Geographic Variation In Access Research Articles

Geographic Variation in Access to Pathology and Laboratory Services in Tanzania: A Cross-Sectional Geospatial Analysis

PURPOSE Increasing noncommunicable disease burden in sub-Saharan Africa requires the urgent scale-up of pathology and laboratory medicine (PALM) services. To identify service gaps at the district level, we studied geographic variation in the correlation between travel time to health facilities and population density. METHODS We linked geospatial data for Tanzania from multiple sources. Facility locations were extracted from a comprehensive facility list in Africa. Data on geographic factors, demographics, and roads were collected from government and nonprofit databases. We classified facilities assuming increasing PALM service readiness by level: dispensaries, health centers, district hospitals, and regional/referral hospitals. We input these data into the AccessMod 5 algorithm to estimate travel time across Tanzania with 1-km resolution for each PALM classification. We then calculated district-level averages of population and travel time for each PALM category. Associations between these variables were estimated using a bivariable local indicator of spatial autocorrelation, specifying immediate contiguity neighborhood definition. Spatial analysis was restricted to 172 contiguous districts (islands not included). Significance tests were two sided, with an α of .05. RESULTS Analysis included 5,342 dispensaries, 667 health centers, 185 district hospitals, and 34 regional/referral hospitals. Maps revealed clusters of estimated travel time in excess of 6 hours in less populated western and southern districts. More districts reported an average travel time of less than 1 hour to the nearest dispensary (69%) than to regional/referral hospitals (16%). Bivariable local indicators of spatial autocorrelation revealed few significant clusters of spatial correlations; however, significant correlations between low population density and longer travel times in neighboring districts were obtained for 13%, 16%, 15%, and 13% of districts for dispensaries, health centers, district hospitals, and regional/referral hospitals, respectively. CONCLUSION Limited variability of district-level spatial correlations suggests somewhat equitable geographic allocation of PALM services in Tanzania, with small areas of low population density and long travel times that demand additional intervention. Limitations include a lack of ascertainment of specific PALM services.

The Schooling and Labor Market Effects of Eliminating University Tuition in Ecuador

This paper estimates the effects of a 2008 policy that eliminated tuition fees at public universities in Ecuador. We use a difference-in-differences strategy that exploits variation across cohorts differentially exposed to the policy, as well as geographic variation in access to public universities. We find that the tuition fee elimination significantly increased college participation and affected occupation choice, shifting people into higher-skilled jobs. We detect no statistically significant effects on income. Overall, the bulk of the benefits of this fee elimination were enjoyed by individuals of higher socioeconomic status.

Geographical variations in access to expert centers for multiple sclerosis in France

Abstract Background Multiple sclerosis (MS) is a chronic neurological disease affecting about 100,000 persons in France. Disease management is mainly supervised by the neurologist, supported by the general practitioner (GP). The complexity of the disease, due to the variety of symptoms as well as the recent changes in the therapeutic arsenal, requires both a high level of expertise and coordination between the different health care providers. To face this challenge, integrated and coordinated network of services “MS expert centers” have been progressively set up from 2000 onwards. Our objectives are to describe referrals to MS expert centers over the 2010-2015 period, to look for geographic variations and if any, to identify potential determinants of access. Methods The analysis is performed on the French health insurance database which covers 97% of the French population. Geographic variations of access are explored, as well as association with the following parameters: demographics (age, sex), socio-economic characteristics (social deprivation index at residence, degree of urbanization), and density of health care services (GPs, neurologists, hospital beds). Results Overall, 112,415 people with MS (70% women, mean age 46 years) were included. Initial results show that over the study period, 98% of patient had at least one visit to GP, 87% to neurologist, and 36% in a CRC SEP. Conclusions The present study will assess to what extent MS patients have been able to take full advantage of an innovative organization of specialized care which was recently deployed in France. This model of care has been generalized by the French Ministry of Health in 2016 and 23 ‘competence and resource centers’ for MS (CRC SEP) are now covering the whole national territory. Further research will be performed to identify whether and how this has modified access to specialized coordinated MS care.

Exploring geographical variation in access to general surgery in Ireland: Evidence from a national study

BackgroundImproving the equity of surgical services is an important objective of all clinical programmes both local and overseas. Variations in access to care threaten to dismantle the structural paradigm of any health service and such information can aid in promoting quality and access to surgical services. The aim of this study was to explore the geographical variation in the utilisation of common general surgical procedures in Ireland as a measure of the population's access to surgical interventions. MethodsAge- and gender-standardized rates for 6 common general surgical procedures were calculated for 28 geographic areas (counties) in the Republic of Ireland using data from the national Hospital Inpatient Enquiry System. Standard statistical indicators (systematic component of variation, coefficient of variation and extremal quotient) were used to measure the extent of regional variation. ResultsA total of 998,406 episodes of hospital care were included in the analysis. Large variation in utilisation was present between the studied counties; CV > 0.3 (range 19.4–31.2), SCV > 5 (range 5.2–14.6). Most procedures were utilised at substantially higher rates outside the larger cities (Dublin, Galway, Waterford). ConclusionVariations stemming from inefficient and unequal access are important components and markers of modern health systems and should be minimal. County of residence appears to have a clear influence on a patients' inaccessibility to certain interventions. Our findings imply a need for improved access at a regional level by facilitating the integration of public policies and promoting services at the appropriate settings.

The big-city bias in access to finance: evidence from firm perceptions in almost 100 countries

There is mounting evidence in the developed world to suggest that there is geographical variation in access to finance. At the same time, there is a growing interest in the advantages of major cities in emerging economies in providing better access to services. Yet there is little evidence on spatial variation in access to finance in the developing world. In this article, we address this gap. We propose that one important function of big cities is to provide better credit markets, but that—as countries develop—this ‘big city bias’ is likely to decline. We test these hypotheses using data on over 80,000 firms in 97 countries and provide new evidence that firms in large cities—with more than 1 million inhabitants—are less likely to perceive access to capital as a constraint. However, this big-city bias in access to finance declines as countries develop.

Quantifying the burden of vampire bat rabies in Peruvian livestock.

BackgroundKnowledge of infectious disease burden is necessary to appropriately allocate resources for prevention and control. In Latin America, rabies is among the most important zoonoses for human health and agriculture, but the burden of disease attributed to its main reservoir, the common vampire bat (Desmodus rotundus), remains uncertain.Methodology/Principal findingsWe used questionnaires to quantify under-reporting of livestock deaths across 40 agricultural communities with differing access to health resources and epidemiological histories of vampire bat rabies (VBR) in the regions of Apurimac, Ayacucho and Cusco in southern Peru. Farmers who believed VBR was absent from their communities were one third as likely to report livestock deaths from disease as those who believed VBR was present, and under-reporting increased with distance from reporting offices. Using generalized mixed-effect models that captured spatial autocorrelation in reporting, we project 4.6 (95% CI: 4.4–8.2) rabies cases per reported case and identify geographic areas with potentially greater VBR burden than indicated by official reports. Spatially-corrected models estimate 505–724 cattle deaths from VBR in our study area during 2014 (421–444 deaths/100,000 cattle), costing US$121,797–171,992. Cost benefit analysis favoured vaccinating all cattle over the current practice of partial vaccination or halting vaccination all together.ConclusionsOur study represents the first estimate of the burden of VBR in Latin America to incorporate data on reporting rates. We confirm the long-suspected cost of VBR to small-scale farmers and show that vaccinating livestock is a cost-effective solution to mitigate the burden of VBR. More generally, results highlight that ignoring geographic variation in access to health resources can bias estimates of disease burden and risk.

Harnessing multiple data sources to good program planning for Rural US Veterans

ABSTRACT
 ObjectivesIdentify geographic variations in health and healthcare among US Veterans living in rural areas and understand the relationships between social determinants of health and these variations.
 ApproachData from 11 data sources will be leveraged to create the US Veterans Rural Health Atlas and chart book (VeRHA) patterned after the Dartmouth Atlas, The VeHRA will provide an interactive map and chart book can be used to efficiently examine a wide range of factors related to health and healthcare of rural Veterans. The analyses will assess the relationships between socioeconomic, cultural and environmental factors and geographical variation in access, utilization, quality, satisfaction and outcomes. Semi-structured qualitative interviews will be used to elicit the perspective of Veterans not using VA care and to identify non-governmental organizations who provide care and support to US Veterans. The project will also identify community, state, and federal entities with which ORH could form strategic partnerships to improve health and healthcare for Rural Veterans.
 Initially, three maps will be created for Veterans who are not enrolled in care, those enrolled but not using care and those enrolled and using care. Areas where many Veterans live and use VA healthcare will be identified as “hot spots” while areas where Veterans live but do not use care will be identified as “cold spots”. Metrics for determining “hot and cold spots” will include measures of temporal and geographic access as well as measures of quality of care. We will first calculate raw rates for outcomes across geographic areas (census tract, county, and market/regions) Exploratory Spatial Data Analysis (ESDA) will be conducted by mapping the geographic distribution of key measures and then calculate the values of the local and global Moran’s I measures of spatial autocorrelation.
 The relationship between social determinants of health and geographical variation in access, needs, utilization, quality, satisfaction, and outcomes for rural Veterans will be assessed, focused primarily on the “cold spots” – areas of greatest need.
 ResultsThe project is a work in progress with initial maps created showing the density of Veterans across the United States. More extensive results will be available for presentation.
 ConclusionThis work demonstrates the value of using large data sets to guide development of policies and programs at a national level.

Linking the Diagnostic Imaging Dataset (DID) to Hospital Episode Statistics (HES) – improving and understanding the diagnosis of lung cancer

ABSTRACT
 ObjectivesTo link the Diagnostic Imaging Dataset (DID) to Hospital Episode Statistics (HES) to explore the association between patient imaging and hospital based care and outcomes for cancer patients in English NHS hospitals. This is the first time this linkage has taken place. The analysis also aims to look at how each patient first presented in HES (A&E, emergency admission, elective care, regular attendance), when and by what route relevant tests were requested and geographic variation in access to imaging
 ApproachPatient imaging records from the DID were linked to HES databases containing details of all inpatient, outpatient and A&E admissions at NHS hospitals in England in 2012/13 and 2013/14. Match rank criteria were developed to ensure that patients in HES were accurately linked to patients in DID by NHS number, date of birth and other unique identifiers. We used HES to identify patients with a lung cancer diagnosis and investigate their use of imaging and the temporal nature of tests to evaluate whether patients were following recommended pathways (e.g. having chest x-rays followed by CT scans before their lung cancer diagnosis) and the time between these events. Lung cancer patients were identified by developing an algorithm to search through diagnostic fields for clinical codes within HES databases. Where there was a lung cancer code the record was flagged and subsequently extracted.
 ResultsThe combined HES and DID datasets consisted of more than 340 million records. Within this large dataset we identified 49,888 patients with a lung cancer code in one of their HES diagnosis fields to a DID diagnostic image record for inpatient records alone. A high proportion (97%) of records were matched in one of the top 3 rank levels, suggesting the linkage was successful. The results illustrate the relationship between the imaging referral pathway and hospital episodes (e.g. surgical resection, emergency presentation).
 ConclusionInvestigating how people engage with imaging services and hospital care will increase our understanding of the pathways associated with lung cancer diagnosis.
 The results from this analysis will contribute new knowledge about how lung cancer patients interact with hospitals and imaging services.

Challenges in the Assessment of Medical Devices: The MedtecHTA Project.

Assessing medical devices (MDs) raises challenges which require us to reflect on whether current methods are adequate. Major features of devices are: (i) device-operator interaction can generate learning curve effects; (ii) incremental nature of innovation needs to be addressed by careful identification of the alternatives for comparative and incremental cost-effectiveness analysis; and (iii) broader organizational impact in terms of training and infrastructure, coupled with dynamic pricing, requires a more flexible approach to costing. The objective of the MedtecHTA project was to investigate improvements in HTA methods to allow for more comprehensive evaluation of MDs. It consisted of several work packages concerning (i) the available evidence on the currently adopted approaches for regulation and HTA of medical devices; (ii) the geographical variation in access to MDs; (iii) the development of methodological frameworks for conducting comparative effectiveness research and economic evaluation of MDs; and (iv) the organizational impact of MDs. This introductory paper summarizes the main results of the project and draws out the main overarching themes. This supplement represents a comprehensive report of all the main findings of the MedtecHTA project, and it is intended to be the main source for researchers and policy makers wanting information on the project. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Geographic variation in access among adults with kidney disease: evidence from medical expenditure panel survey, 2002-2011.

BackgroundTo understand geographic variation in access to care over time in patients with kidney disease.MethodsWe analyzed 4404 (weighted sample of 4,251,129) adults with kidney disease from the United States using the Medical Expenditure Panel Survey over 10 years. Three dependent variables were created to investigate variation in access: usual source of care, overall medical access to care, which took into account usual source of care, ability to get care, and delay in care, and prescription access, which took into account ability to get prescriptions and delay in getting prescriptions. Multiple logistic regression was used with geographic region as the main independent variable, adjusting for relevant covariates.ResultsCompared to the Northeast region, adults living in the Midwest (OR = 0.56; 95 % CI 0.35–0.89), South (OR = 0.48; 95 % CI 0.32–0.72) and West (OR = 0.53; 95 % CI 0.34–0.84) had significantly lower odds of reporting usual source of care. For the combined access measure, compared to Northeast, adults in Midwest (OR = 0.60; 95 % CI 0.40–0.88), South (OR = 0.62; 95 % CI 0.44–0.88) and West (OR = 0.50; 95 % CI 0.34–0.72) had significantly lower odds of medical access to care. Region was not significantly associated with the odds of having prescription access, though a significant increase in prescription access was observed over time.ConclusionsGeographic variation in access to care among adults with kidney disease exists independent of income, education, insurance and comorbid conditions, with those in the South least likely to have a usual source of care and those in the West least likely to have overall access to care when compared to the Northeast United States.

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

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

Behind-the-Counter, but Over-the-Border? The Assessment of the Geographical Spillover Effects of Emergency Contraception on Abortions.

Washington was the first state to ease the prescription requirements making emergency contraception (EC) available behind-the-counter at pharmacies to women of any age in 1998. Using county-level vital statistics data in conjunction with the pharmacy specific location data from the Not-2-Late Hotline database, I study whether the increased access to EC affects fertility rates within the state and beyond the borders of the state that allows it. Unlike other studies that rely on geographic variations in access, I show that increased availability of EC in Washington, measured by the distance to the closest 'no-prescription EC pharmacy', is associated with a statistically significant albeit economically moderate decrease in abortion rates in Washington counties where women had access to 'no-prescription EC'. These effects are localized (i.e., decrease with travel distance) and robust in a number of specifications. Finally, I find some evidence in support of geographical spillover effects in Idaho, but not in Oregon. However, after accounting for the availability of abortion services, the decrease in 'treated' Idaho counties is rather small. Copyright © 2016 John Wiley & Sons, Ltd.

For Better and for Worse? Effects of Access to High-Cost Consumer Credit

I provide empirical evidence that the effect of high-cost credit access on household material well-being depends on if a household is experiencing temporary financial distress. Using detailed data on household consumption and location, as well as geographic variation in access to high cost payday loans over time, I find that payday credit access improves wellbeing for households in distress by helping them smooth consumption. In periods of temporary financial distress—after extreme weather events like hurricanes and blizzards—I find that payday loan access mitigates declines in spending on food, mortgage payments, and home repairs. In an average period, however, I find that access to payday credit reduces well-being. Loan access reduces spending on nondurable goods overall and reduces housing- and food-related spending particularly. These results highlight the state dependent nature of the effects of high-cost credit as well as the consumption-smoothing role that it plays for households with limited access to other forms of credit.

Average and Marginal Returns to Upper Secondary Schooling in Indonesia

SummaryThis paper estimates average and marginal returns to schooling in Indonesia using a semiparametric selection model. Identification of the model is given by geographic variation in access to upper secondary schools. We find that the return to upper secondary schooling varies widely across individuals: it can be as high as 50% per year of schooling for those very likely to enroll in upper secondary schooling, or as low as −10% for those very unlikely to do so. Average returns for the student at the margin are substantial, but they are also well below those for the average student attending upper secondary schooling. Copyright © 2016 John Wiley & Sons, Ltd.

Geographic Variation in Access to Plastic Surgeons.

While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25 million people lived in 468 HSAs (49.3%) without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.

Trauma care and referral patterns in Rwanda: implications for trauma system development.

Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ² and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions.

The Royal College of Ophthalmologists' Cataract Surgery Commissioning Guidance: executive summary.

The Royal College of Ophthalmologists recently published evidence-based guidance on commissioning for cataract surgery in response to reports of wide geographical variation in access to cataract surgery in England, and the increasing use of arbitrary Snellen visual acuity thresholds to govern access to cataract surgery. This article summarises the main findings of the Commissioning Guidance and current issues surrounding cataract surgery provision in the NHS. The methodology used to develop this guidance was granted National Institute for Health and Care Excellence (NICE) accreditation in July 2015.

A systematic review of geographical variation in access to chemotherapy.

BackgroundRising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of ‘postcode prescribing’ in cancer is important. There have been no systematic reviews considering access to cancer drugs by geographical characteristics in the UK.MethodsStudies describing receipt of cancer drugs, according to healthcare boundaries (e.g. cancer network [UK]) were identified through a systematic search of electronic databases and grey literature. Due to study heterogeneity a meta-analysis was not possible and a narrative synthesis was performed.Results8,780 unique studies were identified and twenty-six included following a systematic search last updated in 2015. The majority of papers demonstrated substantial variability in the likelihood of receiving chemotherapy between hospitals, health authorities, cancer networks and UK countries (England and Wales). After case-mix adjustment, there was up to a 4–5 fold difference in chemotherapy utilisation between the highest and lowest prescribing cancer networks. There was no strong evidence that rurality or distance travelled were associated with the likelihood of receiving chemotherapy and conflicting evidence for an effect of travel time.ConclusionsConsiderable variation in chemotherapy prescribing between healthcare boundaries has been identified. The absence of associations with natural geographical characteristics (e.g. rurality) and receipt of chemotherapy suggests that local treatment habits, capacity and policy are more influential.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-2026-y) contains supplementary material, which is available to authorized users.

Geographic Variation in Access to Plastic Surgeons

INTRODUCTION: While recent studies project a future shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the geographic distribution of the plastic surgery workforce across the United States. MATERIALS AND METHODS: Using the 2013–2014 Area Health Resource File, we estimated the number of plastic surgeons at the Health Service Area (HSA) level in 2010 and 20121. The density of plastic surgeons was calculated as a ratio per 100,000 population. HSAs were grouped by plastic surgeon density and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. RESULTS: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7,600 plastic surgeons, or 2.42 plastic surgeons/100,000 population, in the U.S. However, nearly half of the HSAs studied (N=468, 49.3%) were without any plastic surgeons, leaving over 25 million people without access to the specialty. Conversely, 106 million people living in 82 HSAs (8.6%) had more than 3.0 plastic surgeons per 100,000 population (Figure 1). Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger, female, and residing in urban areas with greater healthcare resources (all p-values ≤ 0.001). Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density while 15 HSAs lost all plastic surgeons (Figure 2).Figure 1: Choropleth map depicting plastic surgeons density across health service areas as of 2012.*Figure 2: Choropleth map depicting health service areas that saw an increase or decrease in plastic surgeon density between 2010 and 2012.** Alaska and Hawaii included in statistical analysis but not visual representation.CONCLUSION: Plastic surgeons are asymmetrically distributed across the United States, leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact rural populations. Further research is needed to understand how this impacts patient care and outcomes, with future workforce policy directed at retaining plastic surgeons in areas suffering from plastic surgeon shortages.

Acute care surgery in Rwanda: Operative epidemiology and geographic variations in access to care

Surgical management of emergent, life-threatening diseases is an important public health priority. The objectives of this study were to (1) describe acute care general surgery procedures performed at the largest referral hospital in Rwanda and (2) understand the geographic distribution of disease presentations and referral patterns. We performed a retrospective review of prospectively collected acute care surgery cases performed at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda between June 1 and December 1, 2011. Using Pearson's χ(2) test and the Fisher exact test, we compared cases originating from within Kigali and transfers from other provinces. Geospatial analyses also were used to further describe transfer patterns. During the study period, 2,758 surgical interventions were performed, of which 25.6% (707/2,758) were general surgery operations. Of these, 45.4% (321/707) met the definition of acute care surgery. Only about one-third-32.3% (92/285)-of patients resided within Kigali, whereas about two-thirds-67.7% (193/285)-were transferred from other provinces. Most patients transferred from other provinces were younger than 18 years of age (40.4%; 78/193), and 83.0% (39/47) of patients older than 50 years of age originated from outside of Kigali. Specific operative indications and surgical procedures varied substantially between patients from Kigali and patients transferred from other provinces. Emergency surgical conditions remain important contributors to the global burden of disease, particularly in low- and middle-income countries. Geographic variations exist in terms of operative diagnoses and procedures, which implies a need for improved access to surgical care at the district level with defined transfer mechanisms to greater-level care facilities when needed.