Geographic Access Research Articles

Challenges in Geographic Access to Specialized Pediatric Burn Care in the United States

Abstract Background Geographical access to pediatric burn centers in the US is not well described. Patients may receive care at American Burn Association (ABA)-verified burn centers, unverified burn centers, or non-burn centers. A recent study indicated that most US counties do not have an ABA-verified pediatric burn center within 100 miles. However, access to unverified burn centers that provide care to pediatric burn patients was not considered. We studied access to all pediatric burn centers across different US regions, using American College of Surgeons (ACS) Committee on Trauma-verified pediatric trauma centers as a benchmark. Study Design An observational cohort study was conducted using 2022 US Census data. Individuals aged ≤14 years were included. Geographical location was determined by residence ZIP code. Pediatric burn centers were identified from the ABA directory. Pediatric trauma centers were identified by ACS verification status using the ACS Hospitals and Facilities directory. Population access to pediatric burn and trauma centers within 50, 100, and 300 miles of the home ZIP code was assessed. Results Of US children, 62.1%, 83.5%, and 98.6% live within 50, 100, and 300 miles of a pediatric burn center. Access to ABA-verified pediatric burn centers is lower compared to access to ACS-verified pediatric trauma centers. Conclusions Overall, the US population has limited access to pediatric burn centers compared to pediatric trauma centers. The services offered and outcomes should be studied to better understand differences in the quality of care provided by verified and unverified centers.

EXPRESS: Quality, Necessity, or Accessibility? Impact of Dockless Bike Sharing on Ineffective Use of Medical Resources

In recent years, patients have increasing autonomy in medical decision-making. With great autonomy in selecting medical institutions, patients with low-risk diseases (LRD) may opt for treatment in prestigious hospitals, which limits the access of patients with high-risk diseases (HRD) to these hospitals. Moreover, due to limited medical knowledge and a fear of uncertainty regarding diseases, patients with greater medical autonomy may request various unnecessary medical tests to alleviate their health-related anxiety. This study takes a novel patients’ perspective to investigate how dockless bike sharing, which addresses the “last-mile problem” and improves geographical accessibility to medical institutions, affects two types of ineffective use of medical resources: disease-institution mismatch and overuse of medical tests. By introducing the concept of quality-accessibility trade-off in patients’ decision-making processes, we shed light on the psychological mechanism underlying the effect of dockless bike sharing on patients’ medical institution choices. We also introduce a new concept, perceived necessity of medical tests, to explain how dockless bike sharing reduces unnecessary medical tests. In Study 1, we designed a quasi-experiment and applied a difference-in-differences model based on real-world electronic health record data to show that dockless bike sharing increased the likelihood of patients choosing hospitals over clinics and decreased the number of unnecessary medical tests. In Studies 2a, 2b, 3a, and 3b, four randomized controlled experiments were employed to replicate the findings and reveal the underlying mechanisms. In sum, we found that dockless bike sharing acted as a “double-edged sword” in terms of its impact on exacerbating disease-institution mismatch and alleviating the overuse of medical tests. This study makes significant theoretical contributions to the Operations Management (OM), sharing economy, and medical resource management literature. It also offers important managerial insights for governments, shared mobility platforms, and healthcare providers.

Changing ‘casinoscape’: spatial patterns of casino municipalities and impacts of the new gambling act in the Czech Republic

ABSTRACT Casinos are one of the traditional gambling venues across the world and are often regarded as a symbol of the gambling industry. The Czech Republic has gradually developed into one of the countries where gambling establishments are most accessible. The new Gambling Act aims to concentrate individual establishments closer to each other and thus reduce their level of accessibility. The aim of our study is, therefore, to assess the impact of the new regulatory law on the spatial representation, geographical accessibility, and changes in catchment areas of casinos at the level of municipalities in the Czech Republic (6,258 spatial units) between 2017 (reflecting the situation at the time of the law's implementation) and 2023 (six years after). The main map shows the results of the Huff model, which is used to model the catchment areas of casino municipalities and the changes in these areas and in temporal availability.

Potential geographic accessibility to municipal medical services (Cruz Verde) in the municipality of Guadalajara, Jalisco, Mexico

Potential geographic accessibility to municipal medical services (Cruz Verde) in the municipality of Guadalajara, Jalisco, Mexico

Mapping Geographic Access to Illinois Birthing Hospitals, 2016-2023.

Mapping Geographic Access to Illinois Birthing Hospitals, 2016-2023.

Geo-Spatial Analysis of Acute Ischemic Stroke Reperfusion Treatment in India: An Assessment of Distribution and Access to Centers

Background: Stroke is a leading cause of global mortality and disability, with a disproportionately high burden in low- and middle-income countries. Access to intravenous thrombolysis (IVT) and endovascular treatment (EVT) remains extremely limited. Aims: We evaluated the spatial distribution and geographic accessibility of stroke centers in India. Methods: Data on intravenous thrombolysis capable (IVT-C) and endovascular treatment capable (EVT-C) stroke centers were collected in March 2021 from thrombectomy devices and pharmaceutical industry providers, respectively. Data were collated and geocoded to compare and calculate zonal statistics and state/union territory (UT) summaries using descriptive statistics. Data on population centers were obtained from the Survey of India website. For estimating driving times, we used the Google Distance Matrix API to find the driving distance between each population center and its nearest stroke facility. Subsequently, population coverages were estimated as a proportion of the population having access to stroke centers for each time interval and based on the population projection for the year 2020 and compared across states. Results: A total of 566 IVT-C stroke centers were spread across 26 states and UTs of which 361 (63%) were EVT-C. Ten UTs lacked stroke centers. The average stroke centers per million (SCPM) population was 0.41 and 0.26 for IVT-C and EVT-C, respectively. Median distances to the nearest IVT-C and EVT-C centers were 115 km (IQR 66–175) and 131 km (IQR 79–198), respectively. Access within one hour to an IVT-C and an EVT-C center was available to 26.3% and 20.6% of the Indian population, respectively. Conclusions: Access to stroke care in India is poor, with critical regional disparities as reflected by the low number of SCPM population, long driving times, and a small population with access within the golden hour. There is an urgent need to establish IVT and EVT-capable stroke centers in the existing poorly served regions of India to increase access and improve outcomes for stroke patients.

Medicaid‑Insured Children with Medical Complexity in a Rural State.

To describe children with medical complexity (CMC) in Montana according to their clinical characteristics, rurality and distance from specialty care, and to assess for disparities in geographic access to specialty care for American Indian children. In this cross-sectional study we categorized children in 2016-2021 Montana Medicaid claims data using the Pediatric Medical Complexity Algorithm and compared the associations of medical complexity and demographic traits using Chi-squared tests. Using a database of providers we calculated drive times from children's residences to the nearest pediatric subspecialist and calculated bootstrap confidence intervals for the difference in median driving distances by complexity and race. Among 126,873 children, 23% lived in rural areas and 20% were reported as American Indian. In all, 10,766 children (8.5%) had complex chronic conditions (CMC) and 27431 (21.6%) had non-complex chronic conditions. Medical complexity was associated with age, race, ethnicity, sex, CHIP enrollment, disability, and rurality. CMC had shorter median drive times to care than children with noncomplex medical conditions and children without chronic conditions (28 vs 34 and 43 minutes, 95% CI of differences 4-9 and 6-11). At each level of medical complexity, the median distance from care was greater for American Indian children than children of other races. Although children with medical complexity tend to live closer to specialists than other children, many CMC live far from subspecialty care. American Indian children live farther from specialists than other children, regardless of complexity. Future work should support access to care for rural and American Indian CMC.

Geographical accessibility to healthcare by point-of-interest data from online maps: a comparative study.

Geographical accessibility is important for promoting health equity, and calculating it requires the locations of all existing healthcare facilities in a region. Authoritative location data collected by governments is accurate but mostly not publicly available, while point-of-interest (POI) data from online sources, such as Baidu Maps and AutoNavi Maps are easily accessible. However, the accuracy of the latter has not been thoroughly analyzed. Taking Baotou, a medium-sized city in China, as aneample, we assessed the suitability of using POI data for measuring geographic accessibility to healthcare facilities.We computedthe difference of geographic accessibility calculated based on POI data and that on authoritative data.Logistic regression and a multiple linear regression model was applied to identify factors related to the consistency between the two data sources. Compared to authoritative data, POI data exhibited discrepancies, with completeness of 54.9% and accuracy of 63.7%. Geographic accessibility calculated based on both data showed similar patterns, with good consistency for hospitals and in urban areas. However, large differences (>30 minutes) were shown in rural areas for primary healthcare facilities. The differences were small regarding to population- weighted average accessibility (with slight underestimation of 3.07 minutes) and population coverage across various levels of accessibility (with differences less than 1% of the population) for the entire area. In conclusion, POI data can be considered foruse in both urban areas and at the level of entire city; however, awareness should be raised in rural areas.

Research on Service-Oriented Sharing and Computing Framework of Geographic Data for Geographic Modeling and Simulation

Geographic data are the foundation of geographic model construction, and any stage of their acquisition, processing, and analysis may have an impact on the efficiency and quality of geographic modeling and simulation. With the advent of the era of big data, a large number of data resources are generated in the field of geographic information. However, due to the heterogeneity of geographic data and the security of data usage, massive geographic data resources are difficult to fully explore and utilize, resulting in the formation of data islands. This paper proposes a service-oriented geographic data-sharing and computing framework, which provides users with a complete set of geographic data access and application processes (such as data acquisition, processing, configuration, etc.), so as to reduce the difficulty of using data and improve the efficiency of data sharing. The framework mainly consists of three core components: (1) the “Data service container” can publish data resources as data services to provide a consistent data access interface; (2) the “Workspace” provides a series of methods and tools for users to develop data-computing solutions; and (3) the “Data-computing engine” is responsible for performing computing tasks such as data processing and configuration. Finally, a case of runoff simulation using the SWAT model is designed, in which the whole process of data sharing, acquisition, calculation, and application is realized, so as to verify the validity of the proposed framework.

Inequalities in the geographic access to delivery services in Brazil

BackgroundDespite Brazil’s recent social progress, access to health services is still unequal. This article analyzes the inter-municipal distances traveled by pregnant women to access delivery services, documenting their magnitude and relationship to socioeconomic and risk factors for over a decade in Brazil.MethodsUsing data between 2007 and 2017 from the Brazilian Information System of Live Births and a matrix of inter-municipal distances, we describe the evolution of (i) the share of pregnant women that traveled across municipalities and (ii) the average distance they traveled. Next, we assess which of the previous variables explains the changes in travel distance over time. Finally, we estimate the difference in the average travel distance by individual risk factors and use regression analysis to measure the association between this distance and municipal socioeconomic determinants from the Brazilian census.ResultsWe observe that, on average, (i) the share of women traveling for childbirth increased, reaching 31% in 2017, and (ii) distances got longer, approaching the 60-kilometer mark by 2017. The increase in distance is mainly due to more women traveling. Nevertheless, regional disparities persist, especially between the north/inland and coastal regions. Women with high-risk pregnancies or newborns with risks such as low birth weight tend to travel longer distances. However, those residing in higher-development municipalities tend to travel shorter distances.ConclusionLong distances remain an obstacle to accessing delivery facilities. This matter affects the most vulnerable disproportionately. Policymakers must consider the geographic accessibility of mothers when expanding birth-related services. Additionally, more research is required to understand the decision to travel and the distance effectively traveled as different accessibility facets.

Efficient and Selective Lithium Extraction from Brine Water Via a Photothermal Sandwich Sieve Structure

AbstractLithium is being recognized as a strategic resource on a global scale, mainly because of its growing importance in the production of lithium‐ion batteries for electric vehicles and energy storage systems. Due to its uneven geographical distribution and limited availability on Earth, extracting lithium from brines and seawater presents a sustainable supply pathway. However, conventional lithium extraction techniques are still challenging, necessitating significant costs and energy consumption. This study primarily employs a solar‐utilizing selective extraction strategy for efficient lithium harvesting by designing a solar‐thermal sandwich sieve structure. Herein, a portable solar‐driven lithium extraction device has been developed based on HKUST‐1 and LIG. Due to the sub‐nano channels provided by HKUST‐1, the hydrated Li+ can selectively pass through the MOF layer. The excellent solar heating of the layer enables the device an accelerate vapor escaping, it then facilitates the delivery of Li+, resulting in lithium accumulation at the interface for convenient collection. The maximum lithium extraction capacity in one cycle is 1467 mg m−2, demonstrating good Li+ selectivity absorption with a high Mg2+/Li+ ratio under 1 solar illumination. Moreover, the device shows excellent cycle stability. This work offers an integrated solar utilization for scalable and sustainable lithium extraction from brine water.

Application of Youth-Led Participatory Action Research to Examining Adolescent Sexual and Reproductive Health and Rights in Ontario: What Can We Learn?

Engaging adolescents and young people as partners in research is increasingly acknowledged as a vital strategy to ensure diverse voices are heard and to catalyze social change. This article, coauthored by adolescent and adult researchers, presents the methodological approach and outcomes of a youth-led participatory action research (YPAR) study in which three teams of youth researchers developed and implemented projects examining equity-related factors affecting adolescent sexual and reproductive health and rights (ASRHR) in Ontario, Canada. Teams of four assigned-female youth researchers aged 16-19 years were recruited from three priority regions through purposive sampling. Selected youth completed a paid 5-day virtual YPAR training. Each youth team, supported by adult research mentors, identified key ASRHR issues in their region and developed a related research question. Each team then determined their study's design, obtained institutional ethics approval, and conducted data collection, analysis, and interpretation. Based on their findings, teams proposed potential solutions and communicated results to multiple stakeholders. Methodologically, the YPAR process amplified youth voices through a social justice-framed approach to examining ASRHR. Centering the perspectives, values, and experiences of youth positively impacted the youth researchers themselves, while yielding results that were relevant, meaningful, adolescent-responsive, and culturally informed. Results from the youth-led projects identified multiple barriers to accessing sexual and reproductive health services and products. Policy and practice implications encompassed concerns related to geographical accessibility, equity, service provider competence, and content of sexuality education curricula.

Conceptual framework for optimizing client relationship management to enhance financial inclusion in developing economies

Financial inclusion is a critical driver of socio-economic development, particularly in developing economies where large population segments lack access to formal financial services. This paper proposes a conceptual framework for optimizing Client Relationship Management (CRM) to enhance financial inclusion, focusing on key pillars such as client segmentation, digital outreach, and feedback mechanisms. The framework integrates behavioral insights and localized strategies to address the unique challenges faced by underserved populations, including geographic inaccessibility, lack of trust, and limited financial literacy. By leveraging technology-driven CRM tools and community-based approaches, the framework aims to improve service delivery, foster trust, and empower clients to make informed financial decisions. The paper also outlines policy and operational recommendations, emphasizing the importance of stakeholder collaboration and an enabling regulatory environment for successful implementation. This holistic approach demonstrates how CRM can catalyze financial inclusion, contributing to poverty reduction, economic resilience, and equitable development. Keywords: Financial Inclusion, Client Relationship Management (CRM), Digital Outreach, Behavioral Insights, Underserved Populations

Progress Toward Poliomyelitis Eradication - Afghanistan, January 2023-September 2024.

Since the Global Polio Eradication Initiative began in 1988, wild poliovirus (WPV) types 2 and 3 have been eradicated, and annual polio case numbers have decreased by >99.9%. WPV type 1 (WPV1) transmission remains endemic in Afghanistan and Pakistan, two countries that share a 1,600-mile (2,600-km) border. This report describes immunization and surveillance activities and progress toward polio eradication in Afghanistan during January 2023-September 2024. As of November 1, Afghanistan reported 23 WPV1 cases in 2024, with onset during January-September 30, 2024. During the 3 previous years, 12 WPV1 cases were reported, including six during 2023. In August 2021, the Taliban took control nationwide and allowed increased geographic access for poliovirus vaccination campaigns. Multiple challenges have affected polio eradication activities in Afghanistan, including mandated repatriation of approximately 1 million Afghans by Pakistan beginning in late 2023, the ongoing humanitarian crisis that limits international agency effectiveness, polio program constraints imposed by authorities, and increased restrictions on female participation in vaccination activities. House-to-house vaccination coverage reached 90%-98% of children during June-July 2024. Beginning in 2021, authorities had progressively lifted restrictions on house-to-house campaigns, but abruptly reverted to national restrictions in September 2024. Both nationwide house-to-house activities and strengthening of the routine childhood immunization program would help ensure that every vulnerable child is vaccinated and provide a pathway to polio eradication in Afghanistan.

Technology literacy and access to digital resources for remote assessment among adults enrolled in Alzheimer's disease research.

The SARS-CoV-2 pandemic accelerated development of innovative methods for conducting research remotely via digital technologies. However, few studies have examined participant technological literacy skills or access as key social determinants of brain health in aging populations at risk of Alzheimer's disease and other dementias. To identify associations of sociodemographic and clinical characteristics, cognitive status and geolocation with digital technology access and skill within dementia research cohorts. A self-administered questionnaire surveyed digital access and literacy skills in persons enrolled across various studies conducted at Emory Goizueta Alzheimer's Disease Research Center. We investigated cognitive and sociodemographic characteristics, and neighborhood disadvantage related to these digital attributes. Of 1860 participants (mean age: 65.3 years (SD:11.4)) surveyed, 71.6% were women, 87.1% Whites, 10.4% African Americans, and 46.9% had postgraduate-level education. Most participants had access to digital devices: desktop (53.7%), laptop (81.6%), tablet (71.6%), smartphone (94.6%), internet (82.0%), or videoconferencing (95.5%). Cognitively unimpaired participants had higher odds of digital access (OR:3.75; 95% CI:2.45-5.73) and skill (OR:1.22; 95% CI:1.14-1.30). Although Whites were likelier to have access (OR:1.36; 95% CI:1.01-1.82) than African Americans, no differences were found in skill between the two groups. Living in more disadvantaged neighborhoods was significantly associated with lower technology skills (OR:0.86; 95% CI:0.82-0.91). Cognitive impairment, race, and neighborhood socioeconomic disadvantage are significant barriers which limit digital access and skill. Improving digital knowledge, skill-building, and geographic access may encourage research participation especially in geographically remote or disadvantaged areas and help narrow sociodemographic and racial disparities existing in dementia research.

Access barriers and facilitators to implement mass drugs administration strategies for eliminating trachoma and geohelminthiasis in the department of Amazonas, Colombia.

One of the most important pillars of action to achieve the elimination of trachoma and soil-transmitted helminth infections as a public health problem is the mass administration, at regular intervals, of azithromycin and anthielmintics, respectively, to a high proportion of the eligible population in endemic areas. The objective of the study was to identify access barriers and facilitators for achieving coverage goals in the mass drugs administration, azithromycin and albendazole, in the department of Amazonas, Colombia. Implementation research was used, combining three types of qualitative research methodologies to collect information about access barriers and facilitators already described; These were individual and group interviews, focus group discussions and face-to-face intercultural dialogues. We design, validate and apply different instruments with questions adapted to the context and role of the participants, and recorded and transcribed the sessions and analyzed them in qualitative analysis software. We used the Consolidated Framework for Implementation Research (CFIR) to complement the above instrument questions, to guide data analysis, and apply the Consolidated Criteria for Reporting Qualitative Research (COREQ). Records of 159 participants were included; 21 individual and 3 group interviews, 6 focus group discussions and 4 intercultural dialogues were carried out. 21 strong, 30 weak, 6 neutral barriers as well as 5 weak and 11 strong facilitators were identified. 62% of the strong barriers and 40% of the weak ones were concentrated in the "Outer Setting Domain". Only 16 facilitators were identified, 44% in the "Innovation" domain. Multiple political, administrative, geographical, logistical and cultural access barriers, as well as external and internal migration of the population, explain low coverage in mass administration of azithromycin and albendazole. It is necessary to review them individually to implement an improvement plan that also recognizes the identified facilitators.

Interpreting Context in Rural and Remote Aged Care Facilities in Readiness for a New Care Model: A Mixed Method Study.

Geographical isolation compounds limited access to healthcare services and skilled workforce for the provision of rural aged care. Residents have complex chronic disease management and end-of-life care needs. An undersupply of general medical practitioners due to retirement, attrition or unfilled training places in Australia has impacted recruitment to rural areas. Nurse practitioners have been identified as a potential solution. To describe and explore the inner (local and organisational) and outer (wider health system) contexts of healthcare, from the perspective of care staff and residents' families. This, in turn, aims to inform the planned implementation of a nurse practitioner model, in several aged care facilities, operating within rural and remote settings, in Queensland Australia. A convergent mixed methods design. Qualitative data were collected, in 2022-2023, using semistructured interviews with staff focusing on role, knowledge development, workplace culture and care relationships with local community. Resident's family's perspectives were obtained as a secondary analysis of organisational feedback data. Quantitative data were collected from direct care workers using the Alberta Context Tool for Long-Term Care. Data were analysed according to type and integrated. Relational care for residents and families is highly valued but provision of quality is challenging where time-poor staff are perceived to be doing the best they can. Scarce local healthcare services make it difficult to meet resident healthcare needs. Despite the supportive organisational culture, evolving policy requirements have impacted already difficult staff recruitment in rural settings. Identifying contextual needs of organisations in readiness for change highlights geographical and sectoral nuances influencing any future implementation. As government policy changes to improve the older adult care sector, rural and remote facilities are forced to increasingly adapt. Context-specific needs extend far beyond a nurse practitioner providing additional expertise in care provision. What problem did the study address? Nurse practitioners have been successfully implemented into residential aged care facilities in metropolitan and major regional centres but translating this role into rural and remote Australia requires being cognisant of the needs, unique challenges and context of this setting. What were the main findings? In an organisational culture of support, the importance of staff providing relational care and having connection with older adult residents and families was a central driver. It was challenging for staff to meet complex care requirements in the absence of local healthcare options and support. Time pressures, from inadequate staffing and changing structural aged care sector, force the prioritising of care requirements. Where and on whom will the research have an impact? Older adults, policy makers and aged care providers will benefit from understanding the context of rural and remote settings, particularly in identifying potential solutions when there are gaps in primary and secondary healthcare. The GRAMMS checklist was followed in reporting of this study. Two lived experience consumers were involved as research team members. One was involved during the development and submission of the funding application and another during project activities including data collection and analysis and the development of publications.

Zugangsbarrieren zur Schwangerschaftsabbruchversorgung: Eine Analyse aus der Perspektive ungewollt Schwangerer – Erkenntnisse aus der Studie „Erfahrungen und Lebenslagen ungewollt Schwangerer. Angebote der Beratung und Versorgung (ELSA)“

ZusammenfassungEinleitungBarrieren beim Zugang zur Schwangerschaftsabbruchversorgung können die Inanspruchnahme von Versorgungsleistungen verzögern, was zu einem zeitlich verzögerten Schwangerschaftsabbruch und gesundheitlichen Risiken führen kann. Zu Barrieren gehören u. a. die räumliche Erreichbarkeit, Geheimhaltung, Wartezeiten, Stigmatisierung, schlechte oder schlecht zugängliche Informationen und Kosten für einen Abbruch. Im Beitrag werden Barrieren beim Zugang zur Schwangerschaftsabbruchversorgung in Deutschland untersucht. Eingeschlossen werden Barrieren in der Verfügbarkeit und Erreichbarkeit von Versorgungsangeboten, im Zugang zu Informationen, den Kosten für einen Abbruch sowie organisatorische Hindernisse.MethodenDie Analysen basieren auf den Daten einer Online-Querschnittsbefragung von 594 Frauen mit Schwangerschaftsabbruch in Deutschland, die im Rahmen der ELSA-Studie 2021 und 2022 durchgeführt wurde.ErgebnisseDie Ergebnisse zeigen, dass auch in Deutschland der Zugang zu einem Schwangerschaftsabbruch für viele Frauen mit unterschiedlichen Hürden verbunden ist. 80,1 % der Befragten gaben mindestens eine Barriere beim Zugang zum Schwangerschaftsabbruch an, 65,5 % mehr als 2 und 3 und mehr Barrieren wurden von 40,5 % der Befragten angegeben. Besonders die Geheimhaltung des Eingriffs und damit einhergehende Stigmatisierungsängste stellten für viele Teilnehmerinnen Hürden dar.Diskussion und FazitDie Studienergebnisse unterstreichen die Notwendigkeit, den Zugang zu sicheren Schwangerschaftsabbrüchen zu verbessern. Zum Abbau der Zugangsbarrieren gehören daher die Entkriminalisierung, eine flächendeckende Versorgungsstruktur, finanzielle Unterstützungsangebote, verbesserte Informationsangebote sowie der Abbau von Stigmatisierung und Diskriminierung.

Geographic Access to High-Volume Mechanical Thrombectomy Centers in Florida, 2019.

Mechanical thrombectomy (MT) improves outcomes for acute ischemic stroke (AIS) due to large vessel occlusion, but is time sensitive and requires specialized infrastructure. Professional organizations and certification bodies have promulgated minimum procedural volume standards for centers and for individual proceduralists but it is unclear whether enforcing these requirements would decrease geographic access to MT. Therefore, we sought to evaluate the potential impact of applying a minimum procedural volume threshold on geographic access to MT. We identified all hospital discharges for stroke where an MT procedure was performed at any nonfederal hospital in Florida in 2019 using statewide hospital discharge data. We then generated geographic service area maps based on prespecified ground transport distances for the subset of hospitals that performed at least 1 MT and for those that performed at least 15 MTs that year, the minimum volume threshold required for thrombectomy capable and comprehensive stroke centers by the Joint Commission. Then, using zip code centroids and patient-level discharge hospital data, we computed the proportion of patients with AIS who lived within each of the generated service areas. A total of 105 of 297 hospitals performed MT; of those, 51 (17%) were low-volume centers (1-14 MTs/year) and 54 (18%) were high-volume centers (≥15 MTs/year). High-volume centers accounted for nearly 95% of all MTs performed in the state. Most patients hospitalized with AIS (87%) lived within 20 miles (or an estimated as a 1-hour driving time) of a hospital that performed at least 1 MT, and all (100%) lived within 115 miles (or estimated as 3-hour driving time). Setting a minimum MT volume threshold of 15 would decrease the proportion of stroke patients living within 1-hour driving time of an MT center from 87% to 77%. In 2019, most Florida stroke patients lived within a 1-hour ground transport time to a center that performed at least 1 MT and all lived within 3-hour driving time of an MT center, irrespective of whether a minimum procedural volume threshold of 15 cases per year was applied or not.

Bacteriology testing and antimicrobial resistance detection capacity of national tiered laboratory networks in sub-Saharan Africa: an analysis from 14 countries

Accurate detection of antimicrobial resistance (AMR) depends on adequate laboratory capacity. We aimed to document key weaknesses hindering AMR detection at various tiers of laboratory networks in 14countries in sub-Saharan Africa, and analyse their significance in AMR surveillance and policies. In this analysis, we obtained retrospective data on AMR and antimicrobial consumption from 14countries participating in the Mapping Antimicrobial Resistance and Antimicrobial Use Partnership between May 1, 2019, and June 30, 2020. We established the number, capacity for AMR detection, and other characteristics from all bacteriology laboratories within the national network from existing national health system compendiums, combined with a self-applied scored survey tool. We calculated AMR detection readiness scores at a facility and country level and analysed the pertinence of national strategies to address system gaps for AMR detection and surveillance. Of the 53 770listed laboratories, 675 (1%) were formally assigned to deliver bacterial testing and invited to complete the survey tool. Of the 504 (75%) facilities that returned the completed survey, 393 (78%) reported antimicrobial susceptibility testing (AST) capacity and collectively provided geographical access to less than 50% of the general population in seven countries. Continuous access to water was reported by 347 (88%) laboratories, power sources by 341 (87%) laboratories, and the presence of qualified laboratory scientist or technologist by 377 (96%) laboratories. By contrast, ISO15189 accreditation was reported by 90 (23%) laboratories and use of an electronic laboratory information system by 54 (13%). Reference laboratories were associated with higher AMR detection readiness scores than were district laboratories (odds ratio 4·7 [95% CI 1·3-10·2; p=0·014). Private, not-for-profit laboratories were associated with higher scores than were government-affiliated facilities (9·2 [1·6-53·8; p=0·014). Designated national AMR sentinel sites were associated with higher scores than were non-sentinel sites (5·8[2·9-11·8; p<0·001). Laboratories processing between 1001and 3000bacterial cultures annually were associated with higher scores than were those processing less than 200cultures annually (4·8 [1·7-13·7]; p=0·0040). Strengthening bacterial testing and capacity for AMR detection represented less than 20% of the proposed interventions in 12of the 14national AMR action plans. AMR action plans and other relevant national strategies should prioritise the scale-up of bacterial testing services to improve access to care and promote quality AMR surveillance. Interventions that democratise AST to lower laboratory tiers, formally designate AMR sentinel sites, and implement whole-of-network laboratory information and quality management systems are urgently needed. Fleming Fund, UK Aid, and US Centers for Disease Control and Prevention through the Training Programs in Epidemiology and Public Health Intervention Networks.