Physician Density Research Articles

Deprivation and stroke incidence, treatment and mortality in Germany

Abstract Background Previous research suggests that regional deprivation significantly influences the risk of stroke. However, little is known about regional differences in stroke incidence and mortality within Germany. Methods We utilized data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Register of Physicians (2019). We used negative binomial regression analysis to investigate the relationship between the German Index of Multiple Deprivation 2015, covering 401 districts and district-free cities in Germany, and stroke incidence, treatment, and mortality. Results The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.16 (95% CI [1.14, 1.17]) and 1.19 (95% CI [1.14, 1.23]), respectively. Furthermore, this study showed that the density of physicians was higher in district-free cities than in districts. Conclusions The findings document a relationship between regional deprivation and stroke incidence and mortality, and call for a more targeted approach to stroke prevention in deprived regions. Key messages • Regional deprivation in Germany linked to increased stroke incidence and mortality rates. • Policy action needed for effective prevention measures.

Association between long-term exposure to fine particulate air pollution and risk of death attributed to esophageal cancer in Taiwan

ABSTRACT The International Agency for Research on Cancer (IARC) classifies exposure to fine particulate matter (PM2.5) air pollution as carcinogenic to humans (Group I), most frequently associated with lung cancer. Airborne air pollutants may be associated with other sites of cancer, although few studies have examined this avenue of research. Esophageal cancer mortality rates vary substantially across townships in Taiwan, a fact that suggests environment influence. Therefore, the aim of this study was to investigate the association between long-term exposure to ambient PM2.5 and deaths attributed to esophageal cancer in 66 municipal areas across Taiwan. To conduct this study, annual PM2.5 levels were determined taking into account age-standardized esophageal cancer mortality rates in male and female residents of these municipalities from 2012 to 2021. The annual PM2.5 levels of each municipality were divided into tertiles and computed adjusted risk ratio (RR) using weighted-multiple regression analyses controlling for municipal lung cancer deaths, urbanization level, and physician density. Men residing in those areas with intermediate PM2.5 tertile levels (18.96–25.19 ug/m3) were found to have an adjusted RR of 1.22 (1.15–1.30) and those of residing areas with the highest tertiles levels (25.20–29.48 ug/m3) exhibited an RR of 1.11 (1.051.18). However, in women in the same municipalities, a significant inverse association was found between PM2.5 levels and mortality attributed to esophageal cancer, 0.82 (95% CI = 0.65-1.04) and 0.61 (95% CI = 0.47-0.79), respectively. These findings suggest that long-term exposure to PM2.5 increases the risk of developing esophageal cancer in men in Taiwan.

Exploring cervical cancer mortality in Brazil: an ecological study on socioeconomic and healthcare factors

ObjectiveTo evaluate the correlation between socioeconomic and healthcare factors and cervical cancer mortality rates, as well as the accessibility to prevention and treatment across Brazilian states and macroregions. The aim...

Social determinants of breast cancer screening: a multilevel analysis of proximal and distal factors related to the practice of mammography.

Mammography is crucial for early breast cancer detection. In Latin America, Argentina faces a significant breast cancer burden, with varying mammography rates. The social factors influencing mammography practices remain unclear. This study aimed to identify the proximal and distal social determinants of this practice among Argentinean women using a multilevel approach. This nationwide cross-sectional study included 4,924 women aged 50-70 participating in the 2018 National Risk Factor Survey of Argentina. Two-level logistic models were used to estimate measures of association (ORs) between timely mammography practice (within the last 2 years) and selected covariates (sociodemographics, proximal environment, and distal-level variables). The intraclass correlation coefficient (ICC) and proportional change in variance (PCV) were calculated. 62.8% of women underwent timely mammography. Age (OR=0.96; 95%CI 0.94-0.97), health insurance (OR=2.22; 95%CI 1.87-2.63), education (OR=2.1; 95%CI 1.74-2.64), and income (OR=1.56; 95%CI 1.23-1.97) were associated with mammography practice. Women in non-marital (OR=0.61; 95%CI 0.52-0.72) or larger households (OR=0.61; 95%CI 0.51-0.63) were less likely to have timely mammograph; living in a larger city was positively associated (OR=1.28; 95%CI 1.12-1.46). Women in provinces with higher physician density (OR=1.06; 95%CI 1.01-1.11) and lower maternal mortality ratio (OR=0.9; 95%CI 0.87-0.96) had higher chances of timely mammography. The ICC and PCV suggested that the explored healthcare indicators largely explained the macro-contextual effect. Multilevel factors influenced mammography practices in Argentina. The results highlight disparities linked to sociodemographic characteristics and healthcare resources. Efforts to address social inequalities in breast cancer screening must consider multilevel determinants, including in healthcare settings.

Primary care physician density and mortality in the United States

BackgroundGeographic physician availability differences are associated with healthcare outcomes. However, the association between primary care physician (PCP) density and mortality outcomes is less well-established. MethodsThe study analyzed 2019 county-level nonfederal PCP data from the Health Resources and Services Administration Area Health Resource File and mortality data using the CDC WONDER (Wide-ranging Online Data for Epidemiologic Research). All-cause and cardiovascular disease (CVD)- related age-adjusted mortality rates (AAMR) per 100,000 population stratified by the number of PCPs per 100,000 quartiles were extracted. Using AAMRs as continuous variables, linear regression was performed to determine the association of AAMRs with PCPs per 100,000 (reference, first quartile), adjusting for the social vulnerability index (SVI). ResultsA total of 3142 counties were included in the analysis. Among counties stratified by PCPs per 100,000 quartiles, all-cause AAMRs were 828 (95% CI, 824-832) in the first quartile, 798 (95% CI, 796-801) in the second quartile, 737 (95% CI, 735-739) in the third quartile, and 679 (95% CI, 678-680) in the fourth quartile. Similar trends were seen in CVD-related AAMRs, which were 446 (95% CI, 443-449),439(95% CI, 437-441), 403 (95% CI, 402-404), and 365 (95% CI, 364-366), respectively. Counties without PCP (221, included in first quartile) had all-cause and CVD-related AAMR of 797 (95%CI, 783-812) and 430 (95%CI, 419-440), respectively. Compared with the first quartile, SVI-adjusted analyses showed β-coefficient (95%CI) of all-cause mortality for the second, third, and fourth quartiles of -4.11 (95% CI, -18.31, 10.08), -35.37 (95% CI, -49.57, -21.17) and -85.79 (95% CI, -100.10, -71.48). Similar results were observed for CVD-related AAMR. ConclusionHigher PCP per 100,000 is generally associated with better all-cause and CVD-associated mortality outcomes, however complex factors likely play a role in determining these outcomes in counties with lower PCP per 100,000, which warrant further investigation.

Socioeconomic and medical determinants of state-level subjective cognitive decline in the United States.

It is important to understand the socioeconomic and medical determinants of subjective cognitive decline (SCD) at a population level in the United States. The primary outcomes are state-level rates of SCD and SCD-related functional impairment in adults aged ≥ 45, both measured in the Behavioral Risk Factor Surveillance System from 2016 to 2022. The exposures are state-level rates of poverty, unemployment, homelessness, college education, racial and ethnic minorities, uninsurance, smoking, hypertension, diabetes, and obesity as well as household income and physician density. The strongest state-level associations with rates of SCD were the prevalence of diabetes (rho=0.64), hypertension (rho=0.59), and poverty (rho=0.58; all p<0.001), and with SCD-related functional impairment were prevalence of poverty (rho=0.71), diabetes (rho=0.68), and hypertension (rho=0.53; all p<0.001). This study highlights critical links between SCD and socioeconomic and medical determinants in adults aged ≥ 45 in the United States, including the prevalence of poverty, diabetes, and hypertension. State-level analysis reveals socioeconomic and medical risk factors for subjective cognitive decline (SCD) at a population level. The prevalence of poverty is a critical contributor to the state-level prevalence of SCD. The prevalence of diabetes and hypertension are also strong state-level determinants of SCD. Addressing the burden of cognitive decline at the population level necessitates targeting socioeconomic and medical factors.

S989 Gastrointestinal Physician Density (GIPD) in the USA: The Critical Shortage of Gastroenterologists and the Impact on Upper Gastrointestinal Bleeding Mortality Across All 50 States

S989 Gastrointestinal Physician Density (GIPD) in the USA: The Critical Shortage of Gastroenterologists and the Impact on Upper Gastrointestinal Bleeding Mortality Across All 50 States

Physician Density, Social Vulnerability, and Access to Allogeneic Hematopoietic Cell Transplant in Texas

Physician Density, Social Vulnerability, and Access to Allogeneic Hematopoietic Cell Transplant in Texas

Geographic Patterns of Ocular Oncologist Supply and Patient Demand for Uveal Melanoma Treatment in the United States: A Supply and Demand Analysis.

To study geographic patterns of supply and demand for uveal melanoma and other ocular oncology healthcare by ocular oncology physicians in the United States. Google search interest data was obtained through trends.google.com. The combined-state density of ocular oncology physicians was calculated by dividing the number of practicing ocular oncologists in each state and its surrounding states by the state population. Relative search volume (RSV) values were divided by ocular oncology physician density to calculate the Google relative demand index (gRDI) for each state.Medicare (mRDI) and IRIS® Registry (iRDI) relative demand indices were calculated using prevalence data obtained through the Vision and Eye Health Surveillance System (VEHSS). Data from the US Census Bureau and Centers for Disease Control (CDC) databases were also utilized to analyze associations with poverty rates, percent living in urban or rural areas, vision screening rates, and ocular neoplasm rates. Alabama showed the highest RSV (100), while the lowest was reported in New Mexico (20). Vermont had the highest density of combined-state ocular oncology ophthalmologists (1.85 per 100,000 residents). New Mexico had the lowest RDI (0.013 gRDI, 0.015 mRDI, 0.018 iRDI) with 32 combined-state ocular oncologists and a population of 2,114,371. Ocular neoplasm prevalence rates ranged between 1.32% and 5.40% and significantly correlated with RSV. Single-state gRDI correlated with rural status and negatively correlated with urban areas (≥50,000 individuals). Single-state ophthalmologist density correlated positively with percent living in urban areas and vision screening rates, and negatively with rural status. This study uncovered significant heterogeneity in the geographical distribution of ocular oncology physicians and RDI throughout the United States, highlighting potential undersupply scenarios. This may guide efforts to increase ocular oncology physician and surgeon availability in areas of need.

CT-362 Physician Density, Social Vulnerability and Access to Allogeneic Hematopoietic Cell Transplant in Texas

CT-362 Physician Density, Social Vulnerability and Access to Allogeneic Hematopoietic Cell Transplant in Texas

The impacts of reduction in ambient fine particulate air pollution on natural-cause mortality in Taiwan

ABSTRACT Many epidemiologic studies have reported an association between high concentrations of fine particulate matter (PM2.5) and increased mortality rates. Concurrently an association between decreased concentration of these airborne PM2.5 pollutants and a decline in mortality frequency was noted in certain investigations globally; however, only a very few of these studies were conducted in Asia. Taiwan was found to exhibit a 30% decline in ambient PM2.5 levels over the last 20 years. The aim of this ecological investigation was to examine the contribution of annual reductions in ambient PM2.5 to changes in age-standardized natural-cause mortality rates (ASRs) in 65 townships in Taiwan from 2006 to 2020 controlling for lung cancer mortality rate, physician density, and annual household income. Data demonstrated a 0.9/105 fall in adjusted ASR for every 10 ug/m3 reduction in mean annual PM2.5 level in Taiwan during this 14-year period, suggesting a significant association between reductions in ambient PM2.5 levels and decreases in natural-cause mortality rates.

Geographic and economic influences on benralizumab prescribing for severe asthma in Japan

Benralizumab, a monoclonal antibody targeting IL-5 receptors, reduces exacerbations and oral corticosteroid requirements for severe, uncontrolled eosinophilic asthma. In Japan, geographic disparities in asthma outcomes suggest differential prescribing and access. This study aimed to quantify regional prescribing variations for benralizumab nationwide. Using Japan’s National Database (NDB) of insurance claims (2009–2019), benralizumab standardized claim ratios (SCRs) were calculated for 47 prefectures. Correlations between SCRs and other biologics’ SCRs, economic variables like average income, and physician densities were evaluated through univariate analysis and multivariate regressions. Income-related barriers to optimal prescribing were examined. Wide variation emerged in benralizumab SCRs, from 40.1 to 184.2 across prefectures. SCRs strongly correlated with omalizumab (r = 0.61, p < 0.00001) and mepolizumab (r = 0.43, p = 0.0024). Average monthly income also positively correlated with benralizumab SCRs (r = 0.45, p = 0.0016), whereas lifestyle factors were insignificant. Respiratory specialist density modestly correlated with SCRs (r = 0.29, p = 0.047). In multivariate regressions, average income remained the most robust predictor (B = 0.74, p = 0.022). Benralizumab SCRs strongly associate with income metrics more than healthcare infrastructure/population factors. Many regions show low SCRs, constituting apparent prescribing gaps. Access barriers for advanced asthma therapies remain inequitable among Japan’s income strata. Addressing affordability alongside specialist allocation can achieve better prescribing quality and asthma outcomes.

Individual and geospatial factors associated with receipt of colorectal cancer screening: a state-wide mixed-level analysis

BackgroundColorectal cancer (CRC) is the second leading cause of cancer death in US adults but can be reduced by screening. The roles of individual and contextual factors, and especially physician...

Identifying states for targeted alloHCT access initiatives using social vulnerability, physician density, and unmet need.

1528 Background: Access to allogeneic hematopoietic cell transplantation (alloHCT) is limited by many factors, with only 1 in 3 patients who may need a transplant receiving one. This study examined associations between social vulnerability index (SVI), physician density (PD), and alloHCT unmet need across the United States (U.S.) to identify geographic areas that may be most at-risk of access challenges. Methods: A retrospective analysis aggregated public data across 3,141 U.S. counties, including: SVI [Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry]; National Provider Identifier [Center for Medicare and Medicaid Services] data for all registered hematology-oncology and HCT physicians; and 2017 – 2021 alloHCT unmet need [Center for International Blood and Marrow Transplant Research (CIBMTR), NMDP]. PD was defined as providers per 10,000 population. All variables were collapsed into ordinal categories (very low, low, moderate, high) based on quartiles. Counties with moderate/high SVI and unmet need and low/very low PD were defined as at-risk. By state, linear regression and mediation analysis assessed exploratory relationships. Results: Among 396 counties defined as at-risk, top states are shown (Table). State (n=51) percent unmet need was correlated with SVI (r=0.494, p&lt;0.001) and PD (r=-0.295, p=0.036). Univariate analysis revealed SVI (b=-0.223, p&lt;0.001) and PD (b=-0.187, p=0.036) as predictors of unmet need. However, multivariate regression showed only SVI as significant when included with PD. Race/ethnicity as 1 of 4 SVI subthemes (socioeconomic status [SES], household characteristics [including age], race/ethnicity, and housing/transportation) was not correlated with PD, but all other themes were. SES and household characteristics were found to fully mediate the relationship between PD and unmet need. Conclusions: This study can help prioritize targeted initiatives through a better understanding of how SVI, PD, and unmet need relate to alloHCT access. This study cannot draw causal conclusions and uses multiple population-level data sources. However, data can examine trends on a regional level within at-risk states to allocate resources to overcome barriers to alloHCT, with special attention on SES and household factors like age. Relationships between variables should be further examined. [Table: see text]

Integrating Syrian refugees into Lebanon’s healthcare system 2011–2022: a mixed-method study

IntroductionThe Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic.MethodsThis paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators.ResultsAlthough the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees’ access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities’ access to medications due to shortages and dramatic price increases.ConclusionIntegrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

The impact of incentive scheme on rural healthcare workforce availability: a case study of Kazakhstan

BackgroundDuring the 1990–2000, Kazakhstan experienced a decline in the number of healthcare professionals working in rural areas. Since 2009, the national government has been implementing financial incentives to encourage healthcare professionals to relocate to rural areas. This study aims to investigate the temporal and spatial patterns in the distribution of the rural healthcare workforce and evaluate the impact of this incentive scheme.MethodsInterrupted Time Series Analysis using ARIMA models and Difference in Differences analyzes were conducted to examine the impact of the incentive scheme on the density of different categories of the healthcare workforce in rural Kazakhstan in the period from 2009 to 2020.ResultsThere was a significant increase in the number of rural healthcare professionals from 2009 to 2020 in comparison to the period from 1998 to 2008. However, this increase was less pronounced in per capita terms. Moreover, a decline in the density of internists and pediatricians was observed. There is substantial variation in the density of rural nurses and physicians across different regions of Kazakhstan. The incentive scheme introduced in 2009 by the government of Kazakhstan included a one-time allowance and housing incentive. This scheme was found to have contributed insignificantly to the observed increase in the number of rural healthcare professionals.ConclusionFuture research should be undertaken to examine the impact made by the incentive scheme on other medical subspecialties, particularly primary practitioners. Addressing the shortage of healthcare workers in rural areas is a complex issue that requires a multifaceted approach. Aside from financial incentives, other policies could be considered to increase relocation and improve the retention of healthcare professionals in rural areas.

Preference-Based Implementation of Video Consultations in Urban and Rural Regions in Outpatient Care in Germany: Protocol for a Mixed Methods Study.

Particularly in rural regions, factors such as lower physician density and long travel distances complicate adequate outpatient care. However, urban regions can also be affected by deficits in care, for example, long waiting times. One model of care intending to improve the situation is the implementation of video consultations. The study protocol presents the methodology of the research project titled "Preference-based implementation of the video consultation in urban and rural regions" funded by the German Federal Joint Committee (funding number 01VSF20011). This study aims to identify existing barriers to the use of video consultation and the preferences of insured individuals and physicians as well as psychotherapists in order to optimize its design and thus increase acceptance and use of video consultations in urban and rural regions. Built on a mixed methods approach, this study first assesses the status quo of video consultation use through claims data analysis and carries out a systematic literature review on barriers and promoting factors for the use of video consultations. Based on this preliminary work, focus groups are conducted in order to prepare surveys with insureds as well as physicians and psychotherapists in the second study phase. The central element of the survey is the implementation of discrete choice experiments to elicit relevant preferences of (potential) user groups and service providers. The summarized findings are discussed in a stakeholder workshop and translated into health policy recommendations. The methodological approach used in this study is the focus of this paper. The study is still ongoing and will continue until March 2024. The first study phase has already been completed, in which preliminary work has been done on potential applications and hurdles for the use of video consultations. Currently, the survey is being conducted and analyses are being prepared. This study is intended to develop a targeted strategy for health policy makers based on actual preferences and perceived obstacles to the use of video consultations. The results of this study will contribute to further user-oriented development of the implementation of video consultations in German statutory health insurance. Furthermore, the iterative and mixed methods approach used in this study protocol is also suitable for a variety of other research projects. DERR1-10.2196/50932.

The Role of Climatic, Environmental and Socioeconomic Factors in the Natural Movement of Urban Populations in Kazakhstan, 2012-2020: An Analysis from a Middle-Income Country in Central Asia.

This study addresses the importance of identifying key characteristics influencing demographic indicators for urban populations, emphasizing the need to consider regional climatic features and ecological factors. The research utilized data from ten main regional cities across the Republic of Kazakhstan. This study involved a retrospective analysis based on secondary data from official sources spanning 2012-2020. We employed correlation analysis and multidimensional regression models. Noteworthy predictors for crude birth rate included the influence of effective temperature (β = 0.842, p < 0.0001), marriage rate (β = 0.780, p < 0.0001), Gini coefficient (β = -27.342, p = 0.020) and divorce rate (β = -2.060, p < 0.0001), with overall strong model performance (R2 = 0.940). The degree of atmospheric pollution (β = -0.949, p = 0.044), effective temperature (β = -0.294, p < 0.0001) and Gini coefficient (β = 19.923, p = 0.015) were the predictors for crude mortality rate, with a high model fit (R2 = 0.796). The study unveils significant relationships between demographic indicators (crude birth rate, mortality rate) and variables like effective temperature, marriage rate, divorce rate, Gini coefficient, physician density and others. This analysis of climatic, environmental, and socioeconomic factors influencing demographic indicators may help in promoting specific measures to address public health issues in Kazakhstan.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiencyin rural CHCs.

Dealing with the doctor shortage: a qualitative study exploring French general practitioners' lived experiences, difficulties, and adaptive behaviours.

The shortage of general practitioners (GPs) is a growing concern in Europe, especially in France. This problem is likely to continue until the end of the 2020s. To study the GPs' perceptions of access to care in medically underserved areas (i.e. with low physician density), its consequences on their working conditions, and how they cope with the resulting difficulties. Semi-structured individual interviews were conducted between May and August 2021 of 29 GPs practising in areas of southeastern France with a low physician density or at risk of a doctor shortage. Purposive sampling was used to include profiles of diverse physicians and diverse rural and urban areas. The interviews, conducted with an interview guide, were transcribed and analysed thematically. The participants described a serious degradation of access to care in their areas. These issues also concerned urban areas, where they were, according to the participants, underrecognized. The participants' workloads were rising, at a rate often perceived as unsustainable: many participants, including the youngest group, reported they were exhausted. Their principal source of dissatisfaction was their impression that they could not do their work correctly. Participants reported that these difficulties required them to improvise and adapt without any official or formal method to keep their practice manageable. These GPs were worried about the future of their profession and their patients. They expected strong measures by public policymakers and officials, but paradoxically seemed to have little interest in the solutions these officials are promoting.