Geographic variation in spatial accessibility of U.S. healthcare providers

Association Between Neighborhood Deprivation and Number of Ophthalmology Providers

PURPOSE

The Area Deprivation Index (ADI) is a quantitative measurement of neighborhood socioeconomic disadvantage used to identify high-risk communities. The distribution of physicians with respect to ADI can indicate decreased healthcare access in deprived neighborhoods. This study applies ADI to the distribution of ophthalmologists and demonstrates how practice patterns in the national Medicare Part D program may vary with ADI.

METHODS

The Centers for Medicare and Medicaid Services Data "Medicare Part D Prescribers by Provider" data for 2021 was analyzed. Geocodio identified ADIs corresponding to the practice addresses listed in the dataset. The national rank ADIs were compared against the number of ophthalmologists. Spearman's correlation test and one-way ANOVA determined statistically significant differences in Medicare data extracted between quintiles of ADI ranks.

RESULTS

We identified 14,668 ophthalmologists who provided care to Medicare beneficiaries. Each time ADI increased by 10, there was an average 9.4% decrease in ophthalmologists (p < 0.001). The distribution of ophthalmologists practicing throughout the United States by increasing ADI quintile are: 32%, 23%, 19%, 16%, and 9%. Providers practicing in neighborhoods in the first-ADI quintile were more likely to see Medicare beneficiaries compared to providers in the fifth-ADI quintile (p < 0.001).

CONCLUSION

The lack of ophthalmologists in high-ADI areas results in reduced eye care access in deprived neighborhoods. Many factors contribute to these disparities including limited access to metropolitan areas/academic institutions and fewer residency programs. Future programs and policies should focus efforts on creating an even distribution of ophthalmologists across the United States and improving access to eye care.

Barriers to early diagnosis of chronic kidney disease and use of sodium-glucose cotransporter-2 inhibitors for renal protection: A comprehensive review and call to action

Chronic kidney disease (CKD) affects approximately 13% of people globally, including 20%-48% with type 2 diabetes (T2D), resulting in significant morbidity, mortality, and healthcare costs. There is an urgent need to increase early screening and intervention for CKD. We are experts in diabetology and nephrology in Central Europe and Israel. Herein, we review evidence supporting the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors for kidney protection and discuss barriers to early CKD diagnosis and treatment, including in our respective countries. SGLT2 inhibitors exert cardiorenal protective effects, demonstrated in the renal outcomes trials (EMPA-KIDNEY, DAPA-CKD, CREDENCE) of empagliflozin, dapagliflozin, and canagliflozin in patients with CKD. EMPA-KIDNEY demonstrated cardiorenal efficacy across the broadest renal range, regardless of T2D status. Renoprotective evidence also comes from large real-world studies. International guidelines recommend first-line SGLT2 inhibitors for patients with T2D and estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2, and that glucagon-like peptide-1 receptor agonists may also be administered if required for additional glucose control. Although these guidelines recommend at least annual eGFR and urine albumin-to-creatinine ratio screening for patients with T2D, observational studies suggest that only half are screened. Diagnosis is hampered by asymptomatic early CKD and under-recognition among patients with T2D and clinicians, including limited knowledge/use of guidelines and resources. Based on our experience and on the literature, we recommend robust screening programmes, potentially with albuminuria self-testing, and SGLT2 inhibitor reimbursement at general practitioner (GP) and specialist levels. High-tech tools (artificial intelligence, smartphone apps, etc.) are providing exciting opportunities to identify high-risk individuals, self-screen, detect abnormalities in images, and assist with prescribing and treatment adherence. Better education is also needed, alongside provision of concise guidelines, enabling GPs to identify who would benefit from early initiation of renoprotective therapy; although, regardless of current renal function, cardiorenal protection is provided by SGLT2 inhibitor therapy.

Disparities in Spatial Access to Sleep Health Care in the United States: A Population-Based Geospatial Analysis

OBJECTIVES

To examine spatial access to sleep health care in the United States and investigate associations with demographic and socioeconomic characteristics, thereby identifying high-risk communities with limited spatial access to sleep health service.

DESIGN

A cross-sectional population-based geospatial analysis.

SETTINGS AND PARTICIPANTS

Residents in US Census tracts across the 48 contiguous states, Alaska, and Hawaii.

METHODS

The 2020 American Community Survey 5-year estimates, 2010 rural-urban commuting area codes, 2020 Area Deprivation Index, and sleep care provider locations from the National Provider Identifier file were used to assess the spatial access and related demographic/socioeconomic characteristics. Spatial access was measured by spatial access ratio using enhanced 2-step floating catchment area methods. The associations were investigated using logistic regression analysis and multivariate linear regression analysis.

RESULTS

A total of 45.8 million residents experienced low spatial access to sleep health care. Spatial access decreased in rural and high Area Deprivation Index areas, and in areas characterized by higher population with uninsured status, vehicle unavailability, internet unavailability, cognitive difficulties, and hearing difficulties. With a 10% increase in the percentage of the racial minority (non-white) population, metropolitan census tracts experienced an increase in spatial access (3.268%), whereas micropolitan (-1.526%) and rural (-4.493%) areas experienced a decrease in spatial access. Similar findings were observed within the ethnic minority (Hispanic or Latino) population.

CONCLUSIONS AND IMPLICATIONS

Disparities exist in spatial access to sleep health care across the United States, especially for disadvantaged individuals. Racial/ethnic minorities exhibit contrasting spatial access patterns in urban and rural areas, with those in rural areas facing more challenges in spatial access to sleep health care.

Regional Differences in American Indian/Alaska Native Chronic Respiratory Disease Disparity: Evidence from National Survey Results

American Indian/Alaska Native (AI/AN) persons in the US experience a disparity in chronic respiratory diseases compared to white persons. Using Behavioral Risk Factor Surveillance System (BRFSS) data, we previously showed that the AI/AN race/ethnicity variable was not associated with asthma and/or chronic obstructive pulmonary disease (COPD) in a BRFSS-defined subset of 11 states historically recognized as having a relatively high proportion of AI/AN residents. Here, we investigate the contributions of the AI/AN variable and other sociodemographic determinants to disease disparity in the remaining 39 US states and territories. Using BRFSS surveys from 2011 to 2019, we demonstrate that irrespective of race, the yearly adjusted prevalence for asthma and/or COPD was higher in the 39-state region than in the 11-state region. Logistic regression analysis revealed that the AI/AN race/ethnicity variable was positively associated with disease in the 39-state region after adjusting for sociodemographic covariates, unlike in the 11-state region. This shows that the distribution of disease prevalence and disparity for asthma and/or COPD is non-uniform in the US. Although AI/AN populations experience this disease disparity throughout the US, the AI/AN variable was only observed to contribute to this disparity in the 39-state region. It may be important to consider the geographical distribution of respiratory health determinants and factors uniquely impactful for AI/AN disease disparity when formulating disparity elimination policies.

Providing care in underresourced areas: contribution of the physician assistant/associate workforce

BACKGROUND

Prior studies suggest that physician assistants/associates (PAs) are more likely than physicians to work in underresourced areas. However, data characterizing the current PA workforce in health professional shortage areas (HPSAs) and medically underserved areas (MUAs) are lacking.

METHODS

We analyzed the 2022 cross-sectional dataset from a comprehensive national database to examine the demographic and practice characteristics of PAs working in HPSAs/MUAs compared to those in other settings. Analyses included descriptive and bivariate statistics, along with multivariate logistic regression.

RESULTS

Nearly 23% of PAs reported practicing in HPSAs/MUAs. Among PAs in HPSAs/MUAs, over a third (34.6%) work in primary care settings, 33.3% identify as men, 15.6% reside in rural/isolated areas, and 14.0% are from an underrepresented in medicine (URiM) background. Factors associated with higher odds of practicing in a HPSA/MUA included residing in rural/isolated settings, URiM background, and speaking a language other than English with patients.

CONCLUSIONS

As the PA profession grows, knowledge of these attributes may help inform efforts to expand PA workforce contributions to address provider shortages.

Behavioral Health Workforce Distribution in Socially Disadvantaged Communities

This study sought to understand the geographic distribution of three behavioral health clinician (BHC) types in disadvantaged communities in the U.S. across a standardized index of area disadvantage. CMS National Plan and Provider Enumeration System's data were used to identify BHC practice addresses. Addresses were geocoded and mapped to census block groups across Area Disadvantage Index (ADI) scores. Differences in the proportion of BHCs per 100k people in a block group by ADI, clinician type, and rurality were compared. Zero-inflated negative binomial models assessed associations between ADI score with any amount, and expected count, of BHC type in a block group. The sample included 836,780 BHCs (51.5% counselors, 34.5% social workers, 14.0% psychologists). Results indicated there were fewer BHCs in areas of high disadvantage with 351 BHCs in the lowest need versus 267 BHCs in highest need areas, per 100k people. BHC type was differently associated with the rate of clinicians per 100k by ADI and block groups that were both rural and high ADI had the least BHCs located. Findings suggest the maldistribution of BHCs by ADI underscores how some BHCs may be better positioned to meet the needs of vulnerable communities. Increasing access to behavioral health care requires a workforce equitably positioned in high-need areas. Reforms to payment and practice regulations may support BHCs to deliver services in socially disadvantaged neighborhoods.

Trends in the geographic inequality of advanced practice nursing workforce in cancer care in Japan from 1996 to 2022: a panel data analysis

BACKGROUND

Cancer was ranked as the second leading cause of global mortality in 2019, with an increasing incidence. An adequate workforce of healthcare professionals with special skills and knowledge in cancer care is vital for addressing the disparities in cancer prognosis. This study aimed to elucidate the trends in the advanced practice nursing workforce (APNW) in cancer care, which included certified nurse specialists (CNSs) and certified nurses (CNs) in each prefecture of Japan from the system's inception to the present. Further, it sought to analyze the regional disparities and compare these trends with other healthcare resources to identify contributing factors associated with the APNW in cancer care in each prefecture.

METHODS

We performed a panel data analysis using publicly available data on the APNW in cancer care in each prefecture of Japan from 1996 to 2022. Gini coefficients were calculated to examine the trends in geographic equality. Univariate and multivariable fixed effect panel data regression models were used to examine regional factors associated with an APNW in cancer care.

RESULTS

From 1996 to 2012, the APNW in cancer care increased from four to 6982 staff, while their Gini coefficients decreased from 0.79 to 0.43. However, from 2012 to 2022, the Gini coefficients decreased slightly from 0.43 to 0.41. The coefficient value was comparable to that for the disparity between hospital doctors (0.43) but more pronounced compared to those for other medical resources, such as hospitals (0.34), hospital nurses (0.37), and designated cancer care hospitals (0.29). The APNW in cancer care in each prefecture was significantly associated with a higher number of designed cancer care hospitals in the previous year (see first quartile, the coefficient for second quartile: 0.31, 95% confidence interval (CI) 0.21-0.40), and a fewer number of hospital doctors (- 1.89, 95%CI - 2.70 to - 1.09).

CONCLUSIONS

The size of the APNW in cancer care has increased since the system was established in 1996 up till 2022. With the increase in numbers, geographic inequality narrowed until 2012 and has since then remained stagnant.

Deprescribing medications among patients with multiple prescribers: A socioecological model

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

Access to community pharmacies based on drive time and by rurality across the contiguous United States

BACKGROUND

Considering that mail-order pharmacy use remains low in the United States, geographic accessibility of community pharmacies (pharmacy access) can have an outsized impact on a community's access to services and care, especially among rural residents. However, previous measurements of pharmacy access rely on methods that do not capture all aspects of geographic access.

OBJECTIVES

This study aimed to measure pharmacy access across the contiguous United States and by rural, suburban, and urban areas using drive-time analysis and an improved methodological approach.

METHODS

The 2-step floating catchment area method was used to measure pharmacy access by considering the supply capacity of pharmacies, population demand for pharmacies, and the interaction between them within a reasonable travel time range. This method is a methodologically improved approach compared with previous methods for measuring geographic access. Network analysis was used to measure drive time from the population-weighted centroids of census tracts to the geocoded location of community pharmacies. Census tract-level pharmacy access was measured using a 10- and 20-minute drive time. Census tracts were also categorized based on population per square mile as rural (< 1000), suburban (1000-3000), and urban (> 3000).

RESULTS

Across the contiguous United States, 79.9% and 91.1% of census tracts had access to at least 1 pharmacy per 10,000 people within a 10- and 20-minute drive time, respectively. Rural census tracts had the lowest share of access to at least 1 pharmacy per 10,000 people compared with suburban and urban tracts and for both drive times.

CONCLUSION

Community pharmacies are highly accessible health care access points, specifically in urban and suburban areas. Pharmacies should be considered to expand access to services with limited geographic accessibility such as treatment programs for opioid use disorders, primary care, and healthy foods.

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

PURPOSE

Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion.

METHODS

We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes.

FINDINGS

We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift.

CONCLUSIONS

These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

Geographic Distribution of Facial Plastic and Reconstructive Surgeons

Background: Distribution of the general otolaryngology workforce has been described, but not specifically for the facial plastic and reconstructive surgeon (FPRS) workforce. Objective: To describe the distribution of FPRS within the United States. Methods: The 2022 American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) registry was used to identify active FPRSs. Member addresses were converted into coordinates and overlayed onto a geographic representation of 2020 census data within ArcGIS software. A centroid model of U.S. counties was constructed to determine the average distances residents were from the nearest FPRS. Results: In total, 1312 AAFPRS active members practiced in 373 counties. Thirty-three percent of all residents (115 million) resided in counties without an FPRS and 15.3% of FPRSs practiced in New York City or the Greater Los Angeles Area, which accounted for 8% of the total U.S. population. The mean and median distances a resident in a county without an FPRS was from the nearest FPRS are 63 and 49 miles (101 and 79 kilometers), respectively. Conclusions: Metropolitan areas have greater concentrations of FPRSs than the national average and the distances U.S. residents are from FPRS services are quantifiable.

Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data

Introduction

In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75.

Methods

Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals.

Results

We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75.

Conclusion

To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.

Identification and analysis of spatial access disparities related to primary healthcare in Batna City, Algeria

The issue of reducing spatial disparities is one of the most pressing concerns for policymakers and planners, which consider a crucial focus in planning and public service, especially accessibility to healthcare. Accessibility and proximity are the principal keys to providing good public service. Therefore, a healthcare system that meets the requirements of availability and affordability will be useless if spatial accessibility is not provided equally to all demands (population). Many technics and methods exist to quantify accessibility, including the two-step floating catchment area (2SFCA) method, its widely used to measure healthcare accessibility based on the travel distance threshold. This research paper aims to use the 2SFCA method to measure the spatial healthcare accessibility in Batna City because the 2SFCA method offers to measure accessibility on both spatial and functional levels. The spatial level will consider the threshold distances between the health demand (population) and the health provider location (healthcare facilities); moreover, functional accessibility is measured based on facility to population ratio that will give a better overview of Batna's healthcare provider. As a result, the optimal threshold distance that offers balanced results between the spatial accessibility score and other WHO ratios will be a distance between 1000- and 1500-meters travel distance. In addition, the central census districts have a higher access score than the rest of the city's districts; most census districts that do not have accessibility (12% of the population) to healthcare facilities are concentrated in the southwest of Batna city.

Spatial methods for measuring access to health care

Access to health care is a universal human right and key indicator of health system performance. Spatial access encompasses geographic factors mediating with the accessibility and availability of health services. Equity of health service access is a global issue, which includes access to the specialized nursing workforce. Nursing research applying spatial methods is in its infancy. Given the use of spatial methods in health research is a rapidly developing field, it is timely to provide guidance to inspire greater application in cardiovascular research. Therefore, the objective of this methods paper is to provide an overview of spatial analysis methods to measure the accessibility and availability of health services, when to consider applying spatial methods, and steps to consider for application in cardiovascular nursing research.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States

INTRODUCTION

Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population.

METHODS

U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders.

RESULTS

Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29).

CONCLUSIONS

Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

After 50 Years, Health Professional Shortage Areas Had No Significant Impact On Mortality Or Physician Density

Since 1965, the US federal government has incentivized physicians to practice in high-need areas of the country through the designation of Health Professional Shortage Areas (HPSAs). Despite its being in place for more than half a century and directing more than a billion dollars annually, there is limited evidence of the HPSA program's effectiveness at reducing geographic disparities in access to care and health outcomes. Using a generalized difference-in-differences design with matching, we found no statistically significant changes in mortality or physician density from 1970 to 2018 after a county-level HPSA designation. As a result, we found that 73 percent of counties designated as HPSAs remained physician shortage areas for at least ten years after their inclusion in the program. Fundamental improvements to the program's design and incentive structure may be necessary for it to achieve its intended results.

Provision of evaluation and management visits by nurse practitioners and physician assistants in the USA from 2013 to 2019: cross-sectional time series study

OBJECTIVE

To examine the proportion of healthcare visits are delivered by nurse practitioners and physician assistants versus physicians and how this has changed over time and by clinical setting, diagnosis, and patient demographics.

DESIGN

Cross-sectional time series study.

SETTING

National data from the traditional Medicare insurance program in the USA.

PARTICIPANTS

Of people using Medicare (ie, those older than 65 years, permanently disabled, and people with end stage renal disease), a 20% random sample was taken.

MAIN OUTCOME MEASURES

The proportion of physician, nurse practitioner, and physician assistant visits in the outpatient and skilled nursing facility settings delivered by physicians, nurse practitioners, and physician assistants, and how this proportion varies by type of visit and diagnosis.

RESULTS

From 1 January 2013 to 31 December 2019, 276 million visits were included in the sample. The proportion of all visits delivered by nurse practitioners and physician assistants in a year increased from 14.0% (95% confidence interval 14.0% to 14.0%) to 25.6% (25.6% to 25.6%). In 2019, the proportion of visits delivered by a nurse practitioner or physician assistant varied across conditions, ranging from 13.2% for eye disorders and 20.4% for hypertension to 36.7% for anxiety disorders and 41.5% for respiratory infections. Among all patients with at least one visit in 2019, 41.9% had one or more nurse practitioner or physician assistant visits. Compared with patients who had no visits from a nurse practitioner or physician assistant, the likelihood of receiving any care was greatest among patients who were lower income (2.9% greater), rural residents (19.7%), and disabled (5.6%).

CONCLUSION

The proportion of visits delivered by nurse practitioners and physician assistants in the USA is increasing rapidly and now accounts for a quarter of all healthcare visits.

Racial and Ethnic Differences in Receipt of Nonpharmacologic Care for Chronic Low Back Pain Among Medicare Beneficiaries With OUD

Importance

Nonpharmacologic treatments are important for managing chronic pain among persons with opioid use disorder (OUD), for whom opioid and other pharmacologic therapies may be particularly harmful. Racial and ethnic minority individuals with chronic pain and OUD are vulnerable to suboptimal pain management due to systemic inequities and structural racism, highlighting the need to understand their receipt of guideline-recommended nonpharmacologic pain therapies, including physical therapy (PT) and chiropractic care.

Objective

To assess differences across racial and ethnic groups in receipt of PT or chiropractic care for chronic low back pain (CLBP) among persons with comorbid OUD.

Design, Setting, and Participants

This retrospective cohort study used a 20% random sample of national Medicare administrative data from January 1, 2016, to December 31, 2018, to identify fee-for-service community-dwelling beneficiaries with a new episode of CLBP and comorbid OUD. Data were analyzed from March 1, 2022, to July 30, 2023.

Exposures

Race and ethnicity as a social construct, categorized as American Indian or Alaska Native, Asian or Pacific Islander, Black or African American, Hispanic, non-Hispanic White, and unknown or other.

Main Outcomes and Measures

The main outcomes were receipt of PT or chiropractic care within 3 months of CLBP diagnosis. The time (in days) to receiving these treatments was also assessed.

Results

Among 69 362 Medicare beneficiaries analyzed, the median age was 60.0 years (IQR, 51.5-68.7 years) and 42 042 (60.6%) were female. A total of 745 beneficiaries (1.1%) were American Indian or Alaska Native; 444 (0.6%), Asian or Pacific Islander; 9822 (14.2%), Black or African American; 4124 (5.9%), Hispanic; 53 377 (77.0%); non-Hispanic White; and 850 (1.2%), other or unknown race. Of all beneficiaries, 7104 (10.2%) received any PT or chiropractic care 3 months after a new CLBP episode. After adjustment, Black or African American (adjusted odds ratio, 0.46; 95% CI, 0.39-0.55) and Hispanic (adjusted odds ratio, 0.54; 95% CI, 0.43-0.67) persons had lower odds of receiving chiropractic care within 3 months of CLBP diagnosis compared with non-Hispanic White persons. Median time to chiropractic care was longest for American Indian or Alaska Native (median, 8.5 days [IQR, 0-44.0 days]) and Black or African American (median, 7.0 days [IQR, 0-42.0 days]) persons and shortest for Asian or Pacific Islander persons (median, 0 days [IQR, 0-6.0 days]). No significant racial and ethnic differences were observed for PT.

Conclusions and Relevance

In this retrospective cohort study of Medicare beneficiaries with comorbid CLBP and OUD, receipt of PT and chiropractic care was low overall and lower across most racial and ethnic minority groups compared with non-Hispanic White persons. The findings underscore the need to address inequities in guideline-concordant pain management, particularly among Black or African American and Hispanic persons with OUD.

Continuity of Care in Adults Aging with Cerebral Palsy and Spina Bifida: The Importance of Community Healthcare and Socioeconomic Context

Continuity of care is considered a key metric of quality healthcare. Yet, continuity of care in adults aging with congenital disability and the factors that contribute to care continuity are largely unknown. Using data from a national private administrative health claims database in the United States (2007-2018). we examined continuity of care in 8596 adults (mean age 48.6 years) with cerebral palsy or spina bifida. Logistic regression models analyzed how proximity to health care facilities, availability of care providers, and community socioeconomic context were associated with more continuous care. We found that adults aging with cerebral palsy or spina bifida saw a variety of different physician specialty types and generally had discontinuous care. Individuals who lived in areas with more hospitals and residential care facilities received more continuous care than those with limited access to these resources. Residence in more affluent areas was associated with receiving more fragmented care. Findings suggest that over and above individual factors, community healthcare resources and socioeconomic context serve as important factors to consider in understanding continuity of care patterns in adults aging with cerebral palsy or spina bifida.

Geographic Density of Gastroenterologists Is Associated With Decreased Mortality From Alcohol-Associated Liver Disease

BACKGROUND & AIMS

Alcohol-associated liver disease (ALD) is the leading cause of liver-related mortality and has been increasing. To inform public health efforts to address the growing incidence of ALD, we assessed the association of geographic density of gastroenterologists with ALD-related mortality.

METHODS

National data were obtained for adults aged ≥25 years with state-level demographics and 2010-2019 mortality estimates by linking federally maintained registries (WONDER, NSSATS, BRFSS, HRSA, US Census Bureau). Multivariable linear regression was used to assess the association of state-level geographic density of gastroenterologists with ALD-related mortality, adjusting for age, sex, race/ethnicity, and other potential confounders.

RESULTS

Among 50 states and the District of Columbia, the national mean geographic density of gastroenterologists was 4.6 per 100,000 population, and annual ALD-related mortality rate was 85.6 per 1,000,000 population. There was greater than 5-fold differences in geographic density of gastroenterologists and ALD-related mortality across states. In multivariable analysis, the geographic density of gastroenterologists was significantly associated with lower ALD-related mortality (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population). The association appeared to peak at a threshold of ≥7.5 gastroenterologists per 100,000 population. We estimated that differences in geographic density of gastroenterologists across states may potentially represent 40% of national ALD-related mortality. Exploratory analyses to assess for confounding by generalized subspecialty care, transplant access, alcohol taxation, and substance use or mental health services, including negative control analyses, did not affect primary results.

CONCLUSIONS

State-level geographic density of gastroenterologists is associated with lower ALD-related mortality. These results may inform medical societies and health policymakers to address anticipated workforce gaps to address the growing epidemic of ALD.

Geographic Variation in Access to Cardiac Rehabilitation

BACKGROUND

There is marked geographic variation in cardiac rehabilitation (CR) initiation, ranging from 10% to 40% of eligible patients at the state level. The potential causes of this variation, such as patient access to CR centers, are not well studied.

OBJECTIVES

The authors sought to determine how access to CR centers affects CR initiation in Medicare beneficiaries.

METHODS

The authors used Medicare files to identify CR-eligible Medicare beneficiaries and calculate CR initiation rates at the hospital referral region (HRR) level. We used linear regression to evaluate the percent variation in CR initiation accounted for by CR access across HRRs. We then employed geospatial hotspot analysis to identify CR deserts, or counties in which patient load per CR center is disproportionately high.

RESULTS

A total of 1,133,657 Medicare beneficiaries were eligible for CR from 2014 to 2017, of whom 263,310 (23%) initiated CR. The West North Central Census Division had the highest adjusted CR initiation rate (35.4%) and the highest density of CR programs (6.58 per 1,000 CR-eligible Medicare beneficiaries). Density of CR programs accounted for 21.2% of geographic variation in CR initiation at the HRR level. A total of 40 largely urban counties comprising 14% of the United States population age ≥65 years had disproportionately low CR access and were identified as CR deserts.

CONCLUSIONS

A substantial proportion of geographic variation in CR initiation was related to access to CR programs, with a significant amount of the U.S. population living in CR deserts. These data invite further study on interventions to increase CR access.

Greater spatial access to care is associated with lower mortality for emergency general surgery

BACKGROUND

Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions.

METHODS

A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity.

RESULTS

A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity.

CONCLUSION

This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

The Association of Blood Banks per City with Mortality Due to Traumatic Hemorrhagic Shock in Colombia: A Population-Based Analysis

Background

Hemorrhagic shock is the second leading cause of death for injured people and disproportionately affects low resource economies. The potential role of spatial allocation of blood banks and the unmet transfusion needs of patients are yet to be characterized. We aimed to estimate the effect of the number of blood banks in mortality due to traumatic hemorrhagic shock (THS) in Colombia.

Methods

We performed a population-based cross-sectional study using secondary data from the Colombian Government: including annual reports from the Blood Bank Network, mortality, and population estimates for 2015-2016. International Classification of Disease 10th code T79.4 identified THS as the primary cause of death. A city-clustered multivariate negative binomial regression, weighted by violent deaths rate, was used to obtain incidence rate ratios (IRR) of death due to THS with 95% confidence intervals (95%CI).

Results

Of the 59,030 violent deaths in Colombia in 2015-2016, 36.76% were due to THS. Only 3.13% of Colombian municipalities had a blood bank. THS incidence decreased as the number of blood banks in a city increased, and the lowest incidence was observed at ten banks (IRR:0.18, 95%CI:0.15-0.22). Receiving medical care in a city with blood banks had a more substantial impact on THS (IRR:0.85; 95%CI:0.76-0.96).

Conclusion

The number of blood banks per city was associated with lower incidence of THS deaths. These findings may highlight the inequitable distribution of blood systems and their association with preventable deaths. Further studies with more focused clinical and geographical data might clarify the geographic determinants of blood products' availability.

The number of physicians is related to the number of nighttime emergency surgeries in Japan: An ecological study

PURPOSE

Increasing the number of physicians per population may improve the quality of medical services, but there are few reports on this aspect in the field of surgery. This study aimed to examine whether the number of physicians is associated with the number of nighttime emergency surgeries, which may be one of the indicators of the quality of medical services in the field of surgery.

METHODS

This was a prefecture-based ecological study utilizing open data from Japanese government surveys conducted between 2015 and 2019. The relationship between the number of physicians and the number of nighttime emergency surgeries in 47 prefectures of Japan was evaluated by correlation analysis and panel data regression analysis. The correlation analysis was conducted between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population per year in each prefecture in Japan. In the panel data regression analysis, panel data of the prefectures in Japan from 2015 to 2019 were created. We evaluated whether the number of physicians was related to the number of nighttime emergency surgeries, independent of the number of acute care beds per 100,000 population, population density, and the elderly population ratio.

RESULTS

From the correlation analysis, the correlation coefficient between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population was 0.533 (P < 0.001). In the panel data regression analysis, there was a significant association between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population (P < 0.001). The regression coefficient (95% confidence interval) for the number of physicians per 100,000 population was 0.246 (0.113-0.378).

CONCLUSION

The number of physicians is associated with the number of nighttime emergency surgeries.

A systematic review of the 60 year literature: Effects of outreach programs in supporting historically marginalized and first-generation, low-income students in healthcare education

We have reviewed over 60 years of studies on healthcare education outreach programs that are aimed to support first-generation, low-income, as well as underrepresented racial and ethnic minority groups (historically marginalized students) to pursue pre-health professions. As a systematic literature review, we present the challenges studies on healthcare education outreach programs had as three main categories: 1) Design, 2) Evaluation, and 3) Analysis. 1) Designs of studies on healthcare education outreach programs often lacked theoretical foundations whereby a) the interventions did not present theories underlying a causal mechanism of inequity in health professions; and/or 1b) the defined outcome measures were not clearly aligned with the problem the intervention tried to address. 2) Evaluations of studies on healthcare education outreach programs were not always conducted effectively whereby: 2a) controlled groups were commonly absent for comparison with the intervention group; and/or 2b) post measures were solely used without pre-measures. 3) Analyses of studies on healthcare education outreach programs were not adequate whereby: 3a) the response rates and effect size were commonly low; and/or 3b) qualitative results commonly did not supplement quantitative results. Overall, our findings reveal studies on healthcare education outreach programs have common challenges that hinder the reliability of their effects supporting historically marginalized students in pursuing pre-health professions. To address such challenges with studies on healthcare education outreach programs aimed at supporting historically marginalized students, we created a decision flow chart for researchers to ask themselves: 1) how is the design guided by theoretical goals; 2) how are measurements used to evaluate success; and 3) how does the analysis lead to reliable results?

Disparities in Spatial Access to Emergency Surgical Services in the US

Importance

Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics.

Objective

To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods.

Design, Setting, and Participants

A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022.

Main Outcomes and Measures

Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3).

Results

In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities.

Conclusions and Relevance

In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.

Frequency Of Indirect Billing To Medicare For Nurse Practitioner And Physician Assistant Office Visits

Nurse practitioners (NPs) and physician assistants (PAs) represent a growing share of the health care workforce, but much of the care they provide cannot be observed in claims data because of indirect (or "incident to") billing, a practice in which visits provided by an NP or PA are billed by a supervising physician. If NPs and PAs bill directly for a visit, Medicare and many private payers pay 85 percent of what is paid to a physician for the same service. Some policy makers have proposed eliminating indirect billing, but the possible impact of such a change is unknown. Using a novel approach that relies on prescriptions to identify indirectly billed visits, we estimated that the number of all NP or PA visits in fee-for-service Medicare data billed indirectly was 10.9 million in 2010 and 30.6 million in 2018. Indirect billing was more common in states with laws restricting NPs' scope of practice. Eliminating indirect billing would have saved Medicare roughly $194 million in 2018, with the greatest decrease in revenue seen among smaller primary care practices, which are more likely to use this form of billing.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Medical education interventions influencing physician distribution into underserved communities: a scoping review

BACKGROUND AND OBJECTIVE

Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities.

METHODS

A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations.

RESULTS

There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness.

CONCLUSIONS

Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.

Association of County Race and Ethnicity Characteristics With Number of Insurance Carriers and Insurance Network Breadth

IMPORTANCE

While the Affordable Care Act (ACA) set out to eliminate insurer discrimination based on preexisting conditions, the ACA health exchanges allow insurers to select what markets to enter and afford them great freedom on how they design their physician networks. Strategic market participation and physician network design based on population race, ethnicity, and health characteristics may give rise to a present-day form of redlining within health insurance markets-ie, a systematic underprovision of insurance plans and in-network practitioners within areas that are populated with higher proportions of non-Hispanic Black residents.

OBJECTIVE

To examine if markets with relatively higher non-Hispanic Black populations have systematically fewer insurers and lower network inclusion of physicians residing within these areas.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted a regression analysis of the US ACA health insurance exchange marketplace across 34 states with federal exchanges and physicians located within the 500 most populous US cities in 2014. County-level data were sourced from individual market and issuer enrollment databases and county health rankings; census tract data came from a national database of physician networks in 2014 marketplace plans, US Census Bureau data, and the Centers for Disease Control and Prevention's PLACES database. Adjustment was made for a rich set of county (or census tract) controls and state fixed effects to capture broad market and/or policy differences across states. Analyses were performed in June 2021.

MAIN OUTCOMES AND MEASURES

The raw count of insurers within a county and the mean percentage of insurance networks that physicians participate in within each census tract.

RESULTS

A total of 2270 counties were examined within our first analyses. In the counties analyzed, a mean (SD) of 23.0% (3.2%) of the population was aged 18 years or younger, and a mean (SD) of 11.0% (15.8%) of the population had non-Hispanic Black race and ethnicity. For the second analysis, 16 006 to 25 096 census tracts were examined (depending on physician specialty). With adjustment for population size, age, and race and ethnicity, a 1-SD increase in the county non-Hispanic Black population was associated with a 14.1% reduction in the number of insurers (mean [SE] marginal effect size, -2.18 [0.13]; P < .001). Accounting for additional county-level risk selection controls and state fixed effects, a 1-SD increase in the non-Hispanic Black population was associated with a 2.3% reduction in available insurers (marginal effect size, -0.36 [0.17]; P = .04). For practitioners network breadth inclusion, a 1-SD increase in the non-Hispanic Black population was associated with a 15.8% (marginal effect size, -0.32 [0.01]; P < .001) to 24.7% (marginal effect size, -0.14 [0.02]; P < .001) reduction in the physicians' network participation depending on their specialty. Adjusting for additional state fixed effects yielded estimates of 6% (marginal effect size, -0.08 [0.01]; P < .001) to 13.5% (marginal effect size, -0.12 [0.02]; P < .001) reductions in practitioner network participation.

CONCLUSIONS AND RELEVANCE

These findings suggest that strategic decisions by insurers may contribute toward markets with higher racial or ethnic minority populations having systematically fewer participating insurers, as well as a higher prevalence of local physicians not included in coverage networks. These findings call for further examination of potential insurance redlining within the ACA marketplaces.

Unmasking unexpected health care inequalities in China using urban big data: Service-rich and service-poor communities

Geographic accessibility plays a key role in health care inequality but remains insufficiently investigated in China, primarily due to the lack of accurate, broad-coverage data on supply and demand. In this paper, we employ an innovative approach to local supply-and-demand conditions to (1) reveal the status quo of the distribution of health care provision and (2) examine whether individual households from communities with different housing prices can acquire equal and adequate quality health care services within and across 361 cities in China. Our findings support previous conclusions that quality hospitals are concentrated in cities with high administrative rankings and developmental levels. However, after accounting for the population size an “accessible” hospital serves, we discern “pro-poor” inequality in accessibility to care (denoted as GAPSD) and that GAPSD decreases along with increases in administrative rankings of cities and in community ratings. This paper is significant for both research and policy-making. Our approach successfully reveals an “unexpected” pattern of health care inequality that has not been reported before, and our findings provide a nationwide, detailed benchmark that facilitates the assessment of health and urban policies, as well as associated policy-making.

Recruitment and retention of primary care nurse practitioners in underserved areas: A scoping review

BACKGROUND

The growing nurse practitioner (NP) workforce plays a critical role in primary care delivery in the United States. However, better recruitment and retention of the robust NP workforce in underserved areas are needed; evidence to inform such effort is limited.

PURPOSE

This scoping review aimed to examine the findings, scope, and knowledge gaps of available literature on factors associated with NP recruitment and retention in underserved areas.

METHODS

This review was guided by Joanna Briggs' Scoping Review Methodology and PRISMA-SCR reporting standards. Literature search for peer-reviewed and gray literature was conducted in six databases.

FINDINGS

A total of 22 studies met inclusion criteria. Factors associated with NP recruitment and retention in underserved areas were mapped into five themes, including factors related to: the individual NP, NP education programs/financial aid, organizations employing NPs, the communities NPs work in, and autonomous practice. Majority of the included studies were published before 2010; few used rigorous study designs and analysis methods; and few exclusively studied NPs and unique challenges facing the NP workforce.

DISCUSSION

Available studies demonstrate that NP recruitment and retention can be addressed by various stakeholders (e.g., educators, policy makers); however, up-to-date, methodologically rigorous, and NP-focused studies are needed.

Improving Sexual Health in U.S. Rural Communities: Reducing the Impact of Stigma

Sexually transmitted infections (STI), including HIV, are among the most reported diseases in the U.S. and represent some of America's most significant health disparities. The growing scarcity of health care services in rural settings limits STI prevention and treatment for rural Americans. Local health departments are the primary source for STI care in rural communities; however, these providers experience two main challenges, also known as a double disparity: (1) inadequate capacity and (2) poor health in rural populations. Moreover, in rural communities the interaction of rural status and key determinants of health increase STI disparities. These key determinants can include structural, behavioral, and interpersonal factors, one of which is stigma. Engaging the expertise and involvement of affected community members in decisions regarding the needs, barriers, and opportunities for better sexual health is an asset and offers a gateway to sustainable, successful, and non-stigmatizing STI prevention programs.

Convergence of Service Providers and Managers' Perspectives on Strengths, Gaps, and Priorities for Rural Health System Redesign: A Whole-Systems Qualitative Study in Washington County, Maine

Introduction:

Both rural residents and state government leaders describe a need to redesign rural health care systems. Community members should be at the center of this effort.

Methods:

We conducted 46 in-depth interviews of direct service providers between September and November 2020 in Washington County, Maine. Data were analyzed using a thematic analysis approach.

Results:

Existing strengths included collaboration between government and health systems, and community-based services. Gaps included insufficient workforce, restricted scope of licensing and poor reimbursement, lack of coordination between health systems, and limited paramedicine capacity. Strategies for health system redesign included addressing maldistribution of services and resource optimization, changing federal and state legislation around insurance and scope of practice, and moving toward value-based purchasing models.

Conclusions:

Participants provided pragmatic recommendations based on their deep understanding of the community context. Lessons learned are likely to be salient in areas with similar profiles regarding rurality and poverty.

Oculofacial plastic surgeon distribution by county in the United States, 2021

PURPOSE

To characterize the number of oculofacial plastic surgeons (OPS) per county in the United States (U.S.).

METHODS

The 2021 public databases of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the American Academy of Ophthalmology were used to identify all OPS in the U.S. Surgeon practice location was used to determine per capita physician density by county.

RESULTS

A total of 1184 OPS in the U.S. were identified. Three hundred forty-eight counties were served by at least one OPS whereas 2795 counties (89%), and two states, North Dakota and Wyoming, had no OPS. The average ratio of OPS to 100,000 population was 0.3572 (1 per 279,955). Of the counties with at least one OPS, the average was 0.5860 surgeons per 100,000 population (1 per 170,648), ranging from 0.0705 (1 per 1,418,440) to 11.26 (1 per 8,881) per 100,000. The counties with the greatest OPS density were Pitkin County, CO (1 per 8,881), San Juan County, WA (1 per 17,580), and Montour County, PA (1 per 18,231). Counties with the lowest density of those with at least one OPS were Bronx County, NY (1 per 1,418,238), San Bernardino County, Ca (1 per 1,090,037), and Gwinnett County, GA (1 per 936,329). The counties with the most OPS were Los Angeles County, CA (46), New York County, NY (38), and Cook County, IL (25).

CONCLUSIONS

Geographic disparities in OPS distribution exist in the U.S. Future investigations of OPS supply according to population and other characteristics for demand may be useful.

Changes in dermatology practice characteristics in the United States from 2012 to 2017

Background

Dermatology practice has recently seen multiple changes. A better understanding of trends pertaining to dermatology practice setups is necessary.

Objective

To analyze the recent changes in dermatology practice in terms of geography, practice size, and gender distribution as well as to analyze the availability of dermatologists based on zip codes’ income levels.

Methods

This was a cross-sectional study. We extracted data on the sex and billing addresses of dermatologists from Medicare provider utilization and payment data for 2012 and 2017. We used 2017 tax returns data to calculate the poverty level for each zip code.

Results

Between 2012 and 2017, the number of solo practitioners decreased, while that of dermatologists working in large groups increased. The southern region experienced the largest changes. The male-to-female ratio decreased. Dermatology practices mainly comprised mixed genders, with a higher proportion of all-male groups versus that of all-female groups, but this difference decreased over time. In the northeastern and western regions, more than one third of dermatologists were located in the wealthiest zip codes.

Limitations

The Medicare data may not be exhaustively representative of the dermatology workforce, and the zip codes of 489 dermatologists’ billing addresses were missing in the tax return dataset.

Conclusions

These findings provide an understanding of the recent changes pertaining to dermatology practice setups and of the substantial health care disparities based on geographic distribution.

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: a multimethod study

OBJECTIVES

The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme.

DESIGN

Multimethod: survey and retrospective review of referral forms.

SETTING

Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia.

PARTICIPANTS

Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed.

RESULTS

Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases.

CONCLUSIONS

This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes.

Understanding The Health Landscapes Where Latinx Immigrants Establish Residence In The US

The diversity of health contexts in which members of the US Latinx population establish residence may provide insights into the variety of health challenges they face. We investigated differences in health professional shortages, general health services, health care safety-net supply, health access, and population health rankings across 3,113 US counties classified as established, new, or other Latinx population destinations. Compared with new destinations, established destinations had more health professional shortages, as well as higher rates of child and adult health uninsurance. New destinations had fewer health care safety-net services per 100,000 county residents than established destinations. Health contexts thus differ in significant ways across new and established Latinx destinations, and these differences have key implications for Latinx immigrant health.

The Effect of Reduced Access to Chiropractic Care on Medical Service Use for Spine Conditions Among Older Adults

OBJECTIVE

The purpose of this study was to examine the extent to which access to chiropractic care affects medical service use among older adults with spine conditions.

METHODS

We used Medicare claims data to identify a cohort of 39,278 older adult chiropractic care users who relocated during 2010-2014 and thus experienced a change in geographic access to chiropractic care. National Plan and Provider Enumeration System data were used to determine chiropractor per population ratios across the United States. A reduction in access to chiropractic care was defined as decreasing 1 quintile or more in chiropractor per population ratio after relocation. Using a difference-in-difference analysis (before versus after relocation), we compared the use of medical services among those who experienced a reduction in access to chiropractic care versus those who did not.

RESULTS

Among those who experienced a reduction in access to chiropractic care (versus those who did not), we observed an increase in the rate of visits to primary care physicians for spine conditions (an annual increase of 32.3 visits, 95% CI: 1.4-63.1 per 1,000) and rate of spine surgeries (an annual increase of 5.5 surgeries, 95% CI: 1.3-9.8 per 1,000). Considering the mean cost of a visit to a primary care physician and spine surgery, a reduction in access to chiropractic care was associated with an additional cost of $114,967 per 1,000 beneficiaries on medical services ($391 million nationally).

CONCLUSIONS

Among older adults, reduced access to chiropractic care is associated with an increase in the use of some medical services for spine conditions.

Predictors of Health Information-Seeking Behavior: Systematic Literature Review and Network Analysis

Background

People engage in health information–seeking behavior to support health outcomes, and being able to predict such behavior can inform the development of interventions to guide effective health information seeking. Obtaining a comprehensive list of the predictors of health information–seeking behavior through a systematic search of the literature and exploring the interrelationship of these predictors are critical first steps in this process.

Objective

This study aims to identify significant predictors of health information–seeking behavior in the primary literature, develop a common taxonomy for these predictors, and identify the evolution of the concerned research field.

Methods

A systematic search of PsycINFO, Scopus, and PubMed was conducted for all years up to and including December 10, 2019. Quantitative studies identifying significant predictors of health information–seeking behavior were included. Information seeking was broadly defined and not restricted to any source of health information. Data extraction of significant predictors was performed by 2 authors, and network analysis was conducted to observe the relationships between predictors with time.

Results

A total of 9549 articles were retrieved, and after the screening, 344 studies were retained for analysis. A total of 1595 significant predictors were identified. These predictors were categorized into 67 predictor categories, with the most central predictors being age, education, gender, health condition, and financial income. With time, the interrelationship of predictors in the network became denser, with the growth of new predictor grouping reaching saturation (1 new predictor identified) in the past 7 years, despite increasing publication rates.

Conclusions

A common taxonomy was developed to classify 67 significant predictors of health information–seeking behavior. A time-aggregated network method was developed to track the evolution of the research field, showing the maturation of new predictor terms and an increase in primary studies reporting multiple significant predictors of health information–seeking behavior. The literature has evolved with a decreased characterization of novel predictors of health information–seeking behavior. In contrast, we identified a parallel increase in the complexity of predicting health information–seeking behavior, with an increase in the literature describing multiple significant predictors.

Nurse Practitioner Scope-of-Practice Laws and Opioid Prescribing

Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states.

CONTEXT

As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids.

METHODS

This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers.

FINDINGS

Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs.

CONCLUSIONS

No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.

Effects of a Specialized Primary Care Facility on Preventive Service Use Among Autistic Adults: a Retrospective Claims Study

BACKGROUND

While in some studies, the patient-centered medical home has been linked with increased receipt of preventive services among other populations, there is a paucity of literature testing the effectiveness of medical homes in serving the healthcare needs of autistic adults.

OBJECTIVE

To compare the receipt of preventive services by patients at a patient-centered medical home specifically designed for autistic adults (called the Center for Autism Services and Transition "CAST") to US national samples of autistic adults with private insurance or Medicare.

DESIGN

Retrospective study of medical billing data.

SAMPLE

The study sample included CAST patients (N = 490) who were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years old, 79% were male, and the median duration of observation was 2.2 years.

MAIN MEASURES

The primary outcome measure was the receipt of any preventive service, as defined by the Medicare Learning Network and AAPC (formerly the American Academy of Professional Coders). Secondary outcome measures included receipt of specific preventive service types (i.e., general health and wellness services, screenings, counseling and therapies, vaccinations, and sexual/reproductive health services).

KEY RESULTS

CAST patients had significantly greater odds of receiving any preventive service than Medicare-enrolled (OR = 10.3; 95% CI = 7.6-13.9) and privately insured (OR = 3.1; 95% CI = 2.3-4.2) autistic adults. CAST patients were also significantly more likely to receive screenings and vaccinations than either Medicare beneficiaries (screenings OR = 20.3; 95% CI = 14.7-28.0; vaccinations OR = 5.5; 95% CI = 4.3-7.0) or privately insured beneficiaries (screenings OR = 2.0; 95% CI = 1.6-2.5; vaccinations OR = 3.3; 95% CI = 2.6-4.1).

CONCLUSIONS

Autistic adults receiving care through CAST were significantly more likely to recieve preventive care services than national samples of autistic adults. Future comparative effectiveness trials are needed to rigorously assess the impact of primary care-based initiatives to improve care for autistic adults.

Increased Driving Distance to Screening Colonoscopy Negatively Affects Bowel Preparation Quality: an Observational Study

BACKGROUND

To prepare for colonoscopy, patients must consume a bowel purgative and travel from their home to the site of their procedure. The timing of bowel purgative ingestion predicts bowel preparation quality. Currently, it is not known if driving distance impacts bowel preparation quality or adenoma detection.

OBJECTIVE

This study investigates the effect of driving distance on bowel preparation and adenoma detection.

DESIGN

This is a cross-sectional retrospective analysis of outpatient screening colonoscopy procedures that were completed at an academic medical center.

PARTICIPANTS

A total of 5089 patients who completed screening colonoscopy across 3 procedure units were analyzed.

MAIN MEASURES

Description of bowel preparation was dichotomized to either adequate or inadequate. Patient residential addresses were converted into geographic coordinates for geospatial analysis of driving distance to their colonoscopy site.

KEY RESULTS

Median driving distance was 13.1 miles. Eighty-nine percent of patients had an adequate bowel preparation. The rate of adenoma detection was 37%. On multivariable logistic regression adjusting for age, sex, race, insurance, endoscopist, and site, increasing driving distance (10-mile increments) was negatively associated with adequate bowel preparation (odds ratio = 0.91; 95% confidence interval 0.85 to 0.97), while adenoma detection was positively associated with adequate bowel preparation (odds ratio = 1.53; 95% confidence interval 1.24 to 1.88) but not with driving distance (odds ratio = 1.02; 95% confidence interval 0.98 to 1.06). Driving distances of 30 miles or less were associated with adequate bowel preparation (odds ratio = 1.37; 95% confidence interval 1.09 to 1.72).

CONCLUSIONS

Increasing driving distance to screening colonoscopy was negatively associated with adequate bowel preparation but not adenoma detection. Among an academic medical center population, the likelihood of adequate bowel preparation was highest in patients traveling 30 miles or less to their screening colonoscopy. Patient driving distance to colonoscopy is an important consideration in optimizing screening colonoscopy quality.

Different configurations of the two-step floating catchment area method for measuring the spatial accessibility to hospitals for people living with disability: a cross-sectional study

BACKGROUND

Poor spatial accessibility to hospital services is associated with higher morbidity and mortality rates among people living with disability. Improved methods to evaluate spatial accessibility are needed. This study measured the potential spatial accessibility of people living with disability by applying four configurations of the two-step floating catchment area (2SFCA) method to recommend the best model for use in health services research.

METHODS

2SFCA and an enhanced version (E2SFCA) were used to measure hospital accessibility for people living with disability. We also developed and embedded a non-spatial severity index into the two 2SFCA models. We used 16,186 records of people living with disability experience to evaluate the methodological performance across 68 neighbourhoods of the city of Ahvaz, located in south-western Iran. The models' performance were measured through correlation of the four accessibility scores with the distance to closest hospital for each neighbourhood centroid.

RESULTS

Among the four models used to measure spatial accessibility, the E2SFCA integrated with the severity index displayed the best performance. Most people with disabilities lived in neighbourhoods located in the South-western and central areas of the city. Interestingly, south-western neighbourhoods had poor hospital accessibility score and were identified as unmet need areas for access to health services.

CONCLUSIONS

Inclusion of the severity factor in the E2SFCA improved access measurements. Identifying areas with poor levels of hospital accessibility can help policymakers design tailored interventions and improve accessibility to hospital-based care in urban settings for people living with disability.

The Effect of Healthcare Provider Availability on Spine Spending

BACKGROUND

Spine conditions are costly and a major cause of disability. A growing body of evidence suggests that healthcare utilization and spending are driven by provider availability, which varies geographically and is a topic of healthcare policy debate.

OBJECTIVE

To estimate the effect of provider availability on spine spending.

DESIGN

Retrospective cohort study using relocation as a natural experiment.

PARTICIPANTS

Fee-for-service Medicare beneficiaries over age 65 who relocated to a new hospital referral region between 2010 and 2014.

MAIN MEASURES

We used generalized linear models to evaluate how changes in per-beneficiary availability of three types of healthcare providers (primary care physicians, spine surgeons, and chiropractors) affected annual per-beneficiary spine spending. We evaluated increases and decreases in provider availability separately. To account for the relative sizes of the provider workforces, we also calculated estimates of the effects of changes in national workforce size on changes in national spine spending.

KEY RESULTS

The association between provider availability and spending was generally stronger among beneficiaries who experienced a decrease (versus an increase) in availability. Of the three provider groups, spine surgeon availability was most strongly associated with spending. Among beneficiaries who experienced a decrease in availability, a decrease in one spine surgeon per 10,000 beneficiaries was associated with a decrease of $36.97 (95% CI: $12.51, $61.42) in annual spending per beneficiary, versus a decrease of $1.41 (95% CI: $0.73, $2.09) for a decrease in primary care physician availability. However, changes in the national workforce size of primary care physicians were associated with the largest changes in national spine spending.

CONCLUSIONS

Provider availability affects individual spine spending, with substantial changes observed at the national level. The effect depends on provider type and whether availability increases or decreases. Policymakers should consider how changes in the size of the physician workforce affect healthcare spending.

Telemedicine practice guidelines of India, 2020: Implications and challenges

Telemedicine Guidelines of India, 2020 promises to pave a road map for regularization and diversification of teleconsultation services across the country. This guideline is the need of the hour, especially during the current coronavirus disease pandemic. All modes of communications (text, audio, video, etc.) between the service provider and user are included in the broad rubric of the guidelines. Scope, inclusions, exclusions, and restrictions are clearly specified in the guideline. Medications are grouped and listed for the specific type of consultation, and restricted drugs are notified. This guideline especially helps mitigate the gaps in legislation and reduces the uncertainty while providing a practical, safe, and cost-effective framework to improve healthcare service delivery in this article; the authors discuss the implications of this new guideline and the challenges during the implementation of teleconsultation services across the country.

Geographical analysis of the distribution of certified genetic counselors in the United States

The number of certified genetic counselors (CGCs) in the genetic counseling workforce has increased over the past few decades as the number of training programs increases and CGCs expand into new patient-facing and non-patient-facing roles. Few studies have explored the distribution of CGCs across the United States. We sought to identify the U.S. geographical regions with the highest number of CGCs and those regions where the physical presence of CGCs is sparser. Deidentified city, state, and ZIP code information for each CGC in the United States were obtained from the American Board of Genetic Counseling (ABGC) database. A countrywide analysis of the distribution of CGCs was completed using geographic information system (GIS) mapping software. The data were organized into U.S. metropolitan or micropolitan statistical areas, if applicable, and analyzed by CGC per capita. We included a total of 4,554 data points (92.2%) in the analysis. Results showed there is one CGC for every 71,842 people nationwide. Of 3,141 total counties (or county equivalents) in the United States, 535 counties had at least one CGC (17.0%). The majority (98.7%) of CGCs live or work within metropolitan statistical areas (MSAs), which are defined by this study as geographical areas with greater than 50,000 people. Of the MSAs with a CGC, approximately half have more than one CGC per 100,000 people. These results are consistent with the overall distribution of the U.S. population. We believe that the MSAs with the most CGCs per capita are due to associations with specific institutions, that is, genetic counseling training programs, health system headquarters, or genetic laboratories. Although the present study cannot draw definite conclusions regarding direct patient care services provided by CGCs, it does provide a snapshot of current CGC distribution within the country. Knowing the distribution of CGCs provides a tool to conduct further workforce analyses to determine the number of CGCs needed to serve the U.S. population.

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.