Geographic Disparities In Access Research Articles

State-level differences in personality and geographic disparities in access to palliative care: Findings on openness.

57 Background: There are geographic disparities in access to palliative care that cause unnecessary suffering near the end of life in low-access U.S. states. The psychological mechanisms explaining state-by-state variation in access to palliative care are poorly understood. Our objective was to examine whether state-level differences in personality explain state-by-state variation in palliative care access. Methods: We combined four datasets with state-level data for the 50 U.S. states and the national capitol. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. Statewide personality differences were identified from a report on 619,387 adults who completed the well-validated Big Five Inventory, which assesses the five core personality dimensions: openness, conscientiousness, agreeableness, neuroticism, and extraversion. The U.S. Census and Gallup provided data on covariates. Regression analyses examined whether state-level differences in personality predicted statewide access to palliative care, controlling for differences in population size, age, gender, race/ethnicity, socioeconomic status, and political views. Results: Access to palliative care was worse in states that were younger, more racially diverse, lower in socioeconomic status, more politically conservative, and lower in openness. In regression analyses that simultaneously accounted for all predictors and covariates, only lower openness continued to explain worse state-level access to palliative care (β = 0.428, p = 0.008). Conclusions: Palliative care access is worse in states where people are lower in openness, meaning residents who are more skeptical, traditional, and concrete. Personality theory offers specific recommendations for palliative care advocates communicating with hospital administrators, legislators, philanthropists, and patients to expand access in low-openness states.

Transforming Access to Specialist Care for Inflammatory Bowel Disease: The PACE Telemedicine Program.

BackgroundThere are significant geographic disparities in the delivery of IBD healthcare in Ontario which may ultimately impact health outcomes. Telemedicine-based health services may potentially bridge gaps in access to gastroenterologists in remote and underserved areas.MethodsWe conducted a needs assessment for IBD specialist care in Ontario using health administrative data. As part of a separate initiative to address geographic disparities in access to care, we described the development and implementation of our Promoting Access and Care through Centres of Excellence (PACE) Telemedicine Program. Over the first 18 months, we measured wait times and potential cost savings.ResultsWe found substantial deficiencies in specialist care early in the course of IBD and continuous IBD care in regions where the number of gastroenterologists per capita were low. The PACE Telemedicine Program enabled new IBD consultations within a median time of 17 days (interquartile range [IQR], 7–32 days) and visits for active IBD symptoms with a median time of 8.5 days (IQR, 4–14 days). Forty-five percent of new consultations and 83% of patients with active IBD symptoms were seen within the target wait time of two weeks. Telemedicine services resulted in an estimated cost savings of $47,565 among individuals who qualified for Ontario’s Northern Travel Grant.ConclusionsThe implementation of telemedicine services for IBD is highly feasible and can reduce wait times to see gastroenterologists that meet nationally recommended targets and can lead to cost savings.

Rural-Urban Disparities in Access to Breast Cancer Screening: A Spatial Clustering Analysis.

The purpose of this study was to examine rural-urban differences in access to breast cancer screening in a predominantly rural Midwestern state in the United States. The study is a retrospective analysis of pooled cross-sectional data for the years 2008 to 2012. We conducted hot spot analyses of the rate of late-stage diagnosis of breast cancer at the census tract level in Nebraska for cases diagnosed between 2008 and 2012, using cancer registry data. We also conducted hot spot analyses of access to mammography facilities (distance to the nearest center) using data on mammography facilities from the US Food and Drug Administration and rates of screening using the National Private Insurance Claims data for year 2013. The spatial clustering analyses found that urban areas in Nebraska had lower distances to mammography centers, higher screening rates and lower rates of late-stage diagnosis of breast cancer. Rural areas had higher distance to the mammography centers and higher rates of late-stage at diagnosis for breast cancer. The evidence from this study points to geographic disparities in access to screening for breast cancer. Mitigating the access issues that rural women face would require interventions specifically targeted to rural populations.

Center Characteristics Play a Leading Role in Geographic Disparities in Access to Heart Transplantation in France

Transplantation represents the ultimate option for patients with advanced heart failure refractory to other treatments. This study aimed to investigate geographic disparities in access to transplantation in France.

Abstract MP09: Geographic Disparities in Rates of End-Stage Renal Disease and Organ Supply in Gulf States Compared to Non-Gulf States

Background: Organ Procurement Organizations are responsible for procuring and allocating organs for transplantation from deceased donors in Donation Service Areas (DSAs). The Final Rule prohibits geographic disparities in access to organs, but the current kidney allocation system does not account for potential supply variations based on disease burden and other population characteristics within DSAs. As such, regions with traditionally high rates of comorbid disease, such as the Gulf States region, may be disadvantaged if local supply is limited. Methods: Using data from the 2016 Robert Wood Johnson Foundation County Health Rankings, the Scientific Registry of Transplant Recipients public reports, and the United States Renal Data System, we compared comorbid disease prevalence, rates of end-stage renal disease (ESRD), and expected organ donation rates by Gulf States location. Results: Prevalence of African American ethnicity, diabetes, fair/poor self-rated health, physical inactivity, food insecurity, and uninsurance were higher among DSAs in the Gulf States region vs. non-Gulf States (Table). Conversely, the prevalence of non-Hispanic White ethnicity, college education, and median household income were higher among non-Gulf States. The rate of ESRD varied by DSA, ranging from < 162 cases per 100,000 to > 225 cases per 100,000 (Figure). Median rate of ESRD was 214.4 per 100,000 among DSAs in the Gulf States, vs. 187.1 per 100,000 in the non-Gulf States (p=0.003). Expected rate of organ donation per 100 eligible deaths was 71.1 in Gulf States and 75.4 in non-Gulf States (p=0.01). Conclusion: Higher rates of ESRD were observed in the Gulf States region, suggesting a greater need for organs than non-Gulf States. However, fewer donors were estimated in Gulf States, likely due to high comorbid disease burden, compared to non-Gulf States. These data suggest the need to examine allocation policy to prevent geographic disparities in access to deceased donor transplantation.

OPTN/SRTR 2016 Annual Data Report: Kidney.

Data from 2016 show ongoing positive trends in short- and long-term allograft survival, and a decrease in the number of active listed candi- dates for the first time in more than a decade, with a concomitant in- crease in deceased donor kidney transplants. Transplant rates that had changed dramatically for some groups after implementation of the new kidney allocation system in 2014 are stabilizing, allowing for evaluation of new steady states and trends. Many challenges remain in adult kid- ney transplantation, including stagnant rates of living donor transplant, geographic disparities in access to transplant, racial disparities in living donor transplant, and overall a continuing demand for kidneys that far outpaces the supply. For pediatric recipients, a decline in the proportion of living donor transplants is of concern. In 2016, only 34.2% of pediatric transplants were from living donors, compared with 47.2% in 2005. The number of related donors decreased dramatically over the past decade, and the number of unrelated directed transplants performed in pediatric candidates remained low (50).

Factors contributing to geographic disparities in access to heart transplantation in France

Transplantation represents the ultimate option for patients with advanced heart failure refractory to other treatments. We aimed to assess the between-center disparities in access to heart transplantation 1-year after listing in France by adjusting for candidate and center factors identified to be significantly associated with access to heart transplantation. Adults ( n = 2,347) registered on the French national waiting list between January 1, 2010 and December 31, 2014 in the 23 transplant centers were included. The association of candidate and transplant center characteristics with access to transplantation was assessed with mixed-effects Cox models. Within 1-year of listing, 65% of candidates underwent transplantation. Candidates blood type O and A, sensitization and body mass index ≥ 30 kg/m 2 were independently associated with lower access to transplantation, while female gender, heart failure severity and high serum bilirubin level were independently associated with greater access to transplantation. Center factors associated with access to transplantation were heart procurement rate in the geographic area, proportion of high-urgency candidates among listed patients and donor heart offer decline rate. Access to transplantation between-center variability increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. However, after adjustment for candidate and center factors, 5 centers were still outside of normal variability. Regional disparities in access to heart transplantation were largely driven by center factors. These findings will be taken into consideration in the future French heart allocation system with priority statuses defined according to objective candidate characteristics rather than medical management and with extending nationwide graft sharing to candidates without priority.

Geographic Disparities in Access to Nursing Home Services: Assessing Fiscal Stress and Quality of Care.

We test whether nursing homes serving predominately low-income and racial minority residents (compositional explanation) or located in neighborhoods with higher concentrations of low-income and racial minority residents (contextual explanation) have worse financial outcomes and care quality. Healthcare Cost Report Information System, Nursing Home Compare, Online Survey Certification and Reporting Certification, and American Community Survey. A cross-sectional study design of nursing homes within U.S. metropolitan areas. Data were obtained from Centers for Medicare & Medicaid Services and U.S. Census Bureau. Medicaid-dependent nursing homes have a 3.5 percentage point lower operating ratio. Those serving primarily racial minorities have a 2.64-point lower quality rating. A 1 percent increase in the neighborhood population living in poverty is associated with a 1.20-point lower quality rating, on a scale from 10 to 50, and a 1 percent increase in the portion of neighborhood black residents is associated with a 0.8 percentage point lower operating ratio and a 0.37 lower quality rating. Medicaid dependency (compositional effect) and concentration of racial minority residents in neighborhoods (contextual effect) are associated with higher fiscal stress and lower quality of care, indicating that nursing homes' geographic location may exacerbate long-term care inequalities.

OrganJet: Overcoming Geographical Disparities in Access to Deceased Donor Kidneys in the United States

There are over 90,000 patients in the United States waiting for a kidney transplant. Under the current allocation policy, the vast majority of deceased organs are allocated locally. This causes significant disparities in waiting times and access to transplant across different geographical areas. To ameliorate this inequity, we propose an operational solution that offers affordable jet services (OrganJet) to patients on the transplant waiting list, allowing them to list in multiple different, and possibly very distant, donation service areas (DSAs) of their choosing. First, using a fluid approximation, we formulate the patients’ problem of choosing a location to multiple list as a selfish routing game in which each patient tries to minimize his “congestion cost,” i.e., maximize his life expectancy. Through a combination of numerical, simulation, and analytical results, we show that multiple listing can lead to a significant improvement in geographic equity. In the special case when sufficiently many patients can multiple list, the geographic inequity disappears. Moreover, the supply of deceased donor organs increases under multiple listing, leading to more transplants and saved lives. We also consider a diffusion approximation and study the resulting multiple-listing game. The equilibrium outcome under the diffusion approximation is a second-order perturbation of that under the selfish routing formulation. In particular, the geographic equity metric, waiting times, and probabilities of receiving a transplant at various DSAs in equilibrium are second-order perturbations of those predicted by the selfish routing equilibrium. Hence, the analysis under the diffusion approximation also supports the finding that multiple listing leads to an improvement in geographic equity. In addition, restricting attention to the special case of sufficiently many patients multiple listing leads to an explicit characterization of the equilibria, which in turn yields additional structural insights. Last, we undertake a simulation study that supports aforementioned findings. This paper was accepted by Assaf Zeevi, stochastic models and simulation.

Impact of the National Essential Public Health Services Policy on Hypertension Control in China.

Hypertension remains a severe challenge to population health worldwide. This study assessed the impact of a nationwide program in China-Essential Public Health Services (EPHS) on improvement of hypertension treatment and control. A cohort of hypertensive patients was identified from the 2011-2013 China Health and Retirement Longitudinal Study. Hypertension was defined based on: (i) an average systolic blood pressure of ≥140 mm Hg, and/or an average diastolic blood pressure of ≥90 mm Hg; and/or (ii) currently taking antihypertensive medications. Outcomes assessed included the rate of hypertension control, medication use, and blood pressure monitoring at a doctor's office. The key independent variable was defined as whether one received services from the EPHS-covered physical examination by 2013. Probit regression models with a difference-in-difference approach were performed for each of the 3 outcomes. Data were analyzed in 2017. Among the 4,958 hypertensive patients, 404 (8.1%) received the EPHS-covered service by 2013. Coverage by the EPHS program was associated with an increase of 7.9% in hypertension control rate (SE = 2.9%, P = 0.020), an increase of 10.3% in the rate of medication use (SE = 2.5%, P < 0.001), and an increase of 10.5% in the rate of blood pressure monitoring (SE = 2.5%, P < 0.001). Results also showed that the EPHS program helped mitigate the geographic disparities in access to health services such as blood pressure monitoring. The National EPHS program improved the treatment and control among hypertension patients. Expanding its program reach could further benefit the cardiovascular health of the population.

Geographic Disparities in Access to Syringe Services Programs Among Young Persons With Hepatitis C Virus Infection in the United States.

Using commercial laboratory data, we found 80% of 29382 young persons currently infected with hepatitis C virus lived >10 miles from a syringe services program. The median distance was 37 miles, with greater distances in rural areas and Southern and Midwestern states. Strategies to improve access to preventive services are warranted.

Liver allocation and distribution: time for a change.

Liver allograft allocation has been a topic of hot debate for over a decade. New redistricting changes have been proposed by the Liver and Intestinal Transplant Committee to the existing United Network for Organ Sharing (UNOS) liver allocation policy. The basis of this new proposal is similar to the old one with an aim to distribute organs in a fair, efficient and equitable fashion. In this review, we plan to look in depth at the redistribution proposals thus far, their merits and how they may help patients who do not have adequate access to livers. Many authors have criticized the proposed changes to organ distribution to reduce geographic disparity in access to liver transplantation. Our focus in this article is to bring forth the most recent literature and proposed changes in the current distribution system. We will also mention two other possible methods that have been proposed to redesign distribution using concentric circles and neighborhoods. In this article, we also look at the economics of the redistricting proposal and its effects on transplant centers. The UNOS Liver and Intestinal Transplant Committee has recommended a proposal using the eight-district model with proximity circles and three additional Model for End-Stage Liver Disease (MELD) points with initial sharing MELD threshold of 25 as a starting point to reduce disparity in patient access to deceased donor livers for transplantation. This proposal has met with significant resistance because of concerns of cost, logistics and impact on existing transplant centers. Other methodologies have also been proposed that have the potential to significantly improve our current disparity of access to life-saving organs. Variation in the supply of donor organs vs. the demand or need for liver transplant by geography and the current defined areas of distribution drive this disparity. Cost benefits to the healthcare system in caring for patients with advanced stages of liver disease may outweigh increased costs of transportation and transplantation. The current allocation boundaries are not optimal for liver distribution, as modeled by all suggested solutions thus far. The need to identify a more optimal and equitable allocation/distribution system is paramount.

Socioeconomic and geographic disparities in access to pharmacotherapy for alcohol dependence

A higher rate of alcohol-attributable morbidity and mortality exists in remote and socioeconomically disadvantaged regions of Australia. This study aimed to explore the dispensing pattern of pharmacotherapy for alcohol dependence across these groups. A retrospective cohort study of patients (aged 15–84) dispensed acamprosate or naltrexone (July 2009–June 2013) was conducted. Observed dispensing rates were obtained for 541 local government areas (LGA) of Australia. Expected dispensing was based on national rates and age standardized to each LGA. Mean dispensing ratios (observed to expected) for each medicine over the period were calculated for remoteness and socioeconomic disadvantaged groups. For both medications, the mean dispensing ratio significantly differed across geographical groups and across socioeconomic groups (p's<0.05). For naltrexone and acamprosate, respectively, the mean dispensing ratio in remote areas was 6 and 9 times less than for the major cities. The mean dispensing ratio for both medications in the most socially disadvantaged areas was approximately 5 times less than that of the most disadvantaged areas. Our data highlight geographical and socioeconomic disparities in Australia regarding access to pharmacological treatment for alcohol use disorder. Targeted strategies aimed at bridging the gap of accessibility for relapse prevention medications are required.

New organ allocation policy in liver transplantation in the United States.

New organ allocation policy in liver transplantation in the United States.

Geographic disparities in access to surgical abortion services in western New York

Geographic disparities in access to surgical abortion services in western New York

Geographical disparities in access to cancer management and treatment services in England

This study seeks to examine the extent to which cancer services are geographically located according to cancer incidence, and assess the association with cancer survival. We identified hospital sites serving English PCTs (Primary Care Trusts) with the management and treatment of breast, lung and colorectal cancer. Geographical access was estimated as travel time in minutes from LSOAs (Lower Super Output Areas) to the nearest hospital site and aggregated to PCT level. Correlations between PCT level mean travel times and cancer cases were estimated using Spearman's rank correlation. Associations between PCT level mean travel times and cancer relative survival rates were estimated using linear regression with adjustment for area deprivation and for a PCT level measure of the reported ease of obtaining a doctor's appointment. We found that cancer services tended to be located farther from areas with more cancer cases, and longer average travel times are associated with worse survival after adjustment for age, sex, year and area deprivation. This suggests that geographical access to cancer services remains a concern in England.

Racial Disparities In Geographic Access To Primary Care In Philadelphia.

Primary care is often thought of as the gateway to improved health outcomes and can lead to more efficient use of health care resources. Because of primary care's cardinal importance, adequate access is an important health policy priority. In densely populated urban areas, spatial access to primary care providers across neighborhoods is poorly understood. We examined spatial variation in primary care access in Philadelphia, Pennsylvania. We calculated ratios of adults per primary care provider for each census tract and included buffer zones based on prespecified drive times around each tract. We found that the average ratio was 1,073; the supply of primary care providers varied widely across census tracts, ranging from 105 to 10,321. We identified six areas of Philadelphia that have much lower spatial accessibility to primary care relative to the rest of the city. After adjustment for sociodemographic and insurance characteristics, the odds of being in a low-access area were twenty-eight times greater for census tracts with a high proportion of African Americans than in tracts with a low proportion of African Americans.

Geographic disparities in access to urban trauma care: defining the problem and identifying a solution for gunshot wound victims in Chicago

BackgroundTimely transport to designated trauma centers impacts mortality following serious injury. We examined whether the distribution of trauma centers in Chicago has created disparities in access to trauma care. MethodsUsing the Illinois State Trauma Registry, locations of Chicago-area gunshot wounds (GSWs) from 1999 to 2009 were geocoded and transport times were analyzed for pediatric (age ≤ 15) and adult (age ≥ 16) GSWs. ResultsA total of 11,744 included pediatric and adult GSWs were analyzed. Adults experienced longer mean transport times (11.3 vs 10.2 minutes, P < .001). Disproportionate numbers of adult GSW victims experienced over 30-minute transport times on Chicago's south side. Pediatric GSWs demonstrated no such disparity, likely attributable to the presence of a pediatric trauma center on the southeast side. ConclusionsGeographic disparities in access to trauma care exist even within urban trauma systems. The absence of an adult trauma center on Chicago's southeast side has contributed to these disparities.

Increasing access to care for young adults with cancer: Results of a quality-improvement project using a novel telemedicine approach to supportive group psychotherapy.

Young adults with cancer experience high levels of psychological distress. Group interventions for cancer patients have been effective in reducing levels of psychological distress but suffer from high levels of attrition and serve a limited geographic area. In a quality-improvement project, we converted an existing in-person support group to a telemedicine format in the hopes of improving attendance and reducing geographic disparities in access to care. Eight young adults (18-40 years) with cancer were recruited from across Colorado. Participants received a tablet equipped with Wi-Fi and downloaded an HIPAA-compliant video-conferencing application. Participants attended six weekly supportive psychotherapy sessions. Participants found the group to be beneficial: the technology worked, they enjoyed the group format, and they would recommend it to others. The novel treatment interface allowed for low attrition rates due to the flexibility of a patient's location during the intervention. It allowed for provision of services to a geographically diverse population of medically ill young adults, as participants lived an average of 148 miles from the cancer center (range = 25-406 miles). Internet-based mental health care is an area of growing interest for providers, but few studies have evaluated its efficacy in patients with cancer, and even fewer in young adults with cancer. Incorporating technological advances into clinical practice will increase access to care, reduce geographic health disparities, and provide more consistent services.

Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care.

Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006-2014) and five-state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002-2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist- and transplant-related outcomes. We included patients aged 18-75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD-9)-based algorithms. Among 16 824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0-16.6%) and 8.1% (7.5-8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7-10.4%) and 6.7% (6.5-7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6-38.5%, ESLD 3-year mortality: 48.9-62.0%; waitlist transplant rates: 36.3-72.7%, ESLD transplant rates: 4.8-13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: ρ = -0.06, p-value = 0.83 (HealthCore); ρ = -0.87, p-value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ = 0.36, p-value = 0.55) but were positively correlated in HealthCore (ρ = 0.73, p-value = 0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.