Abstract
The association between proximity to health care facilities and improved disease management and population health has been documented, but little is known about small-area health care environments and how the presence of health care facilities has changed over time during recent health system and policy change. To examine geographic access to health care facilities across neighborhoods in the United States over a 15-year period. Using longitudinal business data from the National Establishment Time-Series, this cross-sectional study examined the presence of and change in ambulatory care facilities and pharmacies and drugstores in census tracts (CTs) throughout the continental United States between 2000 and 2014. Between January and April 2019, multinomial logistic regression was used to estimate associations between health care facility presence and neighborhood sociodemographic characteristics over time. Change in health care facility presence was measured as never present, lost, gained, or always present between 2000 and 2014. Neighborhood sociodemographic characteristics (ie, CTs) and their change over time were measured from US Census reports (2000 and 2010) and the American Community Survey (2008-2012). Among 72 246 included CTs, the percentage of non-US-born residents, residents 75 years or older, poverty status, and population density increased, and 8.1% of CTs showed a change in the racial/ethnic composition of an area from predominantly non-Hispanic (NH) white to other racial/ethnic composition categories between 2000 and 2010. The presence of ambulatory care facilities increased from a mean (SD) of 7.7 (15.9) per CT in 2000 to 13.0 (22.9) per CT in 2014, and the presence of pharmacies and drugstores increased from a mean (SD) of 0.6 (1.0) per CT in 2000 to 0.9 (1.4) per CT in 2014. Census tracts with predominantly NH black individuals (adjusted odds ratio [aOR], 2.37; 95% CI, 2.03-2.77), Hispanic/Latino individuals (aOR 1.30; 95% CI, 1.00-1.69), and racially/ethnically mixed individuals (aOR, 1.53; 95% CI, 1.33-1.77) in 2000 had higher odds of losing health care facilities between 2000 and 2014 compared with CTs with predominantly NH white individuals, after controlling for other neighborhood characteristics. Census tracts of geographic areas with higher levels of poverty in 2000 also had higher odds of losing health care facilities between 2000 and 2014 (aOR, 1.12; 95% CI, 1.05-1.19). Differential change was found in the presence of health care facilities across neighborhoods over time, indicating the need to monitor and address the spatial distribution of health care resources within the context of population health disparities.
Highlights
Geographic access to health care is associated with increased use of preventive care and improved health outcomes for certain chronic conditions.[1,2,3,4,5,6,7] geographic access is one of several components that can alter an individual’s overall access to health care, including insurance status, out-of-pocket costs, facility hours, appointment wait times, and linguistic services, prior research has shown increased geographic access is associated with greater use and improved outcomes
The presence of ambulatory care facilities increased from a mean (SD) of 7.7 (15.9) per census tracts (CTs) in 2000 to 13.0 (22.9) per CT in 2014, and the presence of pharmacies and drugstores increased from a mean (SD) of 0.6 (1.0) per CT in 2000 to 0.9 (1.4) per CT in 2014
Census tracts with predominantly NH black individuals, Hispanic/Latino individuals, and racially/ethnically mixed individuals in 2000 had higher odds of losing health care facilities between 2000 and 2014 compared with CTs with predominantly NH white individuals, after controlling for other neighborhood characteristics
Summary
Geographic access to health care is associated with increased use of preventive care and improved health outcomes for certain chronic conditions.[1,2,3,4,5,6,7] geographic access is one of several components that can alter an individual’s overall access to health care, including insurance status, out-of-pocket costs, facility hours, appointment wait times, and linguistic services, prior research has shown increased geographic access is associated with greater use and improved outcomes. Neighborhoods with more income inequality and residential segregation along sociodemographic lines may not attract or may underinvest in institutions that benefit the general population, resulting in unequal geographic health care access.[8] Previous analyses of geographic access to health care services, including trauma centers, specialty care for neonatal populations, and mental health care, have indicated that neighborhoods with predominantly minority residents, lower socioeconomic status, and high residential turnover have less geographic access to care.[9,10] This observation was confirmed by Smiley et al,[11] who reported that health-related resources are not distributed across space and that disadvantage often clusters with residential racial/ethnic patterning. Recent data indicate access to health care, as measured by insurance coverage or self-report of having a usual source of care, has improved since implementation of the Patient Protection and Affordable Care Act,[12] few sources are available to understand geographic health care environments, including the presence of ambulatory care facilities, retail clinics, and pharmacies and drugstores, beyond county-level geographies
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