Geographic Variation In Access Research Articles

Individual and Regional Factors of Access to the Renal Transplant Waiting List in France in a Cohort of Dialyzed Patients

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non-medical factors at both these levels associated with these geographical variations in waiting-list placement in France. We included all incident patients aged 18-80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non-autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.

Geographic Variation in Access to Kidney Transplantation in the United States By Race.

Background: Racial disparities exist in access to kidney transplantation in the United States (US), and kidney transplant rates are lowest in the Southeastern US compared to other regions. However, it is unknown whether racial disparities vary across geographic regions in the US. Methods: Among a cohort of 681,521 adult ESRD patients in the United States Renal Data System from 2005 through 2011, we examined black vs. white racial disparity in waitlisting and transplantation across geographic regions. We used Cox proportional hazards models to estimate crude hazard ratios (HRs) of waitlisting and transplantation by ESRD Network region. Results: On average, there are minor black vs. white racial disparities in access to waitlisting in the US (HR=0.98; 95% CI: 0.97-0.99). However, regional differences exist in racial disparities in access to waitlisting (interaction p<0.0001), with the Southeastern US having the worst racial disparity in access to waitlisting (HR=0.81; 95% CI: 0.77-0.84).Figure: No Caption available.Racial disparities exist in access to both deceased and living donor kidney transplantation in the US, where blacks have half the rate of transplantation vs. whites (HR=0.49; 95% CI: 0.48-0.50). Regional differences exist in racial disparities in access to kidney transplantation (interaction p <0.0002), and similar to waitlisting access, the Southeastern US has the worst racial disparity in access to kidney transplantation (HR=0.38; 95% CI: 0.35-0.40).Figure: No Caption available.Conclusion: We observed a large difference in racial disparity between access to waitlisting and transplantation, such that racial disparities were more pronounced after waitlisting. Further, disparities differed dramatically by US region, suggesting that it is essential to consider geographical differences when examining racial disparities in access to kidney transplantation.

Geographic variations in access and utilization of cancer screening services: examining disparities among American Indian and Alaska Native Elders.

BackgroundDespite recommendations for cancer screening for breast and colorectal cancer among the Medicare population, preventive screenings rates are often lower among vulnerable populations such as the small but rapidly growing older American Indian and Alaska Native (AIAN) population. This study seeks to identify potential disparities in the availability of screening services, distance to care, and the utilization of cancer screening services for Medicare beneficiaries residing in areas with a higher concentration of AIAN populations.MethodsUsing the county (n =3,225) as the level of analysis, we conducted a cross-sectional analysis of RTI International’s Spatial Impact Factor Data (2012) to determine the level of disparities for AIAN individuals. The outcomes of interest include: the presence of health care facilities in the county, the average distance in miles to the closest provider of mammography and colonoscopy (analyzed separately) and utilization of screening services (percent of adults aged 65 and older screened by county).ResultsCounties with higher concentrations of AIAN individuals had greater disparities in access and utilization of cancer screening services. Even after adjusting for income, education, state of residence, population 65 and older and rurality, areas with higher levels of AIAN individuals were more likely to see disparities with regard to health care services related to mammograms (p ≤ .05; longer distance, lower screening) and colonoscopies (p ≤ .05; longer distance, lower screening).ConclusionsThese findings provide evidence of a gap in service availability, utilization and access facing areas with higher levels of AIAN individuals throughout the US. Without adequate resources in place, these areas will continue to have less access to services and poorer health which will be accelerated as the population of older adults grows.

Accountability for end-stage organ care: Implications of geographic variation in access to kidney transplantation

The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by "accountable" providers of transplant services. Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to "accountable" transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008. In total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001). Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.

Geographic variation in access to dog-bite care in Pakistan and risk of dog-bite exposure in Karachi: prospective surveillance using a low-cost mobile phone system.

BackgroundDog-bites and rabies are under-reported in developing countries such as Pakistan and there is a poor understanding of the disease burden. We prospectively collected data utilizing mobile phones for dog-bite and rabies surveillance across nine emergency rooms (ER) in Pakistan, recording patient health-seeking behaviors, access to care and analyzed spatial distribution of cases from Karachi.Methodology and Principal FindingsA total of 6212 dog-bite cases were identified over two years starting in February 2009 with largest number reported from Karachi (59.7%), followed by Peshawar (13.1%) and Hyderabad (11.4%). Severity of dog-bites was assessed using the WHO classification. Forty percent of patients had Category I (least severe) bites, 28.1% had Category II bites and 31.9% had Category III (most severe bites). Patients visiting a large public hospital ER in Karachi were least likely to seek immediate healthcare at non-medical facilities (Odds Ratio = 0.20, 95% CI 0.17–0.23, p-value<0.01), and had shorter mean travel time to emergency rooms, adjusted for age and gender (32.78 min, 95% CI 31.82–33.78, p-value<0.01) than patients visiting hospitals in smaller cities. Spatial analysis of dog-bites in Karachi suggested clustering of cases (Moran's I = 0.02, p value<0.01), and increased risk of exposure in particular around Korangi and Malir that are adjacent to the city's largest abattoir in Landhi. The direct cost of operating the mHealth surveillance system was USD 7.15 per dog-bite case reported, or approximately USD 44,408 over two years.ConclusionsOur findings suggest significant differences in access to care and health-seeking behaviors in Pakistan following dog-bites. The distribution of cases in Karachi was suggestive of clustering of cases that could guide targeted disease-control efforts in the city. Mobile phone technologies for health (mHealth) allowed for the operation of a national-level disease reporting and surveillance system at a low cost.

Intermediate input sharing in the hospital service industry

This paper addresses two related questions that help to explain geographic variation in access to medical services. The first question examines the existence of agglomeration economies in the hospital service industry. The second considers whether the sharing of intermediate inputs contributes to spillovers from spatial concentration of hospital services. These questions are addressed by estimating a bivariate probit model that explicitly controls for potential correlations between whether a service is provided and how the service is provided. Three key findings are obtained. First, hospitals in more concentrated areas are more likely to outsource intermediate services to specialized intermediate service suppliers. This suggests that agglomeration economies exist in the hospital service industry and are generated in part through the sharing of intermediate inputs. Second, the presence of nearby small hospitals increases the tendency to outsource, which is consistent with a “Chinitz” effect identified elsewhere in the literature. Third, the agglomeration effect attenuates geographically.

Intermediate Input Sharing in the Hospital Service Industry

This paper addresses two related questions that help to explain geographic variation in access to medical services. The first question examines the existence of agglomeration economies in the hospital service industry. The second considers whether the sharing of intermediate inputs contributes to spillovers from spatial concentration of hospital services. These questions are addressed by estimating a bivariate probit model that explicitly controls for potential correlations between whether a service is provided and how the service is provided. Three key findings are obtained. First, hospitals in more concentrated areas are more likely to outsource intermediate services to specialized intermediate service suppliers. This suggests that agglomeration economies exist in the hospital service industry and are generated in part through the sharing of intermediate inputs. Second, the presence of nearby small hospitals increases the tendency to outsource, which is consistent with a “Chinitz” effect identified elsewhere in the literature. Third, the agglomeration effect attenuates geographically.

Determinants of demand for total hip and knee arthroplasty: a systematic literature review

BackgroundDocumented age, gender, race and socio-economic disparities in total joint arthroplasty (TJA), suggest that those who need the surgery may not receive it, and present a challenge to explain the causes of unmet need. It is not clear whether doctors limit treatment opportunities to patients, nor is it known the effect that patient beliefs and expectations about the operation, including their paid work status and retirement plans, have on the decision to undergo TJA. Identifying socio-economic and other determinants of demand would inform the design of effective and efficient health policy. This review was conducted to identify the factors that lead patients in need to undergo TJA.MethodsAn electronic search of the Embase and Medline (Ovid) bibliographic databases conducted in September 2011 identified studies in the English language that reported on factors driving patients in need of hip or knee replacement to undergo surgery. The review included reports of elective surgery rates in eligible patients or, controlling for disease severity, in general subjects, and stated clinical experts’ and patients’ opinions on suitability for or willingness to undergo TJA. Quantitative and qualitative studies were reviewed, but quantitative studies involving fewer than 20 subjects were excluded. The quality of individual studies was assessed on the basis of study design (i.e., prospective versus retrospective), reporting of attrition, adjustment for and report of confounding effects, and reported measures of need (self-reported versus doctor-assessed). Reported estimates of effect on the probability of surgery from analyses adjusting for confounders were summarised in narrative form and synthesised in odds ratio (OR) forest plots for individual determinants.ResultsThe review included 26 quantitative studies−23 on individuals’ decisions or views on having the operation and three about health professionals’ opinions-and 10 qualitative studies. Ethnic and racial disparities in TJA use are associated with socio-economic access factors and expectations about the process and outcomes of surgery. In the United States, health insurance coverage affects demand, including that from the Medicare population, for whom having supplemental Medicaid coverage increases the likelihood of undergoing TJA. Patients with post-secondary education are more likely to demand hip or knee surgery than those without it (range of OR 0.87-2.38). Women are as willing to undergo surgery as men, but they are less likely to be offered surgery by specialists than men with the same need. There is considerable variation in patient demand with age, with distinct patterns for hip and knee. Paid employment appears to increase the chances of undergoing surgery, but no study was found that investigated the relationship between retirement plans and demand for TJA. There is evidence of substantial geographical variation in access to joint replacement within the territory covered by a public national health system, which is unlikely to be explained by differences in preference or unmeasured need alone. The literature tends to focus on associations, rather than testing of causal relationships, and is insufficient to assess the relative importance of determinants.ConclusionsPatients’ use of hip and knee replacement is a function of their socio-economic circumstances, which reinforce disparities by gender and race originating in the doctor-patient interaction. Willingness to undergo surgery declines steeply after the age of retirement, at the time some eligible patients may lower their expectations of health status achievement. There is some evidence that paid employment independently increases the likelihood of operation. The relative contribution of variations in surgical decision making to differential access across regions within countries deserves further research that controls for clinical need and patient lifestyle preferences, including retirement decisions. Evidence on this question will become increasingly relevant for service planning and policy design in societies with ageing populations.

Trends over time and geographical variation in rates of intravitreal injections in England

AimsThe recent emergence of antivascular endothelial growth factor (anti-VEGF) drugs has led to increased numbers of patients undergoing intravitreal injection for age-related macular degeneration (AMD). The aims of this study...

Geographic Variation in End-Stage Renal Disease Incidence and Access to Deceased Donor Kidney Transplantation

The effect of demand for kidney transplantation, measured by end-stage renal disease (ESRD) incidence, on access to transplantation is unknown. Using data from the U.S. Census Bureau, Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) from 2000 to 2008, we performed donation service area (DSA) and patient-level regression analyses to assess the effect of ESRD incidence on access to the kidney waiting list and deceased donor kidney transplantation. In DSAs, ESRD incidence increased with greater density of high ESRD incidence racial groups (African Americans and Native Americans). Wait-list and transplant rates were relatively lower in high ESRD incidence DSAs, but wait-list rates were not drastically affected by ESRD incidence at the patient level. Compared to low ESRD areas, high ESRD areas were associated with lower adjusted transplant rates among all ESRD patients (RR 0.68, 95% CI 0.66-0.70). Patients living in medium and high ESRD areas had lower transplant rates from the waiting list compared to those in low ESRD areas (medium: RR 0.68, 95% CI 0.66-0.69; high: RR 0.63, 95% CI 0.61-0.65). Geographic variation in access to kidney transplant is in part mediated by local ESRD incidence, which has implications for allocation policy development.

Variability in Access to Hospital Palliative Care in the United States

Hospital palliative care programs provide high-quality, comprehensive care for seriously ill patients and their families. To examine geographic variation in patient and medical trainee access to hospital palliative care and to examine predictors of these programs. Primary and secondary analyses of national survey and census data. Hospital data including hospital palliative care programs were obtained from the American Hospital Association (AHA) Annual Survey Databasetrade mark for fiscal year 2006 supplemented by mailed surveys. Medical school-affiliated hospitals were obtained from the American Association of Medical Colleges, Web-site review, and telephone survey. Health care utilization data were obtained from the Dartmouth Atlas of Health Care 2008. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of hospital palliative care. A total of 52.8% of hospitals with 50 or more total facility beds reported hospital palliative care with considerable variation by state; 40.9% (144/352) of public hospitals, 20.3% (84/413) of for-profit hospitals, and 28.8% (160/554) of Medicare sole community providers reported hospital palliative care. A total of 84.5% of medical schools were associated with at least one hospital palliative care program. Factors significantly associated (p < 0.05) with hospital palliative care included geographic location, owning a hospice program, having an American College of Surgery approved cancer program, percent of persons in the county with a university education, and medical school affiliation. For-profit and public hospitals were significantly less likely to have hospital palliative care when compared with nonprofit institutions. States with higher hospital palliative care penetration rates were observed to have fewer Medicare hospital deaths, fewer intensive care unit/cardiac care unit (ICU/CCU) days and admissions during the last 6 months of life, fewer ICU/CCU admission during terminal hospitalizations, and lower overall Medicare spending/enrollee. This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study.

A personal viewpoint against the motion that breast cancer patient advocacy groups unfairly distort the cancer budget

A personal viewpoint against the motion that breast cancer patient advocacy groups unfairly distort the cancer budget

The First Three Years of Buprenorphine in the United States: Experience to Date and Future Directions

Buprenorphine, primarily as the buprenorphine/naloxone combination, has been available in the United States for office and specialty treatment program-based care since 2003. The existing evidence, collected primarily from federal sources, indicates that access to this type of treatment has expanded, that more than 50% of the 12,000 physicians able to provide this care are not addiction specialists, that buprenorphine diversion is low, that physician scrutiny by federal agents is infrequent, and among those receiving treatment patient acceptance is high. Implementation has been slowed because of physician training and support needs, reimbursement, and limits on the number of patients each physician can treat. As a result there are geographic variations in access and unmet treatment needs. The United States Congress has moved twice to loosen numerical limitations, now allowing each physician to treat up to 100 patients. Future research and evaluation are needed to ensure that opioid-dependent patients receive optimal care with buprenorphine.

Who’s afraid of red, yellow and green?: Redlining in Rotterdam

Redlining research is common practice in the US but not in other countries. Does this imply redlining does not take place elsewhere? This paper presents evidence from Rotterdam, the second largest city of the Netherlands, showing that in the 1990s it was impossible to get a home mortgage in large parts of the city. However, after Rotterdam joined the National Mortgage Guarantee (an institutional control measure) in 2000, hardly any evidence of redlining was found. This paper not only shows that redlining takes place outside of the US context, but also that a (discursive) treatment based on case study research has the possibility to gain a fuller understanding of redlining practices than a statistical/correlation analysis of mortgage data. Interviews with key actors are instrumental to unravelling how, why and when those in power make their decisions: agents are structured by the existing system while, at the same time, some of these agents have the power to re-produce as well as re-structure (transform) the system. One of the geographical outcomes of the agency-structure interaction is that credit is “redirected away from poorer to richer (and therefore “safer”) groups” as part of a strategy of risk avoidance [Leyshon and Thrift, 1997]. Thus redlining, like any other form of financial exclusion, deepens and accentuates prevailing levels of uneven development by creating geographical variations in access to the financial system [Dymski and Veitch, 1992].

‘Breaking out of the asylum’: developments in the geography of mental ill-health — the influence of the informal sector

This paper focuses on the changing role of the voluntary sector in the provision of care and support to community-based individuals with mental ill-health (MIH) in contemporary Scotland. In doing so, it reflects on the ways in which deinstitutionalisation is contributing to changing interrelationships between the formal and informal sector, the influence of the voluntary sector in the development of the locational geographies of individuals with MIH, and factors contributing to geographical variations in access and availability of voluntary sector supports. These developments are considered within the framework of the shadow state.