Geographic Variation in Access to Care - The Relationship with Quality

Institute for Healthcare Improvement, Cambridge, MA, USA.
New England Journal of Medicine (Impact Factor: 55.87). 06/2012; 367(1):3-6. DOI: 10.1056/NEJMp1204516
Source: PubMed


Three decades of research focused predominantly on costs and the use of services among Medicare beneficiaries has repeatedly found wide regional variations in health care experiences and health system performance.(1) Much less attention has been paid to variations in access to care and their associated implications for quality of care and health outcomes. Our recent Commonwealth Fund report, "Rising to the Challenge: Results from a Scorecard on Local Health System Performance,"(2) shows that when we look beyond state averages, there are staggeringly wide gaps in people's ability to gain access to care in different communities around the country. We also . . .

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Available from: David C Radley, Apr 04, 2014
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    • "The definition of teaching hospitals changed from 1997 to 2000. In the data of 2001, 20.1% of the hospitals were designated as teaching hospitals, as compared to 14.3% under the definition of 1997 [45]. Furthermore, new US states were added to the Kids Inpatient Database longitudinally, resulting in a higher percentage of US population covered in 2003 than in 1997. "
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    ABSTRACT: Background The volume-outcome relationship is supposed to be stronger in high risk, low volume procedures. The aim of this systematic review is to examine the available literature on the effects of hospital and surgeon volume, specialization and regionalization on the outcomes of the Norwood procedure. Methods A systematic literature search was performed in Medline, Embase, and the Cochrane Library. On the basis of titles and abstracts, articles of comparative studies were obtained in full-text in case of potential relevance and assessed for eligibility according to predefined inclusion criteria. All relevant data on study design, patient characteristics, hospital volume, surgeon volume and other institutional characteristics, as well as results were extracted in standardized tables. Study selection, data extraction and critical appraisal were carried out independently by two reviewers. Results We included 10 studies. All but one study had an observational design. The number of analyzed patients varied from 75 to 2555. Overall, the study quality was moderate with a huge number of items with an unclear risk of bias. All studies investigating hospital volume indicated a hospital volume-outcome relationship, most of them even having significant results. The results were very heterogeneous for surgeon volume. Conclusions The volume-outcome relationship in the Norwood procedure can be supported. However, the magnitude of the volume effect is difficult to assess.
    Full-text · Article · Aug 2014 · BMC Pediatrics
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    • "Many studies have analysed the effect of location of patients’ residence on ACSCs admission rates [17,20,26,27,32,34-39]. These studies consistently found that the highest rates of hospitalisations for ACSCs admissions occurred in the most rural areas compared to their respective counterparts residing in metropolitan areas. "
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    ABSTRACT: Background Ambulatory Care Sensitive Conditions (ACSCs) are those for which hospitalisation is thought to be avoidable with the application of preventive care and early disease management, usually delivered in a primary care setting. ACSCs are used extensively as indicators of accessibility and effectiveness of primary health care. We examined the association between patient characteristics and hospitalisation for ACSCs in the adult and paediatric population in Victoria, Australia, 2003/04. Methods Hospital admissions data were merged with two area-level socioeconomic indexes: Index of Socio-Economic Disadvantage (IRSED) and Accessibility/Remoteness Index of Australia (ARIA). Univariate and multiple logistic regressions were performed for both adult (age 18+ years) and paediatric (age <18 years) groups, reporting odds ratios (OR) and 95% confidence intervals (CI) for a number of predictors of ACSCs admissions compared to non-ACSCs admissions. Results Predictors were much more strongly associated with ACSCs admissions compared to non-ACSCs admissions in the adult group than for the paediatric group with the exception of rurality. Significant adjusted ORs in the adult group were 1.06, 1.15, 1.13, 1.06 and 1.11 for sex, rurality, age, IRSED and ARIA variables, and 1.34, 1.04 and 1.09 in the paediatric group for rurality, IRSED and ARIA, respectively. Conclusions Disadvantaged paediatric and adult population experience more need of hospital care for ACSCs. Access barriers to primary care are plausible causes for the observed disparities. Understanding the characteristics of individuals experiencing access barriers to primary care will be useful for developing targeted interventions meeting the unique ambulatory needs of the population.
    Full-text · Article · Dec 2012 · BMC Health Services Research
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    ABSTRACT: Purpose Hepatocellular carcinoma (HCC) incidence rates continue to increase in the United States. Geographic variation in rates suggests a potential contribution of area-based factors, such as neighborhood socioeconomic deprivation, retail alcohol availability, and access to healthcare. Methods Using the NIH-AARP Diet and Health Study, we prospectively examined area socioeconomic variations in HCC incidence (n=434 cases) and chronic liver disease (CLD) mortality (n=805 deaths) and assessed contribution of alcohol outlet density, healthcare infrastructure, diabetes, obesity and health behaviors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from hierarchical Cox regression models. Results Area socioeconomic deprivation was associated with increased risk of HCC incidence and CLD mortality (HR=1.48,95%CI:1.03-2.14 and HR=2.36,95%CI:1.79-3.11, respectively) after accounting for age, sex, and race. Additionally accounting for educational attainment and health-risk factors, associations for HCC incidence were no longer significant; associations for CLD mortality remained (HR=1.78, 95%CI:1.34-2.36). SES differences in alcohol outlet density and health behaviors explained the largest proportion of SES-CLD mortality association, 10% and 29%, respectively. No associations with healthcare infrastructure were observed. Conclusions Our results suggest a greater effect of area-based factors for CLD than HCC. Personal risk factors accounted for the largest proportion of variance for HCC, but not for CLD mortality.
    No preview · Article · Jan 2013 · Annals of epidemiology
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