Geographic Access Barriers Research Articles

Impact of a remote second opinion program on changes in recommended treatment plans for patients with cancer across the U.S.

386 Background: Second opinion consultations are a promising strategy to identify errors in diagnosis and recommend the optimal course of treatment for the patient. Yet, there are several barriers to patients accessing second opinions, including geographic barriers. By bringing high-level care to patients where they live, remote second opinion programs might benefit populations without access to subspecialty cancer centers, including those from underserved communities. While meaningful changes from in-person second opinions have been observed at several institutions, little is known about how often remote second opinions lead to similar improvements in treatment plans. Thus, our objective was to examine the extent to which the Memorial Sloan Kettering Cancer Center (MSK) remote second opinion program led to changes in treatment plans for cancer patients residing across the U.S. Methods: MSK is a high-volume cancer center based in NYC. MSK’s remote second opinion program was developed and rolled out as part of a national cancer benefits solution in 2016. Each second opinion review process is conducted by an MSK subspecialist and enabled by a customized digital platform. The process is asynchronous. To capture subspecialists’ perceptions of the importance of any changes to diagnosis or treatment recommended, we designed and administered a questionnaire starting in December 2023 that subspecialists completed after each case. Here, we report summary findings from the first 100 second opinion cases with complete information from this questionnaire. Results: These 100 case reviews were completed between December 2023 and April 2024. Spanning cancer types, the cases were reviewed by 49 unique subspecialists. There were 17 patients with breast cancer, 9 with colon cancer, 9 with lymphoma, 9 with prostate cancer, 7 with endometrial cancer, 7 with squamous cell carcinoma, 6 with myeloma, 5 with ovarian cancer, and 31 with one of 18 other cancer types. Patients had a mean age of 57 years (median 58) and 61% were female. Patients were from 27 different U.S. states. Of the 100 cases reviewed, subspecialists made a “meaningful change” (expected to affect patient outcomes) in recommended treatment, in 39 cases (39%). These meaningful changes included better prognosis / survival (n=26, 67%), reduced short-term morbidity / quality of life / toxicity (n=17, 44%), or improved long-term morbidity / quality of life / toxicity (n=29, 74%). There was a higher percent of recommended changes for liquid tumor cases compared to solid tumor cases (11/17, 65% for liquid; 28/83, 34% for solid). Conclusions: Findings are crucial for understanding potential opportunities to grow remote second opinion programs to benefit patients. This information is also essential for identifying the most effective strategies to reach underserved communities with geographic access barriers to high-quality subspecialty cancer care.

Social vulnerability and geographic access barriers to earthquake early warning education in museums and other free choice learning environments

Given the earthquake risk on the West Coast of the United States, individuals and communities require a basic understanding of ShakeAlert earthquake early warning technology, which may provide crucial seconds of warning. Free choice learning environments (FCLEs), such as museums, public libraries, and national parks, are uniquely positioned to expand the reach of earthquake early warning through educational initiatives and resources. Earthquake education in these spaces creates awareness of earthquake hazards and risk in areas where people live or visit and may also increase engagement in preparedness behavior as they are trusted sources of information in their communities. However, population demographics within the ShakeAlert states has yet to be examined; audience segmentation theories require a better understanding of the demographics of the people the system seeks to serve. Here we build upon previous typology research that examined over 150 earthquake displays around the United States and found that most did not include information about earthquake preparedness or associated protective actions. This new research shifts to a hierarchical clustering analysis that identifies seven main population groups within the ShakeAlert states. We also find that the cost of admission and the geographic distance away from FCLEs, including the potential cost and time of transportation, may lead to an urban-rural divide in visitor access. Using audience segmentation theories as related to earthquakes, we can understand critical barriers to FCLEs and opportunities for ShakeAlert education. As earthquake early warning systems expand internationally, thoughtful and equitable education initiatives are beneficial to reach critical audiences.

Improving geographic access to methadone clinics

IntroductionOpioid misuse is a nationwide public health crisis. Methadone treatment is proven to be highly successful in preventing opioid use disorder, reducing the use of illicit drugs, and preventing overdoses. Clients acquire methadone daily from clinics, making geographic access crucial for the initiation of and adherence to treatment. MethodsThis work estimates unsatisfied methadone demand due to lack of geographic access at a census tract level and models the problem of identifying optimal locations to open new methadone clinics. The objective function of the model is a weighted combination of providing access to individuals with unmet methadone demand and improving the travel time of individuals currently attending a clinic. Data on existing methadone clinics and statewide methadone demand is acquired from Substance Abuse and Mental Health Services Administration (SAMHSA) surveys from 2019. Unsatisfied demand is estimated through a linear regression model after aggregating the population, heroin use, and satisfied methadone demand at the state level. ResultsNationwide, we find 18.2 % of the United States population does not have geographic access to a methadone clinic and estimate 77,973 individuals in these areas would attend a clinic if geographic access barriers were removed (95 % CI: 67,413–88,532). In a case study of six Midwestern states, we find that geography significantly contributes to the value of opening additional clinics and we see large differences in expected gains between states sharing similar characteristics such as population and satisfied methadone demand. The number of additional clients served by opening one new clinic ranges from 180 to 804 across these six states, representing between 8.4 % and 16.2 % of state unmet demand. Between 1.2 % and 14.1 % of existing clients were reassigned with a single newly opened clinic, with a one-way average travel distance improvement between 6.3 and 11.9 miles / person / day for these clients. ConclusionsThe results demonstrate the large unserved methadone demand in the United States, the significant improvement in methadone access for new and existing clients that can be achieved by opening new clinics, and the important role state-specific geography plays in these decisions.

Financial and Geographic Barriers to Health Care Access in Kenya: The Quest towards Universal Health Coverage

Abstract Background: Access to health care services without being plunged into financial hardship is a life blood of the Universal Health Coverage. Kenya's health sector is heavily dependent on out of pocket health expenditure. This model of health financing is inequitable and leads to underutilization of the much needed health care services. Majority of Kenyans travel for longer distances to access health care services. The geographic access barrier is linked to delayed care, missed appointments, delayed medication and undue loss of life. This study examines the correlates of financial and geographic health care access barriers in the UHC implementing Counties in Kenya. Methodology: The study used a cross-sectional data collected from 249 respondents using exit interviews at the health facilities drawn from the Kenya Master Health Facility List (KMHL). A multivariate log it regression model was used to analyze the predictors of probability of failure to access health care services owing to prohibitive health care and transport costs. Results: High out-of-pocket monthly expenditure on medicine; wider proximity, higher transportation cost and a longer traveling time to a health facility increases the probability of not seeking medical treatment owing to prohibitive health care and transportation costs. These factors thus, acts as key barriers to health care access. Conclusion: Financial and geographic access barriers negatively impact on health care access. To hasten the realization of the Universal Health Coverage, prepayment models such as use of taxes and insurance should be pursued.

Impact of geographic access to primary care providers on pediatric behavioral health screening

Behavioral Health (BH) screening is critical for early diagnosis and treatment of pediatric mental disorders. The objective of this study was to assess the impact of geographic access to primary care providers (PCP) on pediatric BH screening in children with different race/ethnicity. A retrospective cohort study was conducted using the 2013–2016 administrative claims data from a large pediatric Medicaid Managed Care Plan that have been linked to 2010 US Census data and the 2017 National Provider Identifier (NPI) Registry. Geographic access was defined as the actual travel distance to nearest PCP and the PCP density within 10-mile travel radius from each individual's residence. Stratified multivariate logistic regression was conducted to examine the association between the geographic access to PCP and the likelihood of receiving screening for behavioral disorders within each racial/ethnic group. BH screening rate was 12.6% among 402,655 children and adolescents who met the inclusion criteria. Multivariable analysis stratified by individual race/ethnicity revealed that Hispanic and Black children were more vulnerable to the geographic access barriers than their non-Hispanic White counterparts. The increase in travel distance to the nearest PCP was negatively associated with screening uptake only among Hispanics (10–20 miles vs. 0–10 miles: OR = 0.78, 95% CI [0.71–0.86]; 20–30 miles vs. 0–10 miles: OR = 0.35, 95% CI [0.23–0.54]). In a subgroup that had access to at least one PCP within 10 miles of travel distance, the variation in PCP density had a greater impact on the screening uptake among Hispanics and Blacks than that in non-Hispanic Whites.

Addressing vaccine hesitancy and access barriers to achieve persistent progress in Israel\u2019s COVID-19 vaccination program

As of March 31, 2021, Israel had administered 116 doses of vaccine for COVID-19 per 100 population (of any age) – far more than any other OECD country. It was also ahead of other OECD countries in terms of the share of the population that had received at least one vaccination (61%) and the share that had been fully vaccinated (55%). Among Israelis aged 16 and over, the comparable figures were 81 and 74%, respectively. In light of this, the objectives of this article are:To describe and analyze the vaccination uptake through the end of March 2021To identify behavioral and other barriers that likely affected desire or ability to be vaccinatedTo describe the efforts undertaken to overcome those barriersIsrael’s vaccination campaign was launched on December 20, and within 2.5 weeks, 20% of Israelis had received their first dose. Afterwards, the pace slowed. It took an additional 4 weeks to increase from 20 to 40% and yet another 6 weeks to increase from 40 to 60%. Initially, uptake was low among young adults, and two religious/cultural minority groups - ultra-Orthodox Jews and Israeli Arabs, but their uptake increased markedly over time.In the first quarter of 2021, Israel had to enhance access to the vaccine, address a moderate amount of vaccine hesitancy in its general population, and also address more intense pockets of vaccine hesitancy among young adults and religious/cultural minority groups. A continued high rate of infection during the months of February and March, despite broad vaccination coverage at the time, created confusion about vaccine effectiveness, which in turn contributed to vaccine hesitancy. Among Israeli Arabs, some residents of smaller villages encountered difficulties in reaching vaccination sites, and that also slowed the rate of vaccination.The challenges were addressed via a mix of messaging, incentives, extensions to the initial vaccine delivery system, and other measures. Many of the measures addressed the general population, while others were targeted at subgroups with below-average vaccination rates. Once the early adopters had been vaccinated, it took hard, creative work to increase population coverage from 40 to 60% and beyond.Significantly, some of the capacities and strategies that helped Israel address vaccine hesitancy and geographic access barriers are different from those that enabled it to procure, distribute and administer the vaccines. Some of these strategies are likely to be relevant to other countries as they progress from the challenges of securing an adequate vaccine supply and streamlining distribution to the challenge of encouraging vaccine uptake.

PRO56 THE GEOGRAPHIC AVAILABILITY OF SUB-SPECIALIZED METABOLIC AND PEDIATRIC TRANSPLANT CARE AND ITS IMPACT ON TREATMENT CHOICE IN PATIENTS WITH UREA CYCLE DISORDERS

Urea cycle disorders (UCD) are rare inherited metabolic diseases (IMDs) characterized by episodes of hyperammonemia, which, if untreated, lead to brain damage and death. There are two treatment options for UCD: 1) medical management (MM) with diet and medications, or 2) liver transplant (LT). Both are associated with mortality and morbidity but evidence comparing outcomes is sparse. Patients with IMDs also face geographic access barriers to sub-specialized care, which further complicates treatment decision-making. This study applied Geographic Information System (GIS) technology to examine how the geographic availability of care, as a metric of health care access, impacts treatment choice in this population. Residence data (N=252) was combined with hospital address data in ArcGIS to model geographic proximity to regionalized expert UCD care sites and pediatric LT centers. Proximity was linked to patient disease and treatment history to test the association between geographic availability of sub-specialized care and treatment choice. Interaction terms were integrated to examine how associations change in response to disease severity or control. Analysis found that the odds of LT is 3.22 times higher among patients whose nearest pediatric LT center is one of two considered to deliver the “gold standard” in transplant care. These findings suggest that treatment choice may be driven by the patient’s distance to certain programs where LT as treatment for UCD is strongly supported. Interaction models suggest that treatment decisions among patients with a less severe condition may be even more responsive to the characteristics of their nearest expert institution (OR=4.45). Findings suggest that treatment choice in UCD may be guided by the culture of the institution where patients are geographically able to access care. Researchers and practitioners should strive to better understand the drivers of unwarranted variation in treatment guidance for IMDs and evaluate interventions that address inter-institutional inconsistencies in treatment practice.

Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil

BackgroundUnequal distribution of emergency care services is a critical barrier to be overcome to assure access to emergency and surgical care. Considering this context it was objective of the present work analyze geographic access barriers to emergency care services in Brazil. A secondary aim of the study is to define possible roles to be assumed by small hospitals in the Brazilian healthcare network to overcome geographic access challenges.MethodsThe present work can be classified as a cross-sectional ecological study. To carry out the present study, data of all 5843 Brazilian hospitals were categorized among high complexity centers and small hospitals. The geographical access barriers were identified through the use of two-step floating catchment area method. Once concluded the previous step an evaluation using the Getis-Ord-Gi method was performed to identify spatial clusters of municipalities with limited access to high complexity centers but well covered by well-equipped small hospitals.ResultsThe analysis of accessibility index of high complexity centers highlighted large portions of the country with nearly zero hospital beds by inhabitant. In contrast, it was possible observe a group of 1595 municipalities with high accessibility to small hospitals, simultaneously with a low coverage of high complexity centers. Among the 1595 municipalities with good accessibility to small hospitals, 74% (1183) were covered by small hospitals with at least 60% of minimum emergency service requirements. The spatial clusters analysis aggregated 589 municipalities with high values related to minimum emergency service requirements. Small hospitals in these 589 cities could promote the equity in access to emergency services benefiting more than eight million people.ConclusionsThere is a spatial disequilibrium within the country with prominent gaps in the health care network for emergency services. Taking this challenge into consideration, small hospitals could be a possible solution and foster equity in access to emergency and surgical care. However more investments in are necessary to improve small hospitals capabilities to fill this gap.

Geographic Information Systems Mapping of Diabetic Retinopathy in an Ocular Telemedicine Network

Minimal information exists on the use of geographic information systems mapping for visualizing access barriers to eye care for patients with diabetes. To use geographic information systems mapping techniques to visualize (1) the locations of patients participating in the North Carolina Diabetic Retinopathy Telemedicine Network, (2) the locations of primary care clinicians and ophthalmologists across the state, and (3) the travel times associated with traveling to the 5 primary care clinics in our study. Cross-sectional study conducted from January 6, 2014, to November 1, 2015, at 5 Area Health Education Center primary care clinics that serve rural and underserved populations in North Carolina. In total, 1787 patients with diabetes received retinal screening photographs with remote expert interpretation to determine the presence and severity of diabetic retinopathy. Participants included patients 18 years or older with type 1 or type 2 diabetes who presented to these 5 clinics for their routine diabetes care. Development of qualitative maps illustrating the density of patients with diabetes and their distribution around the 5 North Carolina Diabetic Retinopathy Telemedicine Network sites by zip code and the density of ophthalmologists and primary care clinicians by zip code relative to US Census Urban Areas. A travel time map was also created using road network analysis to determine all areas that can be reached by car in a user-specified amount of time. Mean (SD) age of patients was 55.4 (12.7) years. Women made up 62.7% of the study population. The study included more African American patients (55.4%) compared with white (35.5%) and Hispanic (5.8%) patients. The mean (SD) hemoglobin A1c level was 7.8% (2.4%) (to convert to proportion of total hemoglobin, multiply by 0.01), and the mean (SD) duration of diabetes was 9.2 (8.2) years. Whereas the clinics located in Greensboro, Asheville, and Fayetteville screened patients from more immediate surrounding areas, the Greenville site had the widest distribution of zip codes, suggesting that patients travel from greater distances to reach this facility. Primary care clinicians were spread somewhat uniformly across the state, whereas ophthalmologists were concentrated around urban centers. Also, the number and type of surface roads surrounding the clinics determined the distance and time patients must travel to receive care. Geographic information systems mapping is a useful technique for visualizing geographic access barriers to eye care for patients with diabetes and may help to identify underserved areas that would benefit from the expansion of retinal screening programs via telemedicine.

Barriers to alcohol and other drug treatment use among Black African and Coloured South Africans

BackgroundThere are racial disparities in the use of alcohol and other drug (AOD) treatment services in South Africa but little is known about the factors contributing to these disparities. This study aimed to redress this gap through identifying differences in barriers to AOD treatment use among Black African and Coloured persons from Cape Town, South Africa. The Behavioral Model of Health Services Utilization was used as an analytic framework.MethodsA case-control design was used to compare 434 individuals with AOD problems who had accessed treatment with 555 controls who had not accessed treatment on a range of variables. Logistic regression procedures were employed to examine the unique profile of variables associated with treatment utilization for Black African and Coloured participants.ResultsAfter controlling for the influence of treatment need and predisposing factors on treatment use, several barriers to treatment were identified. Greater awareness of treatment options and fewer geographic access and affordability barriers were strongly associated with an increased likelihood of AOD treatment use for both race groups. However, Black African persons were more vulnerable to the effects of awareness and geographic access barriers on treatment use. Stigma consciousness was only associated with AOD treatment utilization for Coloured participants.ConclusionDifferences in barriers to AOD treatment use were found among Black African and Coloured South Africans. Targeted interventions that address the unique profile of barriers experienced by each race group are needed to improve AOD treatment use by these underserved groups. Several strategies for improving the likelihood of treatment entry are suggested.

Expanding HIV Testing Efforts in Concentrated Epidemic Settings: A Population-Based Survey from Rural Vietnam

BackgroundTo improve HIV prevention and care programs, it is important to understand the uptake of HIV testing and to identify population segments in need of increased HIV testing. This is particularly crucial in countries with concentrated HIV epidemics, where HIV prevalence continues to rise in the general population. This study analyzes determinants of HIV testing in a rural Vietnamese population in order to identify potential access barriers and areas for promoting HIV testing services.MethodsA population-based cross-sectional survey of 1874 randomly sampled adults was linked to pregnancy, migration and economic cohort data from a demographic surveillance site (DSS). Multivariate logistic regression analysis was used to determine which factors were associated with having tested for HIV.ResultsThe age-adjusted prevalence of ever-testing for HIV was 7.6%; however 79% of those who reported feeling at-risk of contracting HIV had never tested. In multivariate analysis, younger age (aOR 1.85, 95% CI 1.14–3.01), higher economic status (aOR 3.4, 95% CI 2.21–5.22), and semi-urban residence (aOR 2.37, 95% CI 1.53–3.66) were associated with having been tested for HIV. HIV testing rates did not differ between women of reproductive age who had recently been pregnant and those who had not.ConclusionsWe found low testing uptake (6%) among pregnant women despite an existing prevention of mother-to-child HIV testing policy, and lower-than-expected testing among persons who felt that they were at-risk of HIV. Poverty and residence in a more geographically remote location were associated with less HIV testing. In addition to current HIV testing strategies focusing on high-risk groups, we recommend targeting HIV testing in concentrated HIV epidemic settings to focus on a scaled-up provision of antenatal testing. Additional recommendations include removing financial and geographic access barriers to client-initiated testing, and encouraging provider-initiated testing of those who believe that they are at-risk of HIV.

Inequitable access to substance abuse treatment services in Cape Town, South Africa

BackgroundDespite high levels of substance use disorders in Cape Town, substance abuse treatment utilization is low among people from disadvantaged communities in Cape Town, South Africa. To improve substance abuse treatment utilization, it is important to identify any potential barriers to treatment initiation so that interventions to reduce these barriers can be implemented. To date, substance abuse research has not examined the factors associated with substance abuse treatment utilization within developing countries. Using the Behavioural Model of Health Services Utilization as an analytic framework, this study aimed to redress this gap by examining whether access to substance abuse treatment is equitable and the profile of variables associated with treatment utilization for people from poor communities in Cape Town, South Africa.MethodsThis study used a case-control design to compare 434 individuals with substance use disorders from disadvantaged communities who had accessed treatment with 555 controls who had not accessed treatment on a range of predisposing, treatment need and enabling/restricting variables thought to be associated with treatment utilization. A hierarchical logistic regression was conducted to assess the unique contribution that the need for treatment, predisposing and enabling/restricting variable blocks made on substance abuse treatment utilization.ResultsFindings revealed that non-need enabling/restricting variables accounted for almost equal proportions of the variance in service utilization as the need for treatment variables. These enabling/restricting variables also attenuated the influence of the treatment need and predisposing variables domains on chances of treatment utilization. Several enabling/restricting variables emerged as powerful partial predictors of utilization including competing financial priorities, geographic access barriers and awareness of treatment services. Perceived severity of drug use, a need for treatment variable) was also a partial predictor of utilization.ConclusionsFindings point to inequitable access to substance abuse treatment services among people from poor South African communities, with non-need factors being significant determinants of treatment utilization. In these communities, treatment utilization can be enhanced by (i) expanding the existing repertoire of services to include low threshold services that target individuals with less severe problems; (ii) providing food and transport vouchers as part of contingency management efforts, thereby reducing some of the financial and geographic access barriers; (iii) introducing community-based mobile outpatient treatment services that are geographically accessible; and (iv) employing community-based outreach workers that focus on improving awareness of where, when and how to access existing treatment services.

Access to Ambulatory Medical and Long-Term Care Services Among Elderly Medicare and Medicaid Beneficiaries: Organizational, Financial, and Geographic Barriers

The comprehensive insurance coverage afforded low-income elders with both Medicare and Medicaid coverage (dual enrollees) has substantially reduced financial barriers to care. However, other studies show reduced and less appropriate utilization patterns among dual enrollees compared to Medicare beneficiaries with private supplemental insurance, suggesting access barriers remain. This study found that 59 percent of elderly dual enrollees needed an ambulatory medical or long-term care service in a 1-year period. One third of these individuals experienced barriers to access; organizational and geographic barriers were more prevalent than financial barriers. African American race, trouble paying basic living expenses, fair or poor health status, and an unfavorable assessment of physician information giving were significantly associated with an increased likelihood of organizational and geographic access barriers among elderly dual enrollees.

Determinants of health care use by children in rural western North Carolina: results from the Mountain Accessibility Project.

To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States. Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods. Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >40 000 dollars per year had 76% more visits than those with incomes <20 000 dollars per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >40 000 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group. This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child's pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation.