Cardiac surgery in North America and coronavirus disease 2019 (COVID-19): Regional variability in burden and impact

Objective

The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in hospital resource utilization and the need to defer nonurgent cardiac surgery procedures. The present study aims to report the regional variations of North American adult cardiac surgical case volume and case mix through the first wave of the COVID-19 pandemic.

Methods

A survey was sent to recruit participating adult cardiac surgery centers in North America. Data in regard to changes in institutional and regional cardiac surgical case volume and mix were analyzed.

Results

Our study comprises 67 adult cardiac surgery institutions with diverse geographic distribution across North America, representing annualized case volumes of 60,452 in 2019. Nonurgent surgery was stopped during the month of March 2020 in the majority of centers (96%), resulting in a decline to 45% of baseline with significant regional variation. Hospitals with a high burden of hospitalized patients with COVID-19 demonstrated similar trends of decline in total volume as centers in low burden areas. As a proportion of total surgical volume, there was a relative increase of coronary artery bypass grafting surgery (high +7.2% vs low +4.2%, P = .550), extracorporeal membrane oxygenation (high +2.5% vs low 0.4%, P = .328), and heart transplantation (high +2.7% vs low 0.4%, P = .090), and decline in valvular cases (high –7.6% vs low –2.6%, P = .195).

Conclusions

The present study demonstrates the impact of COVID-19 on North American cardiac surgery institutions as well as helps associate region and COVID-19 burden with the impact on cardiac surgery volumes and case mix.

Geographic disparities in liver supply/demand ratio within fixed-distance and fixed-population circles

Recent OPTN proposals to address geographic disparity in liver allocation have involved circular boundaries: the policy selected 12/17 allocated to 150-mile circles in addition to DSAs/regions, and the policy selected 12/18 allocated to 150-mile circles eliminating DSA/region boundaries. However, methods to reduce geographic disparity remain controversial, within the OPTN and the transplant community. To inform ongoing discussions, we studied center-level supply/demand ratios using SRTR data (07/2013-06/2017) for 27 334 transplanted deceased donor livers and 44 652 incident waitlist candidates. Supply was the number of donors from an allocation unit (DSA or circle), allocated proportionally (by waitlist size) to the centers drawing on these donors. We measured geographic disparity as variance in log-transformed supply/demand ratio, comparing allocation based on DSAs, fixed-distance circles (150- or 400-mile radius), and fixed-population (12- or 50-million) circles. The recently proposed 150-mile radius circles (variance = 0.11, P = .9) or 12-million-population circles (variance = 0.08, P = .1) did not reduce the geographic disparity compared to DSA-based allocation (variance = 0.11). However, geographic disparity decreased substantially to 0.02 in both larger fixed-distance (400-mile, P < .001) and larger fixed-population (50-million, P < .001) circles (P = .9 comparing fixed distance and fixed population). For allocation circles to reduce geographic disparities, they must be larger than a 150-mile radius; additionally, fixed-population circles are not superior to fixed-distance circles.

Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees

OBJECTIVE

The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees.

METHODS

A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had.

RESULTS

During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26).

CONCLUSIONS

In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014

BACKGROUND

The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery.

METHODS

A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants.

RESULTS

The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 ± 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 ± 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency.

CONCLUSION

Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas

OBJECTIVE

Ongoing health reform in the United States encourages quality-based reimbursement methods such as bundled payments for surgery. The effect of such changes on high-risk procedures is unknown, especially at safety net hospitals. This study quantified the burden of diabetes-related amputation and the potential financial effect of bundled payments at safety net hospitals in Texas.

METHODS

We performed a cross-sectional analysis of diabetic amputation burden and charges using publically available data from Centers for Medicare and Medicaid and the Texas Department of Health from 2008 to 2012. Using hospital referral region (HRR)-level analysis, we categorized the proportion of safety net hospitals within each region as very low (0%-9%), low (10%-20%), average (20%-33%), and high (>33%) and compared amputation rates across regions using nonparametric tests of trend. We then used charge data to create reimbursement rates based on HRR to estimate financial losses.

RESULTS

We identified 51 adult hospitals as safety nets in Texas. Regions varied in the proportion of safety net hospitals from 0% in Victoria to 65% in Harlingen. Among beneficiaries aged >65, amputation rates correlated to the proportion of safety net hospitals in each region; for example, patients in the lowest quartile of safety net had a yearly rate of 300 amputations per 100,000 beneficiaries, whereas those in the highest quartile had a yearly rate of 472 per 100,000 (P = .007). Charges for diabetic amputation-related admissions varied almost 200-fold, from $5000 to $1.4 million. Using reimbursement based on HRR to estimate a bundled payment, we noted net losses would be higher at safety net vs nonsafety net hospitals ($180 million vs $163 million), representing a per-hospital loss of $1.6 million at safety nets vs $700,000 at nonsafety nets (P < .001).

CONCLUSIONS

Regions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for the disproportionate burden of high-risk procedures performed by these hospitals.

[Diagnostics of Regional Healthcare Management System in Russia Basing on Modeling and Forecasting of Health and Demographic Indicators]

BACKGROUND

Justification of the study direction of public health improving is quite general. But the identification of the most effective indicators of the healthcare system improvement remains unexplored.

OBJECTIVE

Our aim was to determine the interaction between the basic demographic indicators of the region (Smolensk region) and efficacy endpoints of the Healthcare management identified in the study.

METHODS

The study reviewed the demographic changes of the Smolensk region at present and the forecast for 2015, 2016, 2017. The forecast of demographic and health indicators was based on exponential smoothing models and autoregressive model.

RESULTS

The study identified the most appropriate medical and demographic indicators. 1) The ratio of physicians (per 10,000 people in population, the rate maximum was 62 in 2004, in 2015 this figure has fallen to 52, and it is supposed to decrease to 49 by 2017). 2) The overall mortality rate (per 1000 people in population). Reduction of the resident population of the Smolensk region is 8.2 thousand people in annual average. This fact shows a stable depopulation of the region. 3) The average load on the ambulance. It has been found that the increase and decrease of these parameters directly affect the population rate.

CONCLUSION

The study revealed a stable downtrend of average resident population number which confirms the long regional depopulation. It is associated in particular with the lack of stimulation of the health and demographic indicators' increase including but not limited to inefficient healthcare management arrangements.

De Facto regionalization of care for ST-elevation myocardial infarction in Florida, 2001-2009

ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.

[Regionalisation of perinatal care in Basse-Normandie, France: evolution over 5 years]

OBJECTIVES

To compare evolution and characteristics of in utero transfers (IUT) in Basse-Normandie area, France, between 2004 and 2008, and to describe characteristics of IUT in 2008.

MATERIALS AND METHODS

Analysis of data from the IUT registry, collected prospectively since 2004.

RESULTS

An average of five IUT per week was observed. The rate of IUT regularly increased (P=0.003) and reached 16.2 per 1000 pregnancies in 2008. Extra network IUT decreased steadily (P=0.04). For level 3 units, the proportion of IUT from level 2 units increased (P<10(-3)). Before 32 weeks of gestational age, all IUT were done towards a level 3 unit. Median time between IUT and delivery and caesarean section rates were variable according to IUT indication (for threats of premature delivery, respectively 5 days and 23.3%). The rate of retransfer towards initial unit of towards a birth site of relevant level was 5.3%.

CONCLUSION

The IUT registry gives useful information on evolution and characteristics of IUT in our area. An increased regionalisation and more frequent adequate IUT were observed. The registry must now serve as a basis for practices assessment.

[Structure of human resources and activities of occupational medicine service in Poland in 2009 and dynamics and trends in recent years]

BACKGROUND

The main objective of the study was to provide the most important results concerning the state of human resources and activities of occupational medicine services in Poland in 2009 and their dynamics and trends in the recent years.

MATERIALS AND METHODS

Information about the state of human resources and activities of occupational medicine services has been obtained from statistical forms (more than 10,000) filled by occupational physicians carrying out the preventive g care of workers, and health care centers (or their separate parts), which are the primary occupational medicine units and regional occupational medicine centers (forms: MZ-35A, MZ-35B and MZ-35).

RESULTS

In 2009, essential changes were noted in the structure of the primary occupational medicine units. 'Ihere was a significant decrease in the number of public health care centers. This phenomenon has resulted from the transformation of public health care centers into non-public structures.

CONCLUSIONS

The range of occupational medicine services has reached the level sufficient enough to achieve the objectives of the occupational health care mandatory assignment. However, the structure of the tasks actually performed by regional occupational medicine centers greatly varies, from focusing on the statutory tasks to their marginalization.

[Regional health conferences: assessment, observations, risks, challenges and prospects]

The Public Health Bill of August 9 2004 established that regions are the optimal level for governing interventions. The new law resulted in the creation of the National Health Conference and the new Regional Health Conferences. The Permanent Assembly of the Regional Health Conferences was created in 2006 with a view to fostering closer relations between representatives of the 26 Regional Health Conferences. Three specific missions were officially devolved to the Regional Health Conferences. The object of this article is to provide an overview of these duties and to highlight the difficulties raised by their implementation, as well as their strengths. To conclude, the new Regional Health Conferences are discussed in the light of their recent work.

Public policy and private provisions: changes in residential care from 1991 to 2001

This research examined changes in the number of care homes and their residents in the UK between the 1991 and 2001 Censuses. Local-authority-owned provision universally declined in this period, but changes in private residential and nursing homes were far more varied. Some parts of Britain experienced a growth in this market, in particular Scotland. Regions which were traditionally linked with greater numbers of retired people in their populations declined in their private residential home markets (e.g. the South West and South East). Wales experienced a regional decline that was greater than most English regions. Using additional Department of Health data, it was possible to estimate which local authority areas in England were exporting state-funded supported residents to homes out of their area. Most of these authorities were in urban areas and the highest rates of exporting were from Inner London boroughs. Political control and average property prices were explored as possible independent variables influencing the percentage rate of decline in homes in a local authority area. It appeared that Conservative authorities experienced a more rapid decline in government-owned homes than those run by Labour, but the results were not statistically significant, suggesting that local politics was a not a key influence on the trend. Average property prices did not affect all areas of the country, but were found to have a negative and significant association with percentage rates of decline in care homes in both Wales and London.

The perils of healthcare workforce forecasting: a case study of the Philadelphia metropolitan area

In 1996, a widely circulated and influential forecast for the Philadelphia Metropolitan Area stated that a decline in hospital and healthcare employment in the region would occur over the next five years. It also suggested that this decline would exacerbate the problem of an oversupply of nurses seeking hospital employment. The forecast reflected a regional leadership and expert consensus on the impact of the managed care transformation on workforce needs and was supported by short-term statistical trends in regional utilization and employment. Confounding these predictions was the fact that hospital and healthcare employment actually grew. By the end of 2001, hospitals in the region were experiencing problems in recruiting sufficient numbers of nurses, pharmacists, and technicians. The forecast failed to anticipate the impact of a strong regional economy on supply and underestimated the resilience of underlying forces that have driven the long-term growth in healthcare workforce demand. More effective ongoing monitoring can help moderate the fluctuation of workforce shortages and surpluses.

From home, to market, to headquarters, to home. Relocating health services planning and purchasing in New Zealand

Health sector restructuring has been in vogue, but no country has engaged in as much health sector restructuring as New Zealand where, in a decade, there have been four different public health sector structures. This article discusses New Zealand's four structures with an emphasis on relocating the critical functions of health care planning and purchasing, and on the development of the present district health board system. The four structures include: an area health board system (1989-1991) with planning and purchasing located at "home" in local areas and closely aligned with service provision; a competitive internal market system (1993-1996) which separated planning and purchasing from service provision; a centralised system with a "headquarters" controlling planning and purchasing (1997-1999) while maintaining the distance from provision; and the district health board system currently under development (1999-) which sees purchasing and planning sent home again to regions and linked closely with service provision. The present system entails the devolution of considerable responsibility to the local level, within a framework of strong central government control. Based on New Zealand's experience, the article notes that all but the market structure appear to have provided an adequate environment for effective health care planning and purchasing.

Challenges for District Health Boards as needs assessors

DHBs face the foregoing challenges in the current and future environment, as they take on democratic representation for the population, particularly in health needs assessment, consultation, prioritization and health service purchasing. Need and objectives must be clearly defined at an early stage in the context of resource constraints and timeframes that will challenge the ability of Boards to conduct needs assessments. Consultation with the community and other, expert groups must inform needs assessments. But it is not clear how the prioritization process will work, particularly regarding the ability of local agendas for purchasing of health services that complement the national agenda. Recent health crises have shown that DHBs, without Government support, cannot easily meet such challenges in the new decentralised environment. Consideration must therefore be given to how these identified challenges for DHBs as needs assessors can best be met.

Regional Network for Research, Surveillance and Control of Asian Schistosomiasis (RNAS)

In order to strengthen the communication, cooperation and coordination among scientists and control authorities concerned with these parasitic diseases at the regional level, the establishment of the Regional Network on Asian Schistosomiasis (RNAS) was initiated 1998 in Wuxi, People's Republic of China. The RNAS was facilitated by an initiating collaborative research grant from WHO/TDR in 1999. The main activities and achievements of the RNAS during its first 2 years of existence are described. It is hoped that more interested parties will become involved in the network activities and other international agencies will consider providing technical and financial support to the network in the future to ensure the sustained development of the RNAS. The website of RNAS is now available in both English and Chinese versions with URL address: http://www.rnas.org. Thus far, the RNAS has held two important meetings with a third planned for 2002. The annual meeting will involve scientists and control authorities from all countries endemic for Asian schistosomiasis, providing a forum for more regional cooperation and coordination. More focus will be directed at training activities in specific fields such as immunodiagnostics, standardization of ultrasound use for monitoring infection-related morbidity, cost factor analysis, application of GIS/RS technology, environmental modification and human behaviour, agricultural efforts including livestock management for control of schistosome transmission, etc.

[Importance of regional surgery networks]

The rapid advantages in medicine require large-scale implementation where justified, and concentration where complexity of the care makes this necessary. Cautious initiatives to establish regional surgical networks were taken in many places in the Netherlands. These networks might play an important part in the spreading and concentration of care. New surgical techniques, such as the sentinal node procedure, can be implemented professionally using these networks. Also, within these networks, guest surgeons may in various locations perform relatively rare operations or assist with them, especially if the ultimate result of the treatment is primarily determined peroperatively by specific surgical technical experience. In cases in which the results of the treatment depend not so much on the surgeon himself but rather on the experience of various disciplines with a range of diagnostic and therapeutic interventions, referral to a centre is in general to be preferred.

[Differences in average hospital stay in German inpatient institutions analysed on a regional basis before and after re-unification]

The current German average length of hospital stay (ALOS) is comparatively too high, if seen on an international level. Since 1902 a clear and permanent reduction of ALOS is evident in Germany from official statistics. The decrease of ALOS was synchronous in East and West Germany even after reunification. The interpretation of ALOS results is rendered more difficult because German statistic consider both hospitals and rehabilitation centres when calculating annual case numbers of hospital treatment and ALOS. Consequently, the ALOS data cannot be a suitable parameter for analysing the effectiveness of the German hospital system.

New approaches to managing health services

The Swedish health care system is at the crossroads. During the next decade, decentralizing responsibility and authority in the county councils will be the most urgent task. But whatever changes may take place, the basic health policy that everyone in Sweden, regardless of economic status, is to have access to good health on equal terms will remain unaffected.

[Increasing organ donation by regionalization]

According to the German transplantation law all hospital are obliged to report potential donors. This obligation can only become effective with comprehensive support provided by an organ procurement organization. Together with additional tasks, e.g., in the field of information and motivation, the entire service requires a financial basis which is only available in a region of a certain minimum size, minimum activity and minimum reimbursement, respectively. The regionalization of organ donation has to be considered independently from questions of allocation.

[Epidemiology of dementia and regional health care concepts for dementia patients and relatives]

The prevalence of dementia varies according to the definitions used but shows always an exponential increase with age, a doubling by every five years increase from 60-95 years. Due to the aging of the baby boom generation a doubling of dementia prevalence in the next 50 years is to be expected. Alzheimer's disease is the most frequent cause of dementia. Combinations with vascular, Lewybody, frontotemporal and other causes of dementia are much more frequent than first considered. They all give rise to severe dementia despite only mild Alzheimer changes in the brain. However, a therapeutic response may be expected from cholinergic therapy. Since this pharmacotherapy of dementia only leads to a limited delay of 6-10 months in the progression of dementia, combinations with psychosocial measures such as caregiver-education and care-planning are necessary. We therefore need centers of excellence, such as memory clinics or psychogeriatric counselling centers throughout Switzerland.

A conceptual framework for mental health services: the matrix model

BACKGROUND

The reform of mental health services needs to be guided by an overall conceptual framework. Such a framework is important to avoid many risks, including extrapolating from a specific service site to other services, without taking into account local and regional variables.

METHODS

A conceptual framework, the 'matrix model', is proposed. This model has been developed using the most relevant information that is necessary for describing and interpreting mental health services data as well as patient-based information.

RESULTS

The 'matrix model' has two dimensions: the geographical, which refers to three levels (country, local and patient) and the temporal, which refers to three phases (inputs, processes and outcomes). Using these two dimensions a nine-cell matrix is constructed to bring into focus critical issues for mental health services. The relevance of each level and each phase is briefly presented.

CONCLUSIONS

The matrix is intended to assist clinicians, planners and researchers to deal with clinical phenomena, organizational issues, and research questions that share a degree of complexity that render inadequate analyses and the interventions made only at one level. The matrix model applies particularly to mental health systems of care that are provided with a public health framework, and is less useful for contexts that consist of clinicians offering only one-to-one treatments, within fragmented programmes of care.

Health care reform in the American states: administrative capacity building

As the nation moves to reform Medicare and the health care industry becomes more competitive which will dramatically change the means by which health care is organized and financed, state governments ought to be establishing administrative capacity to administer new systems. This article describes past experiences of states in similar efforts and uses the legislation written in 13 states to analyze in greater detail current state health reform activities. Policies that create new central authorities have the greatest likelihood of building the appropriate administrative infrastructures. Provisions related to establishing data bases, creating regional authorities or advisory committees, establishing uniform claims, and facilitating integrated systems of care are common to several proposals. Previous state experiences with health planning and citizen involvement are evident in the schemes being proposed and enacted.

Beyond ideology: the emerging roles of New Zealand's crown health enterprises

New Zealand has experienced radical public sector restructuring over the last decade, including the corporatization and subsequent privatization of state trading units and the reform of social services, including health. In 1991 a new government proposed and then implemented more radical health reforms, which included the corporatization of state-owned provider units (23 crown health enterprises) and the creation of an internal market with purchasers (four regional health authorities) separated from providers. Interviews with chief executives of crown health enterprises suggest that provider units are seeking a wider role than envisaged, with an interest in the health needs of their populations and undertaking some purchasing on their behalf. The purchasers see a narrower role for crown health enterprises. Both purchasers and providers report that competition between providers is not particularly helpful (and with only limited opportunities for this to occur), with collaboration being seen as more useful. Providers are critical of purchasers ability to adopt a strategic approach. Unlike other aspects of New Zealand's restructuring, there appears to be a retreat from some of the more radical facets of the reforms, reflecting both the resistance of the health sector and a newly uncertain political climate.

Coordinating rural divisions: the workforce window

Divisions of General Practice have been established to alleviate the professional isolation which general practitioners face by being excluded from involvement in other parts of the health care system. Divisions facilitate the development of local communication networks and cooperative activities which improve the integration of general practice with other elements of the health system. Coordination of communication is one of the strengths of divisions at the local level and Rural Divisions Co-ordinating Units at the State level. This strength is being effectively utilised to target general practice workface issues. Given the significant proportion of general practitioners in the medical workforce, particularly in rural and remote areas, this has implications for broader medical workforce issues. Australia faces a maldistribution in its general practitioner workforce, with an excess supply in urban areas and a significant shortfall in rural and remote areas. Since 1995-96, the General Practice Rural Incentives Program, which targets the recruitment and retention of rural doctors, has devolved funding to the Rural Divisions Co-ordination Units to coordinate the statewide provision of practical assistance to rural general practitioners, through their divisions, in relation to continuing medical education and the provision of locums. There is potential to build on the success of these initiatives and also to work with urban divisions through the state-based organisational structures which are currently being developed.

[Regional disparities in accessibility of inpatient treatment for elderly patients]

This article analyzes the supply of residential care facilities for old people in Germany with the aim to discover regional disparities. The analysis is based on the directory of residential institutions for old people (Altenheimadressbuch). On a national level the supply of residential care facilities in this data base is comparable with the results of the national statistic (Heimplatzstatistik). The results show considerable disparities that only to a minor extent coincide with the regional distribution of older people. Although there is no definite coherence between the supply of residential care facilities and the family care potential, there is a significant negative correlation between both.