibility.

[What potential do geographic information systems have for population-wide health monitoring in Germany? : Perspectives and challenges for the health monitoring of the Robert Koch Institute]

Geographic information systems (GISs) are computer-based systems with which geographical data can be recorded, stored, managed, analyzed, visualized and provided. In recent years, they have become an integral part of public health research. They offer a broad range of analysis tools, which enable innovative solutions for health-related research questions. An analysis of nationwide studies that applied geographic information systems underlines the potential this instrument bears for health monitoring in Germany. Geographic information systems provide up-to-date mapping and visualization options to be used for national health monitoring at the Robert Koch Institute (RKI). Furthermore, objective information on the residential environment as an influencing factor on population health and on health behavior can be gathered and linked to RKI survey data at different geographic scales. Besides using physical information, such as climate, vegetation or land use, as well as information on the built environment, the instrument can link socioeconomic and sociodemographic data as well as information on health care and environmental stress to the survey data and integrate them into concepts for analyses. Therefore, geographic information systems expand the potential of the RKI to present nationwide, representative and meaningful health-monitoring results. In doing so, data protection regulations must always be followed. To conclude, the development of a national spatial data infrastructure and the identification of important data sources can prospectively improve access to high quality data sets that are relevant for the health monitoring.

Orthopedic workforce planning in Germany - an analysis of orthopedic accessibility

In Germany, orthopedic workforce planning relies on population-to-provider-ratios represented by the 'official degree of care provision'. However, with geographic information systems (GIS), more sophisticated measurements are available. By utilizing GIS-based technologies we analyzed the current state of demand and supply of the orthopedic workforce in Germany (orthopedic accessibility) with the integrated Floating Catchment Area method. The analysis of n = 153,352,220 distances revealed significant geographical variations on national scale: 5,617,595 people (6.9% of total population) lived in an area with significant low orthopedic accessibility (average z-score = -4.0), whereas 31,748,161 people (39.0% of total population) lived in an area with significant high orthopedic accessibility (average z-score = 8.0). Accessibility was positively correlated with the degree of urbanization (r = 0.49; p<0.001) and the official degree of care provision (r = 0.33; p<0.001) and negatively correlated with regional social deprivation (r = -0.47; p<0.001). Despite advantages of simpler measures regarding implementation and acceptance in health policy, more sophisticated measures of accessibility have the potential to reduce costs as well as improve health care. With this study, significant geographical variations were revealed that show the need to reduce oversupply in less deprived urban areas in order to enable adequate care in more deprived rural areas.