Geographic Disparities In Access Research Articles

Longer Term Follow-up on Acuity Circle Allocation Strategies in Liver Transplantation

Abstract Purpose of Review This review summarizes longer term follow-up of acuity circle–based distribution for livers, which was implemented on February 4, 2020. Recent Findings After 2 years of policy implementation, the likelihood of transplant increased, while removals for death or being too sick decreased. The median transplant score was unchanged, and the variance in the median MELD at transplant decreased for OPTN regions, DSA, and state. Concurrently, median distance from donor to transplant hospital and cold ischemia times increased. A slight increase in liver non-use rate and decrease in liver utilization rate has been observed. Summary Acuity circle–based distribution improved access to liver transplantation for the sickest patients through broader sharing, at the cost of increased travel and logistics. The continuous distribution framework may be an opportunity for the liver transplant community to further address geographic disparities in access to transplant in the United States.

262 Geographic Disparities in Access to Nephrology Care for People with Chronic Kidney Disease in the United States

262 Geographic Disparities in Access to Nephrology Care for People with Chronic Kidney Disease in the United States

Funny things are everywhere: Combatting geographic disparities in aortic stenosis care.

Key points Only 25%–35% of geographic variation in the use of surgical and transcatheter aortic valve replacement can be attributed to differing patient and hospital characteristics. To address geographic disparities, the cardiovascular community must address modifiable cardiovascular risk factors, social determinants of health, and healthcare delivery models. Governmental and professional organizations must study and actively address geographic disparities in access to care for aortic valve disease.

Geographic disparities in access to liver transplant for advanced cirrhosis: Time to ring the alarm!

Decompensated cirrhosis and hepatocellular cancer are major risk factors for mortality worldwide. Liver transplantation (LT), both live-donor LT or deceased-donor LT, are lifesaving, but there are several barriers toward equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure. Rates of LT vary widely worldwide but are lowest in lower-income countries owing to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the Chronic Liver Disease Evolution and Registry for Events and Decompensation consortium defined these barriers toward LT as critical in determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and hepatocellular cancer care to prevent the need for LT. Live-donor LT is predominant across Asian countries, whereas deceased-donor LT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges toward equitable access but uniform definitions of acute-on-chronic liver failure, improving transplant expertise, enhancing availability of resources and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.

Child Health Needs and the Pediatric Infectious Diseases Workforce: 2020-2040.

Pediatric infectious diseases (PID) physicians prevent and treat childhood infections through clinical care, research, public health, education, antimicrobial stewardship, and infection prevention. This article is part of an American Board of Pediatrics Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce. The article offers context to findings from a modeling analysis estimating the supply of PID subspecialists in the United States between 2020 and 2040. It provides an overview of children cared for by PID subspecialists, reviews the current state of the PID workforce, and discusses the projected headcount and clinical workforce equivalents of PID subspecialists at the national, census region, and census division levels over this 2-decade period. The article concludes by discussing the education and training, clinical practice, policy, and research implications of the data presented. Adjusting for population growth, the PID workforce is projected to grow more slowly than most other pediatric subspecialties and geographic disparities in access to PID care are expected to worsen. In models considering alternative scenarios, decreases in the number of fellows and time spent in clinical care significantly affect the PID workforce. Notably, model assumptions may not adequately account for potential threats to the PID workforce, including a declining number of fellows entering training and the unknown impact of the COVID-19 pandemic and future emerging infections on workforce attrition. Changes to education and training, clinical care, and policy are needed to ensure the PID workforce can meet the future needs of US children.

Geographic Disparities in Access to Neurologists and Multiple Sclerosis Care in the United States.

A shortage of neurology clinicians and healthcare disparities may hinder access to neurologic care. This study examined disparities in geographic access to neurologists and subspecialty multiple sclerosis (MS) care among various demographic segments of the United States. Neurologist practice locations from 2022 CMS Care Compare physician data and MS Center locations as defined by the Consortium of Multiple Sclerosis Centers were used to compute spatial access for all U.S. census tracts. Census tract-level community characteristics (sex, age, race, ethnicity, education, income, insurance, % with computer, % without a vehicle, % with limited English, and % with hearing, vision, cognitive, and ambulatory difficulty) were obtained from 2020 American Community Survey 5-year estimates. Rural-urban status was obtained from 2010 rural-urban commuting area codes. Logistic and linear regression models were used to examine access to a neurologist or MS Center within 60 miles and 60-mile spatial access ratios. Of 70,858 census tracts, 388 had no neurologists within 60 miles and 17,837 had no MS centers within 60 miles. Geographic access to neurologists (spatial access ratio [99% CI]) was lower for rural (-80.49%; CI [-81.65 to -79.30]) and micropolitan (-60.50%; CI [-62.40 to -58.51]) areas compared with metropolitan areas. Tracts with 10% greater percentage of Hispanic individuals (-4.53%; CI [-5.23 to -3.83]), men (-6.76%; CI [-8.96 to -4.5]), uninsured (-7.99%; CI [-9.72 to -6.21]), individuals with hearing difficulty (-40.72%; CI [-44.62 to -36.54]), vision difficulty (-13.0%; [-18.72 to -6.89]), and ambulatory difficulty (-15.68%; CI [-19.25 to -11.95]) had lower access to neurologists. Census tracts with 10% greater Black individuals (3.50%; CI [2.93-10.71]), college degree holders (-7.49%; CI [6.67-8.32]), individuals with computers (16.57%, CI [13.82-19.40]), individuals without a vehicle (9.57%; CI [8.69-10.47]), individuals with cognitive difficulty (25.63%; CI [19.77-31.78]), and individuals with limited English (18.5%; CI [16.30-20.73]), and 10-year older individuals (8.85%; CI [7.03-10.71]) had higher spatial access to neurologists. Covariates for access followed similar patterns for MS centers. Geographic access to neurologists is decreased in rural areas, in areas with higher proportions of Hispanics, populations with disabilities, and those uninsured. Access is further limited for MS subspecialty care. This study highlights disparities in geographic access to neurologic care.

BEYOND REDLINING: LAW, PROPERTY VALUES, RACIAL INEQUITIES, AND LTSS

Abstract This presentation will provide background regarding the social construction of property values and the interactive role that public and private institutions have played in creating racial disparities in property values. I will discuss known and proposed mechanisms through which this form of structural racism affects access to long-term services and supports (LTSS) and implications for the health of older adults and their care partners, presenting a specific example from my own research, which found that assisted living communities are located in 30% of communities in America. However, among communities with the highest percent Black population in their county, 31% of those located in counties with a low gap in Black-White economic mobility had access to assisted living, while less than 15% of those located within a county with a high Black-White gap in economic mobility had such access. I will describe how policymakers can use law to address racial disparities in geographic access by developing policies that 1) provide financial incentives for private investors to develop assisted living and other forms of LTSS in neighborhoods that otherwise wouldn’t see development due to low property values; 2) prioritize the location of new buildings in historically marginalized communities; 3) implement anti-displacement measures; 4) incorporate community input and engagement; and 5) ensure accessibility and affordability. Finally, I will describe how policymakers may consider the various actors and institutions that shape the housing market and how they interact with each other to produce outcomes that may reinforce or challenge structural racism.

Geographic Disparities in Access to Assisted Reproductive Technology Centers in China: Spatial-Statistical Study (Preprint)

Geographic Disparities in Access to Assisted Reproductive Technology Centers in China: Spatial-Statistical Study (Preprint)

Race, rurality and geographic accessibility to medication for opioid use disorder in the U.S.

ABSTRACT Disparities in geographic access to medication for opioid use disorder (OUD) are well documented. Further, historical implications of systemic racism and of the longstanding War on Drugs in the United States have driven both social and spatial inequities in access to treatment. This work builds on a previously published spatial access methodology that uses a gravity-based variant of the enhanced two-step floating catchment area model, to determine how OUD pharmacotherapy accessibility varies nationally at the census tract level. Medication for OUD (MOUD) accessibility scores are then analyzed by rurality and racial/ethnic segregation. The Getis-Ord Gi* statistic was used to identify clusters of high or low accessibility to MOUD, while the interaction index was used as a measure of segregation to assess the racial/ethnic population distribution. The results of the clustering statistic, and the associated significance values were then compared to rurality and interaction using the Chi-Square test to determine if hot or cold areas of access are independent of rurality and racial/ethnic spatial distributions. Lastly, the percentage of buprenorphine providers at capacity by census tract was calculated using the binary ‘at-capacity’ data attribute associated with each SAMHSA buprenorphine provider record. The results demonstrate distinct spatial variability of MOUD resources based on urbanicity and racial makeup that have significant implications for intervention or policy reform that seeks to encourage equal access to both treatment modalities.

A catchment and location-allocation analysis of mammography access in Delaware, US: implications for disparities in geographic access to breast cancer screening

BackgroundDespite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. Access to breast cancer screening was evaluated in Delaware, a state that experiences an elevated burden from breast cancer but is otherwise representative of the US in terms of race and urban–rural characteristics. We first conducted a catchment analysis of mammography facilities. Finding evidence of disparities by race and rurality, we next conducted a location-allocation analysis to identify candidate locations for the establishment of new mammography facilities to optimize equitable access.MethodsA catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines.ResultsThe catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 68% (95% CI 38–85%) fewer mammography units and 89% (95% CI 60–98%) fewer BICOEs. The more rural counties in the state accounted for 41% of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas.ConclusionsThe results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.

Racial & ethnic disparities in geographic access to critical care in the United States: A geographic information systems analysis.

It is important to identify gaps in access and reduce health outcome disparities, understanding access to intensive care unit (ICU) beds, especially by race and ethnicity, is crucial. Our objective was to evaluate the race and ethnicity-specific 60-minute drive time accessibility of ICU beds in the United States (US). We conducted a cross-sectional study using road network analysis to determine the number of ICU beds within a 60-minute drive time, and calculated adult intensive care bed ratios per 100,000 adults. We evaluated the US population at the Census block group level and stratified our analysis by race and ethnicity and by urbanicity. We classified block groups into four access levels: no access (0 adult intensive care beds/100,000 adults), below average access (>0-19.5), average access (19.6-32.0), and above average access (>32.0). We calculated the proportion of adults in each racial and ethnic group within the four access levels. All 50 US states and the District of Columbia. Adults ≥15 years old. Adult intensive care beds/100,000 adults and percentage of adults national and state) within four access levels by race and ethnicity. High variability existed in access to ICU beds by state, and substantial disparities by race and ethnicity. 1.8% (n = 5,038,797) of Americans had no access to an ICU bed, and 26.8% (n = 73,095,752) had below average access, within a 60-minute drive time. Racial and ethnic analysis showed high rates of disparities (no access/below average access): American Indians/Alaskan Native 12.6%/28.5%, Asian 0.7%/23.1%, Black or African American 0.6%/16.5%, Hispanic or Latino 1.4%/23.0%, Native Hawaiian and other Pacific Islander 5.2%/35.0%, and White 2.1%/29.0%. A higher percentage of rural block groups had no (5.2%) or below average access (41.2%), compared to urban block groups (0.2% no access, 26.8% below average access). ICU bed availability varied substantially by geography, race and ethnicity, and by urbanicity, creating significant disparities in critical care access. The variability in ICU bed access may indicate inequalities in healthcare access overall by limiting resources for the management of critically ill patients.

Gravity-based models for evaluating urban park accessibility: Why does localized selection of attractiveness factors and travel modes matter?

Gravity-based models have been extensively utilized in urban studies for measuring geographic disparities in access to urban parks over the past several decades. However, despite methodological advancements incorporating various aspects of accessibility, there has been limited focus on the impact of variable selection (e.g., attractiveness factors) and transport modes on accessibility evaluations. This study investigates the differences in gravity-based models for assessing park accessibility based on varying assumptions about attractiveness factors and travel impedance. Semi-structured interviews with local residents were conducted to identify the reasons for park visits in Shanghai. Our bivariate correlation analyses reveal that factors such as park openness and access to public transport were crucial, in addition to conventional factors identified in the literature (i.e., park size and driving accessibility). This insight led to the development of localized accessibility measurements that incorporate park inclusiveness (i.e., entrance fees and opening hours) and multimodal travel options (based on multinomial logistic mode choice models). The results indicate that the refined model produces lower and more varied accessibility levels, which can better capture accessibility gaps across different geographic contexts. This accurate and practical identification of accessibility gaps can assist local planners and decision-makers in formulating effective policies and strategies to promote equitable access to urban public parks.

1714P Geographical disparities in access to cancer clinical trials in Korea

1714P Geographical disparities in access to cancer clinical trials in Korea

Geographic Disparity In Access To Trauma Care In Secondary Schools Across The United States

Geographic Disparity In Access To Trauma Care In Secondary Schools Across The United States

HIV vaccines: Lessons from basic research, clinical trials, and public policy

Forty years since its discovery in 1983, HIV/AIDS still lacks a cure, despite advances in biomedicine that have dramatically improved global understanding of the virus’s biology. Decades of research and improvements to clinical trial infrastructure have promoted the development of novel vaccines for HIV, but these vaccines have shown limited efficacy. The landmark clinical trial “RV144” in Thailand (2003) showed modest efficacy of an HIV vaccine for the first time ever, sparking the formation of public-private partnerships and a wave of other HIV vaccine clinical trials. Around two decades later, the COVID-19 pandemic provided an impetus to move vaccine technology forward and exposed areas for improvement in vaccine and clinical-trial infrastructure. Looking at historical examples from both HIV and COVID-19 research, vaccine trials, and global statistics, it is clear that a successful vaccination campaign will require generous funding, collaboration, clinical trial infrastructure, sharing of data and resources amongst researchers, and policy based on scientific evidence and ethics. Such a successful campaign will also require overcoming several hurdles, such as delivering vaccines to individuals in countries with underdeveloped health care systems and both demographic and geographic disparities in access to care. The perspectives in this article are apropos given the recent development of HIV vaccines that have entered clinical trials.

Geographic Disparities in Access to Cancer Clinical Trials in Canada.

This study aims to evaluate geographic disparities in access to cancer clinical trials across Canada. Cancer clinical trial data recorded within the clinicaltrials.gov and reporting the conduct of any of these trials in Canada, 2005 to 2023 were reviewed. Frequency analyses of the number of clinical trials that were registered on clinicaltrials.gov for Canada, individual Canadian provinces, main Canadian urban centers, and different cancer types, according to the funding source (industry versus non-industry), as well as according to different periods (using 3-y intervals) were conducted. Moreover, a comparison of cancer clinical trials per 10,000 persons was done between Canada and the United States. The number of cancer clinical trials per 10,000 individuals (according to the 2021 census) in each province/territory varied between 6.79 (New Brunswick) to 0 (the 3 territories). The number of cancer clinical trials in relation to 1000 projected cancer cases for some of the common tumor types in Canada was then reviewed. The highest number was for lymphoma clinical trials (32.85), whereas the lowest number was for bladder cancer clinical trials (7.06). Most of the trials have industry funding (69%). Using 3-year intervals, the highest number of cancer clinical trials was observed from 2014 to 2016 (778 trials), and the lowest number was observed from 2020 to 2022 (633 trials). Access to clinical trials in Canada is not equitably distributed, with geographical and primary tumor site disparities. Moreover, access to cancer clinical trials has been negatively impacted during the time of the COVID-19 pandemic.

A Geospatial Analysis of Disparities in Access to Oncofertility Services

Fertility preservation (FP), including oocyte and embryo cryopreservation prior to gonadotoxic therapy, is an urgent and essential component of comprehensive cancer care. Geographic proximity to a center offering FP is a critical component of ensuring equitable access for people with cancer desiring future fertility. To characterize the distribution of centers offering FP services in the US, quantify the number of self-identified reproductive-age female individuals living outside of geographically accessible areas, and investigate the association between geographic access and state FP mandates. This cross-sectional analysis calculated 2-hour travel time isochrone maps for each center based on latitude and longitude coordinates. Population-based geospatial analysis in the US was used in this study. Fertility clinics identified through the 2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Report were defined as oncofertility centers by meeting 4 criteria: (1) offered oocyte and embryo cryopreservation, (2) performed at least 1 FP cycle in 2018, (3) served people without partners, and (4) had an accredited laboratory. County-level data were obtained from the 2020 US Census, with the primary at-risk population identified as reproductive-age female individuals aged 15 years to 44 years. The analysis was performed from 2021 to 2022. Location outside of 2-hour travel time isochrone of an oncofertility center. Oncofertility centers were compared with centers not meeting criteria and were classified by US region, state FP mandate status, number of assisted reproductive technology cycles performed, and number of FP cycles performed. The number and percentage of at-risk patients, defined as those living outside of accessible service areas by state, were identified. Among 456 Centers for Disease Control and Prevention-reporting fertility clinics, 86 (18.9%) did not meet the criteria as an oncofertility center. A total of 3.63 million (5.70%) reproductive-age female individuals lack geographic access to an oncofertility center. States with FP mandates have the highest rates of eligible female patients with geographic access (98.54%), while states without active or pending legislation have the lowest rates (79.57%). The greatest disparities in geographic access to care are most concentrated in the Mountain West and West North Central regions. Patients face numerous barriers to comprehensive cancer care, including a lack of geographic access to centers capable of offering FP services. This cross-sectional study identified disparities in geographic access and potential opportunities for strategic expansion.

EPH191 Identifying Geographic Disparities in Access to Psoriasis Care in Medicaid Patients

To identify and characterize geographic disparities in access to psoriasis (PsO) care for Medicaid patients.

Advancing the Field of Pediatric Liver Transplantation: Urgent Action Items Identified During the 2022 Society of Pediatric Liver Transplantation Meeting.

Advancing the Field of Pediatric Liver Transplantation: Urgent Action Items Identified During the 2022 Society of Pediatric Liver Transplantation Meeting.

Geographic disparities in the care and outcomes in adult chronic immune thrombocytopenia

IntroductionDespite expert-based recommendations, real-world adherence to immune thrombocytopenia (ITP) guidelines is unclear. The impact of geographic and socioeconomic disparities on the quality of care and outcomes is unknown. We sought to determine the association between geographic remoteness and material deprivation on ITP care and outcomes. MethodsWe conducted a multi-centre retrospective cohort study of adults with chronic ITP requiring a second-line therapy between 2012 and 2019 in the province of Alberta, Canada. Socioeconomic status was measured using the Pampalon material deprivation index quintiles. Geographic disparities were assessed by the driving distance to a major centre, with geographic remoteness defined as >200 km from major centre. We examined the impact of geographic and material deprivation on quality of care, resource utilization (hospitalizations, transfusions), and outcomes (major bleeding, all-cause mortality and ITP-related mortality). Cox proportional hazards models were used to examine the impact of geographic remoteness, rural residence and material deprivation on overall survival and ITP-related survival. ResultsWe included 326 ITP patients, median age of ITP diagnosis was 57 years, 182 (56 %) were female. Most patients (58 %) lived within 20 km of a major centre, whereas 49 (15 %) lived in a geographically remote area (>200 km). Geographic remoteness was significantly associated with material deprivation and lower likelihood of management by hematologists (84 % vs 99 %, P = 0.0001). It was also associated with lower rates of hepatitis C (71 % vs 89 %, P = 0.005) and hepatitis B testing (69 % vs 86 %, P = 0.03), and a non-significant trend towards lower rates of HIV testing (73 % vs 83 %, P = 0.051) compared with those <20 km from a major centre. Incomplete hyposplenic vaccinations among splenectomized patients (52 %), early splenectomy within 12 months of ITP diagnosis (35 %), inappropriate platelet transfusions (41 %), and inappropriate hospitalizations for asymptomatic thrombocytopenia (16 %) were common regardless of geographic distribution. There were 28 (9 %) ITP-related deaths (major bleeding or infections), most occurred within the first year of ITP diagnosis. Material deprivation, but not geographic remoteness, was an independent predictor of all-cause mortality (aHR 1.9, 95 % CI 1.1–3.3 in the most deprived quintile vs least deprived quintile). Rural residence trended towards increased hazard of ITP-related deaths (aHR 1.7, 95 % CI 0.9–3.2). ConclusionWe demonstrated substantial deviations of ITP care from consensus guidelines, and geographic disparities in access to care and diagnostic workup. Future quality improvement initiatives are critical to improve the quality of care and reduce inequities.