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Towards Healthy China 2030: Modeling health care accessibility with patient referral
Abstract and Figures
One primary action plan in the Healthy China 2030 initiative is to build innovative patient referral models for health care reform in China. To ensure people have sufficient and equitable health care access when the patient referral policy is enforced, a systematic evaluation of its effects on the health care system is needed. In this paper, we focus on one health policy metric, the health care accessibility, by considering the patient transfer between different levels of health care facilities under the context that the need for specialized treatment cannot be fulfilled by a low-level facility. We then propose three conceptual patient referral models and a hierarchical two-step floating catchment area method to evaluate health care accessibility in different patient referral scenarios. A case study of hospitals in Beijing, China has been conducted to justify the proposed model, revealing the spatial inequality of health care accessibility. We find that while the patient referral can leverage health care resources to a certain extent, such effects are only prominent in areas with good coverage of health care facilities; and the efficiency of the health care system can be compromised in areas with limited health care provisioning. To this end, the study provides scientific evidence for the planning and reform of the health care policy in the Healthy China 2030 initiative.
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... Nevertheless, in many cases, the provision of health services is not distributed equally in one region and among different population groups due to a variety of spatial and nonspatial factors [7,8]. As for non-spatial factors, these mainly significantly affect the quality of the health service offered [7,9]. ...
... Nevertheless, in many cases, the provision of health services is not distributed equally in one region and among different population groups due to a variety of spatial and nonspatial factors [7,8]. As for non-spatial factors, these mainly significantly affect the quality of the health service offered [7,9]. However, spatial aspects can become a physical barrier that hinders adequate access to health services, depending on the separation distance where the patient needs medical assistance to the nearest hospital where he or she can ISPRS Int. ...
... However, the adoption of an equal catchment size was criticized for the lack of nuances in interpreting the effect of decreasing distance [43] and to adapt to the different travel environments where health search behaviors take place, the enhanced two-step floating capture model (ESFCA) was proposed [46]. Nonetheless, in these latter two methods, there is the oversight of regional competition [7]. In fact, it is also known as "intervention opportunities" in the language of spatial interaction models [47], as they limit search behaviors, as in many cases, the patient can be treated outside a particular administrative unit [48,49], to minimize this defect the three-step floating catchment area method (3SFCA) was developed [50][51][52]. ...
Portugal and Spain share one of the greatest European borderland areas. This fact has direct impacts on a large territory and consequently on the communities’ living in it. Still, even if the border areas represent an essential fraction of the territory, planning policies have not resulted in specific cooperation programs that could enable sharing general leisure and recreation assets and infrastructures and collaboration in critical domains—i.e., the case of the health sector. The present study aims to assess the territorial accessibility to the hemodynamic rooms by the potential population of the Spanish-Portuguese transition areas that may suffer an acute myocardial infarction. Contextually, this study employed a spatial interaction model based on the three-step floating catchment area method (method-3SFCA). By applying these methods, it was possible to develop a map of accessibility to health infrastructures equipped with hemodynamics rooms on both sides of the border that may answer the Spanish-Portuguese border populations’ needs. Besides, while granting valuable information for decision-makers regarding the need to develop new infrastructures to guarantee that even considering cross border cooperation, everyone gets access to a hemodynamics room within the critical intervention period.
... Several studies have examined spatial distribution of health care facilities in Nigeria. Sanni [15] examined distributional pattern of healthcare facilities in Osun state using locational quotient. The study revealed that there is variation in healthcare facilities across local governments in Osun state. ...
... Moreover, extant literature affirms that healthcare services cannot be evenly distributed due to multiplicity factors, which are broadly spatial and nonspatial in nature. Furthermore, existing studies on spatial inequalities on health care in Nigeria have considered the role of GIS in locational efficiency of healthcare facilities [18], spatial distribution and spatial pattern in healthcare faciliities distribution [15,16,21]. Some of these studies have recommended the need for more healthcare facilities and personnel [16] and the need to use geospatial statistics for locational efficiency of health care facility [18]. ...
The study examines the inequality of public health and effects of health care accessibility on patient referral system in Ondo state. Explorative research design was used, relying on secondary data, acquired from the Ondo State Bureau of Statistics. The data contains information for the years 2009-2011 on health matters in Ondo state. Data were analyzed using descriptive indexes statistics(i.e ratio, percentage, frequency and locational quotient)to determine the effects of public health inequality on patient-referral model. The study revealed that a healthcare facility served on average 5,045 people in 2011. Also, there was significant increase in reported cases of diseases especially for Malaria which increase by 24.7% between 2009 and 2010.The study revealed that majority (12) of the local governments had a locational quotient below 1.0 of general medical practitioners. Conclusively, there was inequality of public health care accessibility, thus having a negative effect on patient referral system. Therefore, there sholud be effective allocation of general practitioners and health facilities across the local governments especially in the medically underserved areas through effective urban planning intervention.
... Rational spatial accessibility of healthcare facilities is a major objective of the medical system in many countries. As is mentioned in the Healthy China 2030 plan, China is expected to establish equilibrium primary healthcare services for all communities (9). Primary hospitals are therefore planned on the basis of population scale and service radius. ...
... A study has also been conducted to investigate spatial inequity in hospital accessibility by using a 2SFCA model (12), and it found that low-income neighborhoods experienced relatively lower levels of accessibility of multi-tier hospitals, including primary, secondary, and tertiary hospitals. In consideration of healthcare system reform in China, Xiao et al. (9) proposed three patient-referral models to evaluate heath care accessibility in different scenarios and concluded that patient referrals had prominent effects on the balance of healthcare facilities. A study by Agbenyo et al. (29) adopted both spatial analysis and semi-structured interviews to investigate the accessibility of healthcare facilities and reveal the behaviors and needs of patients. ...
In order to improve the health and quality of life of older adults, the Chinese government is dedicated to establishing an equilibrium level of primary healthcare services for all communities. However, little attention has been paid to measuring the accessibility of primary hospitals to older adults, nor to understanding the seniors' satisfaction with and needs for primary healthcare services. Therefore, this study sought to investigate the spatial accessibility of primary hospitals to older adults, and also to examine the impact of walking distances on the seniors' satisfaction with their healthcare services. A two-step floating catchment area method was applied to measure the spatial accessibility of primary hospitals to older adults at the level of subdistricts. In order to investigate the actual opinions of older adults and verify the results of spatial analysis, a large-scale questionnaire survey was also conducted. The analyses found that (1) primary hospitals were not equally distributed; (2) most older adults did not have access to primary hospitals within a threshold walking distance of 1,000 m, but they usually could reach a hospital in their subdistrict within a threshold distance of 2,000 m; (3) older adults' satisfaction levels with primary hospitals were significantly different among subdistricts; (4) long walking distances negatively influenced older adults' satisfaction with primary hospitals; (5) the satisfaction of older adults was highest with a threshold distance of 500 m; and (6) a piecewise regression model indicated that older adults' satisfaction with primary hospitals would decrease with an increase in walking distance to the hospital. When the walking distances exceeded 1,000 m, the slope of the linear regression model increased significantly compared with the slope for walking distances less than 1,000 m. By adopting multiple research methods and capturing older adults' behaviors and satisfaction, our results provide (1) data on the importance of accessibility of primary hospitals to older adults, and (2) insights for future planning to achieve equity in primary healthcare and enhance the spatial distribution of primary hospitals.
... Some consensuses have been reached among these exploratory studies on the heterogeneity in catchment area sizes, distance friction effects and transport modes among different levels [12,15,30,31]. Meanwhile, some studies are focused on the impacts of the referrals between facilities at different levels on healthcare accessibility [13,32,33]. Furthermore, the establishment of a hierarchical medical system would also influence the health seeking behaviors of patients [16]. ...
... Existing studies have made efforts to decipher the inter-level differences in accessibility to hierarchical healthcare facilities [30,31]. Some studies have also examined the impacts of referrals between facilities at different levels on healthcare accessibility [13,32,33]. However, little attention has been paid to the impacts of the insufficient utilization of lower-level facilities on healthcare accessibility. ...
The hierarchical healthcare system is widely considered to be a desirable mode of the delivery of healthcare services. It is expected that the establishment of a hierarchical healthcare system can help provide better and more equal healthcare accessibility. However, limited evidence has been provided on the impacts of a hierarchical healthcare system on healthcare accessibility. This study develops an improved Hierarchical two-step floating catchment area (2SFCA) method, which incorporates variable catchment area sizes, distance friction effects and utilization efficiency for facilities at different levels. Leveraging the Hierarchical 2SFCA method, various scenarios are set up to assess the accessibility impacts of a hierarchical healthcare system. The methods are applied in a case study of Shenzhen. The results reveal significant disparity and inequality in healthcare accessibility and also differences between various facility levels in Shenzhen. The overall healthcare accessibility and its equality can be significantly improved by fully utilizing existing facilities. It is also demonstrated that allocating additional supply to lower-level facilities can generate larger accessibility gains. Furthermore, allocating new supply to primary facilities would mitigate the inequality in healthcare accessibility, whereas inequality tends to be aggravated with new supply allocated to tertiary facilities. These impacts cannot be captured by traditional accessibility measures. This study demonstrates the pivotal role of primary facilities in the hierarchical healthcare system. It can contribute to the literature by providing transferable methods and procedures for measuring hierarchical healthcare accessibility and assessing accessibility impacts of a hierarchical healthcare system in developing countries.
... Improvements in negative living habits and specific drug treatments are the most economical approaches. Therefore, in recent years, the recommendation system based on medical care has gradually entered people's lives and progressively gained in attention, especially in rural and remote mountainous areas with relatively poor medical conditions [1,2]. This can play a more significant role and be more beneficial to the improvement of the living standards of the elderly. ...
Chronic diseases are increasingly major threats to older persons, seriously affecting their physical health and well-being. Hospitals have accumulated a wealth of health-related data, including patients’ test reports, treatment histories, and diagnostic records, to better understand patients’ health, safety, and disease progression. Extracting relevant information from this data enables physicians to provide personalized patient-treatment recommendations. While collaborative filtering techniques and classical algorithms such as naive Bayes, logistic regression, and decision trees have had notable success in health-recommendation systems, most current systems primarily inform users of their likely preferences without providing explanations. This paper proposes an approach of deep learning with a local interpretable model–agnostic explanations (LIME)-based interpretable recommendation system to solve this problem. Specifically, we apply the proposed approach to two chronic diseases common in older adults: heart disease and diabetes. After data preprocessing, we use six deep-learning algorithms to form interpretations. In the heart-disease data set, the actual model recommendation of multi-layer perceptron and gradient-boosting algorithm differs from the local model’s recommendation of LIME, which can be used as its approximate prediction. From the feature importance of these two algorithms, it can be seen that the CholCheck, GenHith, and HighBP features are the most important for predicting heart disease. In the diabetes data set, the actual model predictions of the multi-layer perceptron and logistic-regression algorithm were little different from the local model’s prediction of LIME, which can be used as its approximate recommendation. Moreover, from the feature importance of the two algorithms, it can be seen that the three features of glucose, BMI, and age were the most important for predicting heart disease. Next, LIME is used to determine the importance of each feature that affected the results of the calculated model. Subsequently, we present the contribution coefficients of these features to the final recommendation. By analyzing the impact of different patient characteristics on the recommendations, our proposed system elucidates the underlying reasons behind these recommendations and enhances patient trust. This approach has important implications for medical recommendation systems and encourages informed decision-making in healthcare.
... China's emergency medical services system was established in the 1980s [11]. Since then, hospital medical staff have escorted patients by ambulance from primary hospitals to better or unique hospitals for treatment [11,12]. However, as a vast developing country, emergency services are inequitable, and ambulance transfers can take longer in remote areas [13]. ...
Background
Medical device-related pressure injuries(MDRPI) are prevalent and attracting more attention. During ambulance transfer, the shear force caused by braking and acceleration; extensive medical equipment crowed in a narrow space add external risk factors for MDRPIs. However, there is insufficient research on the relationship between MDRPIs and ambulance transfers. This study aims to clarify the prevalence and characteristics of MDRPI during ambulance transfer.
Method
A descriptive observational study was conducted with convenience sampling. Before starting the study, six PI specialist nurses certified by the Chinese Nursing Association trained emergency department nurses for three MDRPI and Braden Scale sessions, one hour for each session. Data and images of PIs and MDRPIs are uploaded via the OA system by emergency department nurses and reviewed by these six specialist nurses. The information collection begins on 1 July 2022 and ends on 1 August 2022. Demographic and clinical characteristics and a list of medical devices were collected by emergency nurses using a screening form developed by researchers.
Results
One hundred one referrals were eventually included. The mean age of participants was (58.3 ± 11.69) years, predominantly male (67.32%, n = 68), with a mean BMI of 22.48 ± 2.2. The mean referral time among participants was 2.26 ± 0.26 h, the mean BRADEN score was 15.32 ± 2.06, 53.46% (n = 54) of participants were conscious, 73.26% (n = 74) were in the supine position, 23.76% (n = 24) were in the semi-recumbent position, and only 3 (2.9%) were in the lateral position. Eight participants presented with MDRPIs, and all MDRPIs are stage 1. Patients with spinal injuries are most prone to MDRPIs (n = 6). The jaw is the area most prone to MDRPIs, caused by the cervical collar (40%, n = 4), followed by the heel (30%, n = 3) and nose bridge (20%, n = 2) caused by the respiratory devices and spinal board.
Conclusion
MDRPIs are more prevalent during long ambulance referrals than in some inpatient settings. The characteristics and related high-risk devices are also different. The prevention of MDRPIs during ambulance referrals deserves more research.
... Therefore, the World Health Organization considered referral a core part of a comprehensive health care system, suggested that primary care should be strengthened to provide effective and efficient care, and proposed that countries adopt a framework to provide integrated people-centred health services (Jing et al., 2020;Liang et al., 2020;Zeng et al., 2020). Health services in most western countries are delivered in a hierarchical medical system (HMS) and through the mandatory gatekeeping mechanism that involves initial diagnoses at primary care facilities (PCFs) and obligatory two-way referrals among hospitals Xiao et al., 2021). Building on HMS and a strong primary care system, many developed countries managed to establish integrated care models to manage chronic diseases and observed positive results in improving care and reducing costs (Bodenheimer et al., 2002;Zeng et al., 2020). ...
The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly aging population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was issued in November 2014 and fully implemented in 2015 in Ningbo, Zhejiang province, China. This study aimed to investigate the impact of the HMS on the local healthcare system. We conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data was analysed with an interrupted time series (ITS) design to assess the impact of HMS on the changes in levels and trends of three outcome variables: primary care physicians' (PCPs') patient encounter ratio (i.e., the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e., the mean degree of PCPs divided by the mean degree of all other physicians, with the mean degree revealing the mean activity and popularity of physicians, which reflected the extent to which he/she coordinated with others in delivering health services), PCP betweenness centrality ratio (i.e., the mean betweenness centrality of PCPs divided by the mean betweenness centrality of all other physicians; the mean betweenness centrality was interpreted as the mean relative importance of physicians within the network, indicating the centrality of the network). Observed results were compared with counterfactual scenarios computed based on pre-HMS trends. Between January 2010 and December 2018, 272,267 patients visited doctors for hypertension, a representative non-communicable disease with a high prevalence of 44.7% among adults aged 35-75 years, amounting to a total of 9,270,974 patient encounters. We analysed quarterly data of 45,464 observations over 36 time points. Compared to the counterfactual, by the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% (95%CI: 27.1-58.2, p<0.001), the PCP degree ratio increased by 23.6% (95%CI: 8.6-38.5, p<0.01), and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1-171.7, p<0.001). The HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network.
... Unequal access to health care has been identified as a major cause of health inequality [10]. To improve the entire population's health, the Chinese government issued the Healthy China 2030 plan and the Opinions on Promoting the Gradual Equalization of Basic Public Health Services, aiming to establish equitable primary health services in all communities [11][12][13]. ...
Accessibility of health services signifies the quality and equitability of universal health provision. The hierarchical medical system recently implemented in China offers the policy instruments to improve medical services to the elderly in an aging society. As the critical primary care gateway, accessibility to community hospitals has significant impacts on people’s health. However, current research has paid little attention to spatial accessibility within walking distance of community hospitals, especially for the elderly. This study selected four districts with different urbanization levels in the rapidly developing Beijing metropolis. The spatial interaction model was applied to measure the accessibility of community hospitals for the elderly at the community level. An attractiveness index was computed based on key hospital traits. The results showed that: (1) community hospitals could cover 82.66% of elderly residents, and 77.63% of the communities were within walking distance. The served elderly proportion was relatively high in central urban areas and low in the suburbs. (2) The attractiveness indices of hospitals varied notably between districts, with higher values in more urbanized areas. (3) The spatial accessibility for the elderly of hospitals differed significantly between the four districts, with a descending gradient from central to suburban and rural areas, as indicated by the Gini coefficients and Lorenz curves. (4) The accessibility index was strongly related to the served elderly population and the hospital–residence distance. The findings provide policy directions to the government, including providing more primary-care resources to suburban and rural areas, building new community hospitals in identified provision gaps, upgrading some clinics to hospitals in rural areas, and planning hospitals according to the projected trend of the elderly population in terms of quantity and distribution. The considerable provision disparity between core urban, suburban and rural areas can be addressed by refined spatial health planning informed by research.
... Some service problems can be found in border areas that eventually affect hospital utilization. Specifically, the factors influencing hospital service quality are the limited infrastructure, location, and staged referral support system (Xiao et al., 2021). The difference in accessibility among regions sometimes is linked to the government's priority program in development. ...
Background: The border area in Indonesia is often neglected, apart from remote locations and islands. Aims: The study aims to analyze the role of borderlands status on hospital utilization on Kalimantan Island, Indonesia. Methods: The study was a cross-sectional study. The research obtained 61,598 respondents through stratification and multistage random sampling-the study employed hospital utilization as an outcome variable; meanwhile, borderlands status as an exposure variable. Moreover, the study used nine control variables: residence type, age group, gender, marital status, education level, occupation type, wealth status, health insurance ownership, and travel time to the hospital. The study employed binary logistic regression to analyze the data in the last stage. Results: The results show that the average hospital utilization in Kalimantan Island in 2018 in this study was 4.953%. Meanwhile, those who live in the border area have 1.406 times the probability of utilizing the hospital than those in the nor-border area (95% CI 1.392-1.419). On the other hand, the study analysis also found all control variables were significantly related to hospital utilization: residence type, age group, gender, marital status, education level, occupation type, wealth status, health insurance ownership, and travel time to the hospital. Conclusion: The study concludes that borderlands status is related to hospital utilization on Kalimantan Island. Those who live in border areas have a better possibility of hospital utilization than those in non-border areas.
... Benefiting from the maturity and continuous improvement of Geographic Information System (GIS) technology, many methods developed based on the potential model have been introduced to assess hospital accessibility, among which the two-step floating catchment area (2SFCA) method is the most widely used [31][32][33]. Recently, several rectifications and replenishments to the 2SFCA method have been proposed in order to overcome limitations of the 2SFCA method, including the three-step floating catchment area (3SFCA) method [34], the gravity 2SFCA (G2SFCA) method [35], the Gauss 2SFCA (Ga2SFCA) method [36], the dynamic Huff 2SFCA (DH2SFCA) method [37], the enhanced two-step floating catchment area (E2SFCA) method [38], the hierarchical 2SFCA (H2SFCA) method [39], and the kernel density 2SFCA (KD2SFCA) method [40,41]. ...
Urban medical facilities are an irreplaceable foundation for ensuring higher levels of public health and medical equity. Hospital accessibility has an extremely important impact on the allocation efficiency and fairness of medical facilities. Although critical, previous studies on accessibility have often overlooked the layout of medical facilities at different levels and the accurate measures of travel time to hospitals, which are both the most critical and fundamental indicators when assessing hospital accessibility. To avoid these pitfalls, this study considers the Shijingshan District, Beijing, China, as an empirical case and proposes an improved potential model based on Web Mapping API (Application Programming Interface) to assess the hospital accessibility of hospitals at different levels during different time periods. Results show that there are significant spatial and temporal differences in hospital accessibility in Shijingshan District, and traffic congestion and the layout of medical facilities are the two most important factors affecting hospital accessibility. This study further improves the hospital accessibility assessment method, with the findings provide a spatial decision support system for urban planners and policymakers regarding optimizing the spatial structure and layout of transportation systems and medical facilities.
... Currently, the public demand for health is growing due to increasing issues such as social isolation and the COVID-19 pandemic. To address the healthcare in the digital era, the Chinese Government has adopted the Healthy China 2030 plan in 2016 and the Digital China Strategy in 2018 and emphasized population health as a national strategic priority of China's development (Xiao et al., 2021). Therefore, it is of great practical significance and policy value to analyze residents' health issues in the digital era. ...
Purpose
Utilizing data from the 2017 Chinese General Social Survey (CGSS2017), the paper aims to investigate the impact of information and communication technology (ICT) adoption on residents' self-rated health and reveals the mechanisms behind ICT.
Design/methodology/approach
In the study, ICT adoption is defined as a dummy variable, which takes the value of one if respondents adopt the computers or mobile phone. Meanwhile, respondents' perceptions on five categories of self-rated health are used to construct the dependent variable. Then, based on a fixed-effects regression model, the ordinary least squares (OLS) and ordered probit approaches are applied to estimate their association. Moreover, the two-stage least squares (2SLS) and instrumental variable (IV)-oprobit methods are used to tackle the potential endogeneity of ICT adoption. Finally, the heterogeneity across individuals and regions as well as the underlying mechanisms are discussed.
Findings
The results indicate that ICT adoption significantly improves residents' self-rated health, which confirms the health utility model with ICT adoption. The conclusion is robust after overcoming the endogeneity issues with IV. In addition, heterogeneity analysis shows that ICT adoption is more beneficial to the health of residents who are male, young, better educated and those who live in the rural areas and in central and western China. Furthermore, the study demonstrates that ICT adoption for searching health-related information and improving social capital are two crucial mechanisms underlying its health effects.
Practical implications
The findings of this research can help Chinese Government improve population health by issuing corresponding digital and health policies at the regional and individual level.
Originality/value
First, the study provides fresh microscopic evidence on health outcomes of ICT adoption based on data from the latest wave of CGSS2017. Second, individual and regional heterogeneity is extensively discussed in contrast to most related macro studies that consider average effects. Third, the study addresses underlying mechanisms that have not been thoroughly tested or studied primarily on a theoretical level.
... In some countries, health services are delivered in multi-level systems, through a patient referral procedure involving the coordination of health services among various levels of healthcare providers. 6 A notable example is in the UK, one of the first countries to strictly follow such a system, through the National Health Service (NHS) law, which established the NHS in 1948. 7 Although countries differ in their models used, all maintain a structure that clearly divides labour in the medical service system, with primary medical and health institutions at the core, and large hospitals as the auxiliary bodies. ...
Objective
This study aimed to explore the characteristics of Shenzhen residents’ preferences and influencing factors regarding their first choice of medical institution at various medical levels, and to understand their attitudes towards community health services.
Design
Cross-sectional survey.
Participants
A total of 1612 participants at least 18 years of age were randomly sampled with stratification among 10 districts in Shenzhen. Data were gathered through a self-designed questionnaire. The effective questionnaire response rate was 93.05%. All patients participated in the study voluntarily, provided written informed consent and were able to complete the questionnaire.
Main outcome measures
We measured and compared the participants’ expected and actual preferences and influencing factors regarding their first choice of medical service at various medical levels.
Results
More than 50% of the participants preferred municipal and district hospitals as their first choice, and 27.5% chose medical institutions according to specific circumstances. Univariate analysis indicated that age, education, income, medical insurance, housing conditions and registered permanent residence were significantly associated with the actual and expected preferred first medical institution. The main factors influencing participants' actual and expected preferred medical institution differed. With the actual preferred first medical institution as the dependent variable, education, monthly income, medical technology, convenience and providers’ service attitude and medical ethics were the main factors (χ ² =212.63, p<0.001), whereas with the expected preferred first medical institution as the dependent variable, occupation, Shenzhen registered permanent residence, education and medical technology were the main factors (χ ² =78.101, p<0.001).
Conclusion
The main factors influencing participants’ preferred medical institution and their actual first visit differed. Patients with high education or income or registered permanent residence preferred high-level medical institutions for the first visit.
... The performance criteria of local governments are now not only focused on simple economic indicators such as GDP, but also on other indicators such as environmental pollution (53). The Central Committee and the central government of China now pay more attention to people's livelihoods, especially the health of the people in the country (54). Local governments have also paid more attention to public health issues and have created interventions with stricter monitoring measures (55). ...
Since the beginning of the COVID-19 outbreak and the launch of the “Healthy China 2030” strategy in 2019, public health has become a relevant topic of discussion both within and outside China. The provision of public health services, which is determined by public health expenditure, is critical to the regional public health sector. Fiscal decentralization provides local governments with more financial freedom, which may result in changes to public health spending; thus, fiscal decentralization may influence public health at the regional level. In order to study the effects of fiscal decentralization on local public health expenditure and local public health levels, we applied a two-way fixed effect model as well as threshold regression and intermediate effect models to 2008–2019 panel data from China's 30 mainland provinces as well as from four municipalities and autonomous regions to study the effects of fiscal decentralization on public health. The study found that fiscal decentralization has a positive effect on increasing public health expenditure. Moreover, fiscal decentralization can promote improvements in regional public health by increasing public health expenditure and by improving the availability of regional medical public service resources. In addition, fiscal decentralization has a non-linear effect on public health.
... The objective of this hierarchy is to ensure that limited medical resources are allocated efficiently and economically. As reported previously, however, this otherwise well-designed system has exhibited limited effectiveness (9). Lower-level hospitals are less competitive than higher-leverparticularly tertiary-hospitals (10). ...
Background
Although the Hierarchical Medical System has been utilized in China for many years, it is inadequate for guiding patients in adopting appropriate diagnose-seeking behaviors in accordance with related policies. This study examined how patients' diagnose-seeking behavior in tertiary hospitals that is dis-accordance with Hierarchical Medical System related policy (“DSB-dis-accordance”) arise and ways to guide patients away from such behaviors, both from the perspective of physicians.
Methods
A qualitative study based on a mixed method including in-depth interviews and grounded theory. Twenty-seven physicians with more than 2 years of experience serving in tertiary hospitals of Shanghai were involved after reviewing the related purposes and requirements. Patients' “DSB-dis-accordance” was studied from the perspective of physicians.
Results
Patient-related factors (habits, trust, and knowledge), physician-related factors (conservative preference, risk avoidance), and system-related factors (accessibility, operability) affected patients' diagnose-seeking behavior.
Conclusions
Patient-related, physician-related, and system-related factors affecting patients' diagnose-seeking behaviors in tertiary hospitals should be addressed by investing more health resources in lower-level hospitals, enhancing dissemination of health-related and policy-related knowledge, refining the classification of diseases, incentivizing physicians, and developing appropriate follow-up measures. Physicians could then become more involved in guiding patients' “DSB-dis-accordance,” thereby benefitting development of the Hierarchical Medical System in China.
... The 2SFCA method evaluated potential hospital accessibility in light of the maximum acceptable distance of individuals, along with the limitation of the distance decay for different travel zones [45]. Recently, several modifications and extensions methods such as the enhanced two-step floating catchment area (E2SFCA) method [46], the three-step floating catchment area (3SFCA) method [47], the modified 2SFCA (M2SFCA) method [48], the variable 2SFCA (V2SFCA) method [49], the kernel density 2SFCA (KD2SFCA) method [50,51], the Gauss 2SFCA (Ga2SFCA) method [52], the gravity 2SFCA (G2SFCA) method [53], the nearest-neighbor 2SFCA (NN2SFCA) method [54], and the hierarchical 2SFCA (H2SFCA) method [55] have been introduced to address this limitation. These methods have all made great contributions to the measurement of hospital accessibility. ...
The hospital accessibility of Acute Myocardial Infarction (AMI) emergency treatment is of great importance, not only for improving the survival rate of patients but also for protecting the basic human right to health care. Traditional AMI emergency treatment research often does not consider ways to shorten the travel time to hospitals for AMI patients and does not reflect the actual time it takes to travel to hospitals, which is critical to AMI emergency treatment. To avoid these shortcomings, this study proposes a method of accessibility measurement based on Web Mapping API (Application Programming Interface) to obtain travel time to hospitals during different periods, then calculated the AMI hospital accessibility based on these detailed data. This study considered the Shijingshan District, Beijing, China, as an empirical case. The study discovered significant differences in the temporal and spatial characteristics of the AMI hospital accessibility on weekdays and weekends. The analysis revealed that travel time to hospitals and traffic congestion are the two main factors affecting AMI hospital accessibility. The research results shed new light on the accessibility of urban medical facilities and provide a scientific basis with which local governments can optimize the spatial structure of medical facilities.
... In addition, increasingly serious environmental pollution not only affects people's daily lives and health but also becomes a major bottleneck for China's green development . Furthermore, a series of problems, such as the uneven distribution of medical (Xiao et al., 2021) and educational resources (Wu et al., 2008) and the unequal labor market (Wang et al., 2021b), are derived from unbalanced regional development. In particular, the imbalance creates a widening gap between the rich and the poor and urgently needs to be solved. ...
Total factor productivity (TFP) indicators or indices are usual measurements for evaluating economic performance in terms of output and input evolution. This approach has been extended in the environmental dimension in the literature. However, the social dimension is equally important for a comprehensive TFP, which is ignored in existing studies. Using provincial-level data from 2000 to 2017 in China, this paper applies a novel nonparametric approach incorporating three dimensions (economy, environment and society) to estimate the Luenberger productivity indicator in order to understand how to realize sustainable and high-quality development. Then, the overall productivity gain is decomposed into three different parts to evaluate economic, environmental, and social performance. The results show that the growth rate of TFP in China within the sample interval was 6.822%. Regarding its decomposition, medical
care provided the largest contribution to the increase in TFP (3.840%), followed by emission reduction (1.981%), economic growth (0.975%), education (0.016%) and employment (0.010%). However, there is regional variety showing that eastern China had high-quality TFP growth (4.696%), while the TFP change was negative (-1.165%)
in western China due to an inferior economy, environment, and educational development.
... [6] Health services in most western countries are delivered in a hierarchical medical system (HMS) and through the mandatory gatekeeping mechanism which involves initial diagnoses at primary care facilities (PCFs) and obligatory two-way referrals among hospitals. [11,12] With the fundamental HMS and the backbone of a strong primary care system, many developed countries have attempted to establish chronic care models to provide integrated care, which has proved to be effective in improving care and reducing costs. [10,13] While experience from developed countries provides useful references, the routine to rebuild the healthcare delivery system is highly context-speci c, and there is limited evidence in low-and middle-income countries (LMIC). ...
Background
The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly aging population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was implemented in 2015 in Zhejiang province, China. This paper investigated the impact of HMS on the local healthcare system.
Methods
We conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data was analyzed with an interrupted time series (ITS) design to assess the impact of HMS on the changes of three outcome variables: primary care physicians (PCPs) patient encounter ratio (i.e., the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e., the mean degree of PCPs divided by that of all other physicians), PCP betweenness centrality ratio (i.e., the mean betweenness centrality of PCPs divided by that of all other physicians).
Results
272,267 patients visited doctors for hypertension between 2010 and 2018. Compared to the counterfactual in the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% (95%CI: 27.1—58.2, p<0.001), the PCP degree ratio increased by 23.6% (95%CI: 8.6—38.5, p<0.01), and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1—171.7, p<0.001).
Conclusions
The HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network. Local policymakers should sustain HMS policy efforts to obtain long-term and large-scale benefits.
... However, China now faces more challenging problems it shares with resource-rich countries including cardiovascular disease, chronic respiratory diseases, cancer, diabetes, and obesity. A recent series of publications [70][71][72][73] highlight achieving health equity should be China's foremost health goal. The current challenges include incomplete health insurance coverage, uneven health care access, mixed health care quality, escalating costs, and high risk of unsustainable expenditures on health care. ...
This study explored results of therapy of children with acute lymphoblastic leukemia (ALL) in China, recent progress, and challenges. Included are a survey of therapy outcomes of ALL in Chinese children nationwide, comparison of these data with global ALL therapy outcomes, analyses of obstacles to improving outcomes, and suggestions of how progress can be achieved. Therapy outcomes at many Chinese pediatric cancer centers are approaching those of resource-rich countries. However, nationwide outcomes still need improvement. Obstacles include suboptimal clinical trials participation, children without adequate health care funding, human resource shortages, especially physicians expert in pediatric hematology and oncology, and social-economic disparities. We suggest how these obstacles have been and continue to be remedied including expanded access to protocol-based therapy, improved supportive care, health care reforms, recruitment of trained personnel, and international collaborations. China has made substantial progress treating children with ALL. We envision even better outcomes in the near future.
Uluslararası Sağlık Alanları Kongresi 2021 (USAK’21)
18-19 Eylül, 2021 / Online
Kongre Bildiri Kitabı
Editör: Doç. Dr. Muhammet Kerim AYAR
International Health Areas Congress 2021 (IHAC’21)
September 18th-19th, 2021 / Online
Conference Proceedings Book
Editor: Doç. Dr. Muhammet Kerim AYAR
Participated Countries
Turkey - USA - Greece – Malaysia – Iran – Spain – Iraq – Nigeria
- Libya
Presentation
Oral Presentation
Languages
Turkish, English
To examine what built environment characteristics improve the health outcomes of human beings is always a hot issue. While a growing literature has analyzed the link between the built environment and health, few studies have investigated this relationship across different spatial scales. In this study, eighteen variables were selected from multi-source data and reduced to eight built environment attributes using principal component analysis. These attributes included socioeconomic deprivation, urban density, street walkability, land-use diversity, blue-green space, transportation convenience, ageing, and street insecurity. Multiscale geographically weighted regression was then employed to clarify how these attributes relate to cardiovascular disease at different scales. The results indicated that: (1) multiscale geographically weighted regression showed a better fit of the association between the built environment and cardiovascular diseases than other models (e.g., ordinary least squares and geographically weighted regression), and is thus an effective approach for multiscale analysis of the built environment and health associations; (2) built environment variables related to cardiovascular diseases can be divided into global variables with large scales (e.g., socioeconomic deprivation, street walkability, land-use diversity, blue-green space, transportation convenience, and ageing) and local variables with small scales (e.g., urban density and street insecurity); and (3) at specific spatial scales, global variables had trivial spatial variation across the area, while local variables showed significant gradients. These findings provide greater insight into the association between the built environment and lifestyle-related diseases in densely populated cities, emphasizing the significance of hierarchical and place-specific policy formation in health interventions.
County medical alliances (CMAs) in China are considered to be effective in optimizing the layout of medical resources and improving primary healthcare services. To facilitate the implementation of CMAs in multiple geographical clusters, we examine a cluster-based healthcare network design (CHND) problem with patient referral in uncapacitated and capacitated cases. Considering the uncertainty of health demand and unit referral cost, we develop adaptive distributionally robust models for the CHND problem, where the location and allocation decisions anticipate the worst-case expected patient treatment and referral cost over an ambiguity set. In terms of tractability, we reformulate the adaptive distributionally robust models as tractable forms. Further, a hybrid genetic algorithm that combines a genetic algorithm with a commercial solver is designed to improve the computational efficiency for large-scale instances. Finally, we apply our models to a real-world case in Shenzhen, China, to verify the effectiveness of the proposed algorithm and assess the value of the adaptive distributionally robust models over the corresponding robust model. The results show that our algorithm has outstanding efficiency and accuracy when compared to the hybrid particle swarm algorithm and the commercial solver. Moreover, the adaptive distributionally robust model outperforms the robust model in terms of solution quality.
The hierarchical diagnosis and treatment reform of China can guide residents to seek medical treatment in an orderly manner and improve access to medical treatment. Most existing studies on hierarchical diagnosis and treatment used accessibility as the evaluation index to determine the referral rate between hospitals. However, the blind pursuit of accessibility will cause the problem of uneven utilization efficiency of hospitals at different levels. In response to this, we constructed a bi-objective optimization model based on the perspective of residents and medical institutions. This model can give the optimal referral rate for each province considering the accessibility of residents and the utilization efficiency of hospitals, to improve the utilization efficiency and equality of access for hospitals. The results showed that the applicability of bi-objective optimization model is good, and the optimal referral rate based on the model can ensure the maximum benefit of the two optimization goals. In the optimal referral rate model, residents' medical accessibility is relatively balanced overall. In terms of obtaining high-grade medical resources, the accessibility is better in the eastern and central regions, but poorer in the western China. According to the current allocation of medical resources in China, the medical tasks undertaken by high-grade hospitals account for 60%-78%, which are still the main force of medical services. In this way, there is a big gap in realizing the "serious diseases do not leave the county" goal of hierarchical diagnosis and treatment reform.
Background: The border area in Indonesia is often neglected, apart from remote locations and islands. Aims: The study aims to analyze the role of borderlands status on hospital utilization on Kalimantan Island, Indonesia. Methods: The study was a cross-sectional study. The research obtained 61,598 respondents through stratification and multistage random sampling the study employed hospital utilization as an outcome variable; meanwhile, borderlands status as an exposure variable. Moreover, the study used nine control variables: residence type, age group, gender, marital status, education level, occupation type, wealth status, health insurance ownership, and travel time to the hospital. The study employed binary logistic regression to analyze the data in the last stage. Results: The results show that the average hospital utilization in Kalimantan Island in 2018 in this study was 4.953%. Meanwhile, those who live in the border area have 1.406 times the probability of utilizing the hospital than those in the nor-border area (95% CI 1.392-1.419). On the other hand, the study analysis also found all control variables were significantly related to hospital utilization: residence type, age group, gender, marital status, education level, occupation type, wealth status, health insurance ownership, and travel time to the hospital. Conclusion: The study concludes that borderlands status is related to hospital utilization on Kalimantan Island. Those who live in border areas have a better possibility of hospital utilization than those in non-border areas.
Background:
The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.
Methods:
A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.
Results:
A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.
Conclusions:
Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
Improving migrants’ settlement intention is of great importance in the process of China’s new urbanization. By exploiting the data from the China Migrants Dynamic Survey conducted by the National Health and Family Planning Commission of China, this study empirically explores the effects of urban health care on migrants’ settlement intentions. Urban health care is measured by the establishment of migrants’ health records in this article. Additionally, marginal effect analysis, propensity score matching, the random sampling method, the placebo test, and the two-stage least squares method are adopted to tackle potential selection bias and endogeneity concerns. As indicated by the empirical results, urban health care could significantly improve the migrants’ settlement intention. After controlling for the influence of individual characteristics, household characteristics, and migration characteristics, urban health care still plays a significant role in promoting settlement intention. As revealed by the heterogeneity analysis, urban healthcare effects are significantly larger for migrants with agricultural hukou registration, a spouse, younger age, higher income level, and moving into the first and second-tier cities. Meanwhile, considering the impact of housing pressure on migrants’ settlement intentions, this study uses household housing expenditure as a moderator to further analyze the relationship between urban health care and settlement intention. It is found that housing pressure can weaken the positive effect of urban health care on migrants’ settlement intention. The research conclusions contribute to a comprehensive understanding of the migrants’ settlement decisions and provide rich implications for city managers and policymakers.
The geographical accessibility of public healthcare institutions is the key factor affecting the equity of healthcare services. Based on the hierarchical medical system and referral system in China, we analyzed the referral accessibility of hospitals in the Wuhan Metropolitan Development Zone. Before the implementation of the referral system, only 7.91% of the total communities met the accessibility standard for secondary and tertiary hospitals, which meant that there was significant inequality in high-level healthcare. Moreover, 5.4% of the total communities did not meet the accessibility standard for primary hospitals, which meant that there were insufficient primary hospitals. After the implementation of the referral system, the proportions of communities meeting the accessibility standards for the first-stage referral, second-stage referral and cross-level referral were 92.6%, 99.9% and 98.3%, respectively. The results show that the referral system has improved the accessibility of healthcare, but it has not completely solved healthcare inequality. The first-stage referral accessibility of healthcare services in the northern, western and eastern groups does not meet the accessibility standard, which is due to the inefficient layout of secondary hospitals. The Wuhan government should construct secondary hospitals in these groups and primary hospitals in the central urban area and the southeastern, southern, western and eastern groups.
Medical consortia is a form of healthcare capacity sharing and an effective means to maximizing healthcare resource utilization. To fully satiate patient demand and derive maximum efficiency for the medical consortium, patient referrals among the consortium members is a key mechanism. Patient referrals require two main steps: allocating patients to hospitals (i.e., patient assignment) and assigning patients to each time slot (i.e., patient scheduling). Patient treatment cost and tardiness are two concerns for the patients and are treated simultaneously. A clustering algorithm based on Fuzzy-C Means (FCM) is proposed to solve the problem, with patients clustered for each hospital based on their characteristics and preferences. Solution-enhancing strategies are developed to improve the schedule quality, including a virtual patient moving strategy (VPMS) and local search algorithms (LSA). Three spatial distributions of patients, central clumped, random and uniform distributions, are used to validate the performance of the algorithms. From the experimental results, the FCM-VPMS algorithm yields patient referral solutions at the lowest treatment cost, while the FCM-LSA performs better on minimizing total patient tardiness. On the cost efficiency of the algorithms, VPMS performs well with a central clumped distribution, while the LSAs show higher efficiency with the random and uniform distributions respectively.
The retail pharmaceutical sector has been characterized in the last decades by profound deregulation policies, aiming at fostering the entry process of new competitors in the market to improve users' access and quality of services. This paper explores the effects of such reforms in the Navarre Region (Spain), where the existing entry restrictions were relaxed in 2000. Using a GIS-based methodology and very disaggregated real data, we show that the massive entry of new pharmacies improved users' access in urban and rural areas but led to intense agglomeration of competitors within limited distances, thus failing to result in a more fair spatial competition. We then propose solving a mathematical programming model that can support policy-makers for an ex-ante assessment of the (spatial) effects determined by changing regulatory frameworks. Results from our computational experiments demonstrate that, if adequately oriented at guaranteeing predefined minimum profitability to new entrants, spatial deregulation policies may result in win-win scenarios for both users and pharmacies. Indeed, the obtained solutions (almost) perfectly replicate the current accessibility conditions while ensuring more equitable market shares’ distribution.
Motivated by a real-life project, this paper presents several models for designing a network of “walk-in” medical facilities that provide a homogeneous service in competitive and centralized environments. The problem in a competitive environment is to optimize the location and capacity of each open facility for a focal firm so as to maximize its total demand volume, subject to a total capacity limit. We assume that travel time to a facility and expected waiting time at a facility are the two main determinants for clients to choose where to receive the service. We consider two alternative “user-choice” models, one “probabilistic-choice” and the other “deterministic-choice”. In a centralized environment, a central decision maker determines the optimal location and capacity of each open facility, to maximize overall social welfare. We consider a “system-optimal” model and two user-choice models. All the models follow a bilevel structure, i.e., the location-allocation framework. The user-choice models are formulated as mathematical programs with equilibrium constraints. To solve the problems efficiently, we propose a common solution methodology in line with the location-allocation framework. Through a real-life case study, we discuss several interesting managerial insights about model selection and facility network design strategies.
The housing market in Chinese metropolises have become inflated significantly over the last decade. In addition to an economic upturn and housing policies that have potentially fueled the real estate bubble, factors that have contributed to the spatial heterogeneity of housing prices can be dictated by the amenity value in the proximity of communities, such as accessibility to business centers and transportation hubs. In the past, scholars have employed the hedonic pricing model to quantify the amenity value in relation to structural, locational, and environmental variables. These studies, however, are limited by two methodological obstacles that are relatively difficult to overcome. The first pertains to difficulty of data collection in regions where geospatial datasets are strictly controlled and limited. The second refers to the spatial autocorrelation effect inherent in the hedonic analysis. Using Beijing, China as a case study, we addressed these two issues by (1) collecting residential housing and urban amenity data in terms of Points of Interest (POIs) through web-crawling on open access platforms; and (2) eliminating the spatial autocorrelation effect using the Eigenvector Spatial Filtering (ESF) method. The results showed that the effects of nearby amenities on housing prices are mixed. In other words, while proximity to certain amenities, such as convenient parking, was positively correlated with housing prices, other amenity variables, such as supermarkets, showed negative correlations. This mixed finding is further discussed in relation to community planning strategies in Beijing. This paper provides an example of employing open access datasets to analyze the determinants of housing prices. Results derived from the model can offer insights into the reasons for housing segmentation in Chinese cities, eventually helping to formulate effective urban planning strategies and equitable housing policies.
China is setting up a hierarchical medical system to solve the problems of biased resource allocation and high patient flows to large hospitals. The development of big data and mobile Internet technology provides a new perspective for the establishment of hierarchical medical system. This viewpoint discusses the challenges with the hierarchical medical system in China and how big data and mobile Internet can be used to mitigate these challenges.
Civil administration departments require reliable measures of accessibility so that residential care facility shortage areas can be accurately identified. Building on previous research, this paper proposes an enhanced variable two-step floating catchment area (EV2SFCA) method that determines facility catchment sizes by dynamically summing the population around the facility until the facility-to-population ratio (FPR) is less than the FPR threshold (FPRT). To minimize the errors from the supply and demand catchments being mismatched, this paper proposes that the facility and population catchment areas must both contain the other location in calculating accessibility. A case study evaluating spatial accessibility to residential care facilities in Nanjing demonstrates that the proposed method is effective in accurately determining catchment sizes and identifying details in the variation of spatial accessibility. The proposed method can be easily applied to assess other public healthcare facilities, and can provide guidance to government departments on issues of spatial planning and identification of shortage and excess areas.
We examined the uncertainty of the contextual influences on food access through an analytic framework of the uncertain geographic context problem (UGCoP). We first examined the compounding effects of two kinds of spatiotemporal uncertainties on people’s everyday efforts to procure food and then outlined three key dimensions (food access in real time, temporality of the food environment, and perceived nutrition environment) in which research on food access must improve to better represent the contributing environmental influences that operate at the individual level. Guidelines to address the UGCoP in future food access research are provided to account for the multidimensional influences of the food environment on dietary behaviors.
Background:
The primary care in China can be provided by general practitioners (GPs) and other physicians (non-GPs). However, China's general practice system has never been really established. Chinese patients tend to consider the quality of primary care provided by GPs much lower than that of non-GPs. Besides, many GPs presently prefer leaving their own positions and seeking better development in big hospitals, which has made the already weak GP system weaker. Yet, few studies have specially compared the quality of primary care provided by Chinese GPs and other physicians and no studies have explored the independent predictors of Chinese GPs' intentions to stay on their current job. In this study, we aimed to compare the quality of primary care offered by GPs with non-GPs and to explore the independent predictors of GPs' future work intentions.
Methods:
This cross-sectional study applied multi-stage random cluster sampling methodology. The data were collected from November 2013 to September 2014 in Guangdong Province. In total, 401 effective questionnaires were selected from the physicians. Quality of primary care was assessed using the Primary Care Assessment Tool (PCAT) Provider Part, representing six primary care domains: ongoing care, coordination (i.e., referrals and information systems), comprehensiveness (i.e., service available and service provided), family-centeredness, community orientation and cultural competence.
Results:
Of 401 participating physicians, 163 (40.6 %) were GPs. The total PCAT score was 26.32 ± 2.24 which was the sum score of the six domains and represent the quality of primary care. GPs achieved significantly different total scores and scores on three individual scales: comprehensiveness: service available, comprehensiveness: service provided and community orientation. Multiple linear regressions revealed GPs had a higher total score and scores for comprehensiveness: service provided and community orientation after adjusting for sociodemographic characteristics. In addition, GPs were more likely to intend to stay in their current job in the coming year, and this was associated with their educational level.
Conclusions:
Our findings showed that GPs reported higher quality of primary care than other physicians, and were more inclined to stay in their current job. With more comprehensive care and community orientation provided by GPs, residents could reach basic medical cares and needn't to crowd into larger hospitals.
Greater accessibility to geospatial technologies has led to a surge of spatialized public health research, much of which has focused on food environments. The purpose of this study was to analyze differing spatial measures of exposure to supermarkets and farmers׳ markets among women of reproductive age in eastern North Carolina. Exposure measures were derived using participant-defined neighborhoods, investigator-defined road network neighborhoods, and activity spaces incorporating participants׳ time space behaviors. Results showed that mean area for participant-defined neighborhoods (0.04 sq. miles) was much smaller than 2.0 mile road network neighborhoods (3.11 sq. miles) and activity spaces (26.36 sq. miles), and that activity spaces provided the greatest market exposure. The traditional residential neighborhood concept may not be particularly relevant for all places. Time-space approaches capturing activity space may be more relevant, particularly if integrated with mixed methods strategies.
The usefulness of gravity-based spatial access models is limited because of the uncertainty introduced by the range of values of the impedance coefficient. To solve this problem, this paper proposes the concept of spatial access ratio (SPAR) derived from the enhanced 2-step floating catchment area (E2SFCA) method — a recent extension of the gravity model — to assess potential spatial access. First, a sensitivity assessment is conducted to verify the effectiveness of SPAR and its advantages in overcoming the uncertainty problem. Then, the E2SFCA method and the shortest travel time method are employed to measure potential spatial access to colorectal cancer (CRC) prevention and treatment services in Texas based on data at the census tract level. The socio-demographic and geographic distributions of potential spatial access to CRC services are also examined. The sensitivity assessment reveals substantial fluctuations in the values of the spatial access index calculated directly by the E2SFCA method under different values of the impedance coefficient. However, the values of SPAR remain stable under different values of the coefficient. A comparative analysis indicates that potential spatial access to primary care physicians (PCPs), CRC screening facilities, and oncologists varied among different racial/ethnic and socioeconomic population groups as well as in different geographic regions in Texas. Non-Hispanic blacks, Asians, and people in affluent areas had a geographical advantage in accessing CRC services than other groups. The urban/rural difference was more obvious and serious than those of different racial/ethnic groups and groups with different socio-economic statuses, as metropolitan residents had more than three times the potential spatial access than isolated rural residents.
Gravity-based spatial access models have been widely used to estimate spatial access to healthcare services in an attempt to capture the interaction of various factors. However, these models are inadequate in informing health resource allocation work due to their inappropriate assumption of healthcare demand. For the purpose of effective healthcare resource planning, this article proposes a three-step floating catchment area (3SFCA) method to minimize the healthcare-demand overestimation problem. Specifically, a spatial impedance-based competition scheme is incorporated into the enhanced two-step floating catchment area (E2SFCA) method to account for a reasonable model of healthcare supply and demand. A case study of spatial access to primary care physicians along the Austin–San Antonio corridor area in central Texas showed that the proposed method effectively minimizes the overestimation of healthcare demand and reflects a more balanced geographic pattern of spatial access than E2SFCA. In addition, by using an adjusted spatial access index, the 3SFCA method indicates strong potential for identifying health professional shortage areas. The study concludes that 3SFCA is a promising method to provide health professionals and decision makers with useful healthcare accessibility information.
Any study that examines the effects of area-based attributes on individual behaviors or outcomes faces another fundamental methodological problem besides the modifiable areal unit problem (MAUP). It is the problem that results about these effects can be affected by how contextual units or neighborhoods are geographically delineated and the extent to which these areal units deviate from the true geographic context. The problem arises because of the spatial uncertainty in the actual areas that exert the contextual influences under study and the temporal uncertainty in the timing and duration in which individuals experienced these contextual influences. Using neighborhood effects and environmental health research as a point of departure, this article clarifies the nature and sources of this problem, which is referred to as the uncertain geographic context problem (UGCoP). It highlights some of the inferential errors that the UGCoP might cause and discusses some means for mitigating the problem. It reviews recent studies to show that both contextual variables and research findings are sensitive to different delineations of contextual units. The article argues that the UGCoP is a problem as fundamental as the MAUP but is a different kind of problem. Future research needs to pay explicit attention to its potential confounding effects on research results and to methods for mitigating the problem.
Despite spending more than any other nation on medical care per person, the United States ranks behind other industrialized nations in key health performance measures. A main cause is the deep disparities in access to care and health outcomes. Federal programs such as the designations of Medically Underserved Areas/Populations and Health Professional Shortage Areas are designed to boost the number of health professionals serving these areas and to help alleviate the access problem. Their effectiveness relies first and foremost on an accurate measure of accessibility so that resources can be allocated to truly needy areas. Various measures of accessibility need to be integrated into one framework for comparison and evaluation. Optimization methods can be used to improve the distribution and supply of health care providers to maximize service coverage, minimize travel needs of patients, limit the number of facilities, and maximize health or access equality. Inequality in health care access comes at a personal and societal price, evidenced in disparities in health outcomes, including late-stage cancer diagnosis. This review surveys recent literature on the three named issues with emphasis on methodological advancements and implications for public policy.
Conventional integral measures of accessibility, although valuable as indicators of place accessibility, have several limitations when used to evaluate individual accessibility. Two alternatives for overcoming some of the difficulties involved are explored in this study. One is to adapt these measures for evaluating individual accessibility using a disaggregate, nonzonal approach. The other is to develop different types of measures based on an alternative conceptual framework. To pursue the former alternative, this study specifies and examines eighteen gravity-type and cumulative-opportunity accessibility measures using a point-based spatial framework. For the latter option, twelve space-time accessibility measures are developed based on the construct of a prism-constrained feasible opportunity set. This paper compares the relationships and spatial patterns of these thirty measures using network-based GIS procedures. Travel diary data collected in Columbus, Ohio, and a digital data set of 10,727 selected land parcels are used for all computation. Results of this study indicate that space-time and integral indices are distinctive types of accessibility measures which reflect different dimensions of the accessibility experience of individuals. Since space-time measures are more capable of capturing interpersonal differences, especially the effect of space-time constraints, they are more “gender sensitive” and helpful for unraveling gender/ethnic differences in accessibility. An important methodological implication is that whether accessibility is observed to be important or different between individuals depends heavily on whether the measure used is capable of revealing the kind of differences the analyst intends to observe.
This paper presents an enhancement of the two-step floating catchment area (2SFCA) method for measuring spatial accessibility, addressing the problem of uniform access within the catchment by applying weights to different travel time zones to account for distance decay. The enhancement is proved to be another special case of the gravity model. When applying this enhanced 2SFCA (E2SFCA) to measure the spatial access to primary care physicians in a study area in northern Illinois, we find that it reveals spatial accessibility pattern that is more consistent with intuition and delineates more spatially explicit health professional shortage areas. It is easy to implement in GIS and straightforward to interpret.
This article synthesizes two GIS-based accessibility measures into one framework, and applies the methods to examining spatial accessibility to primary health care in the Chicago ten-county region. The floating catchment area (FCA) method defines the service area of physicians by a threshold travel time while accounting for the availability of physicians by their surrounded demands. The gravity-based method considers a nearby physician more accessible than a remote one and discounts a physician's availability by a gravity-based potential. The former is a special case of the latter. Based on the 2000 Census and primary care physician data, this research assesses the variation of spatial accessibility to primary care in the Chicago region, and analyzes the sensitivity of results by experimenting with ranges of threshold travel times in the FCA method and travel friction coefficients in the gravity model. The methods may be used to help the US Department of Health and Human Services and state health departments improve designation of Health Professional Shortage Areas.
Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.
To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.
Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.
Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.
Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.
Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.
This paper reviews the rationales and evidence for horizontal and vertical integration involving hospitals. We find a disjunction between the integration rationales espoused by providers and those cited in the academic literature. We also generally find that integration fails to improve hospitals' economic performance. We offer seven lessons from hospitals' efforts to integrate and then suggest four alternative models for achieving integrated delivery of health care services.
The use of primary care physicians as gatekeepers to specialists and other medical resources—considered to be a managed care innovation in the United States—has proliferated during the past few decades. Its introduction has been accompanied by a government sponsored programme of research into referrals from primary care (box 1). Findings from these studies may offer insights into how the UK's NHS could shape the gatekeeping function of general practitioners. This article discusses the concept of gatekeeping, contrasts the processes of referral to specialists in the United States and the United Kingdom, examines the mechanisms by which gatekeeping influences resource allocation, and discusses the effects of linking gatekeeping with financial incentives and utilisation review.
Summary points
Gatekeeping systems have emerged in countries with scarce medical resources
Gatekeepers ensure equity by judiciously matching healthcare services, including specialty referrals, to healthcare needs
Gatekeeping alters patients' behaviour, increasing levels of first contact care with primary care physicians, thereby reducing patients' self referrals
Patients in US health plans with gatekeeping arrangements are twice as likely to be referred to specialist care as their UK counterparts
There is little evidence that gatekeeping has had much effect on patients' referral rates in the United States, a healthcare environment rich in specialists
Gatekeeping in the United States and the United Kingdom
Within modern societies, gatekeepers are positioned between organisations and individuals who wish to use resources within those organisations. Gatekeepers use discretion when determining who will be granted access to these resources. Physician gatekeepers collaborate with patients to identify their healthcare needs and choose services that effectively meet those needs. Public acceptance of gatekeeping is strengthened when there are too few resources to satisfy everyone's demands. In the United Kingdom, where long queues to see specialists are common because specialists are in short supply, the general practitioner gatekeeper has enjoyed widespread support. In the United States, the public perceives the supply of specialised healthcare resources as limitless and accessible to all—hence its dissatisfaction with primary care gatekeepers.2
Box 1: Key research issues at the primary care-specialist care interface1
How do economic incentives and healthcare organisation structure affect the referral behaviour of primary care physicians and specialists?Do economic incentives to refer more or less often lead to changes in patients' outcomes?Is it desirable or even possible to standardise the content and language of the information transferred between referring clinician and specialist through use of communication protocols?How can new technology most effectively be used to improve the process and outcomes of communication at the interface of primary and specialist care?Which specific primary care physician competencies (in knowledge, skills, and attitude) have been proved to have an impact on patients' outcomes?Can the effect of physician competencies be separated from the effects of practice organisation and the healthcare system physicians work in?How do patients regard the referral process?What factors shape patient expectations, preferences, attitudes, and understanding about referrals to specialists, and how are these measured?
RETURN TO TEXT
Gatekeeping intertwines the roles of physicians and healthcare organisations.3 This enmeshment benefits delivery systems because the population trusts healthcare organisations much less than it trusts doctors. Over time, the newly developed primary care trusts in the United Kingdom will align general practitioners more closely with healthcare organisations. Patients' satisfaction with and trust in their doctors will remain high only if the public believes the trusts are acting on their behalf, rather than making decisions in their own financial interests. In the United States, some of the harshest criticism of gatekeeping has resulted from the public's perception that medical decision making was unduly influenced by financial considerations.
Although physicians are gatekeepers to almost all medical resources, their role in managing referral to specialists has been the most controversial aspect of gatekeeping. The US federal government is considering a “patients' bill of rights,” which among its many provisions requires healthcare organisations to give patients freer access to specialists. Some health maintenance organisations which use primary care physicians as gatekeepers to specialists are allowing patients to refer themselves if they are prepared to pay more out of pocket. In Britain, some analysts view the referral process as too loose, asserting that high referral rates have led to inappropriate demands on consultants. Referral guidelines are being considered for improving the appropriateness of general practitioners' referrals and for reducing demand at the interface between primary and specialist care.4 General practitioners' referral patterns will be examined more closely through the introduction of new monitoring systems and unified budgets for primary care trusts.5
Box 2: Types of US health plans and health maintenance organisations
Indemnity plans—No physician gatekeeper; unrestricted choice of practitioner; fee for service payment; may use some utilisation review (typically for hospital admissions)
Preferred provider organisations—No physician gatekeeper; generally use fee for service payments; patients have financial incentives to use practitioners within a defined network; costs are contained by discounted payments to providers and through some utilisation review
Health maintenance organisations—Use primary care physicians as gatekeepers; patients' access to specialists must be “authorised” by the gatekeeper; costs are contained by discounted payments, utilisation review of high cost procedures, and gatekeeping
Staff or group model—Physicians either are employed by the health maintenance organisation (staff model) or exclusively contract with a single health maintenance organisation (group model); most commonly they are paid by salary, with bonuses linked to productivity or quality assessments
Network model or independent practice association model—The health maintenance organisation contracts with physicians practising in their own offices (network model) or a physician organisation that in turns contracts with physicians (independent practice association model); physicians are free to contract with multiple health maintenance organisations; payment may be through capitation fees or fee for service
Point of service plan— Individuals choose a physician gatekeeper; patients have the option of obtaining care approved by the gatekeeper (lowest cost to patient) or referring themselves for care (higher cost to patient)
RETURN TO TEXT
The US healthcare system has a mixture of health plans (box 2). During the past 20 years, formal gatekeeping (physicians authorising referrals to specialists) proliferated in tandem with the growth of health maintenance organisations. Currently 38% of the US population has a primary care physician who acts as a formal gatekeeper.6 In response to the public's discontent with restricted access to specialists, health maintenance organisations have created new organisational models that weaken the physician gatekeeper function. For example, the point of service plan gives patients the option to use services approved by their gatekeeper or, at increased cost to themselves, to refer themselves to any physician within or outside the plan (but only 5% per year use this option).7 The self referral option gives patients the perception of less restricted access to specialist care, even though most are still referred to specialists by their primary care physician gatekeeper. Access to specialists in point of service plans is partly determined by ability to pay, which raises equity concerns. It seems unlikely that the NHS will consider similar mechanisms for managing demand, as this would require a radical change in the underlying principles of the NHS and the way it is funded.
Specialty referral rates
During an office visit, patients in either country have approximately equal chances of being referred to a specialist (table). Rates of keeping appointments with specialists are strikingly similar among referred patients in the two countries. However, a third of referrals made from primary care physicians' offices in the United States do not involve a face to face encounter with the patient.9 Many are made during telephone conversations with patients and others are made by non-physician staff, which may be part of an integrated sequence of contacts between patients and physicians and can provide an efficient mechanism for reducing physicians' workload. Inappropriately made, however, such referrals can lead to unnecessary specialist care and increased costs.
View this table:View PopupView InlineReferrals to specialists and supply of specialists in United Kingdom and United States
Patients in the United States are twice as likely as patients in Britain to see a specialist during any 12 months. This large difference is partly because patients refer themselves more often in the United States, even when they have physician gatekeepers and then must pay for the full costs of care. In the United Kingdom, access to specialists has generally not been possible without a general practitioner's authorisation. General practitioners' exclusive control of the referral process may change as nurse practitioners, nurse specialists, nurse consultants, and staff of NHS walk-in centres gain authority to refer patients. The US experience suggests that this may lead to a substantial increase in rates of referrals to specialists. An important explanation for the differences in referral rates between the United States and the United Kingdom is the greater availability of specialists in the United States. The high referral rates in the United States are certainly one of the contributing causes of the country's exceptionally high healthcare expenditures.
Gatekeeping and resource allocation
In 1998, European countries with gatekeeping systems spent less on healthcare as a percentage of their gross national product than those that allowed direct access to specialists (7.8% v 8.6%). 12 13 Among European nations and in the United States, more referrals are made by physicians who act as gatekeepers than those who do not. 14 15 Although gatekeeping is associated with a greater range of conditions managed by general practitioners at the point of first contact, it has not been linked to other changes in the diagnostic or management styles of general practitioners or primary care physicians,13 or their coordination of referral care. 15 16
In the United States, patients newly enrolling into gatekeeping health plans are less likely to see a specialist than are others in non-gatekeeping plans with unrestricted access to specialists.17–19 When patients switch out of a gatekeeping plan, there is little short term effect on their patterns of use of specialists.20 In US multispecialty medical groups, gatekeeping systems are not associated with any cost savings.21
Gatekeeping systems have developed in countries with a limited supply of specialists. Studies have shown that countries without gatekeeping (n=5) had an average wait of 8.4 days for a specialist appointment, whereas those with gatekeeping (n=8) had an average wait of 23.2 days. 8 13 Gatekeeping itself therefore does not seem to increase waiting time; rather, it is a logical organisational response to scarcity of specialist within a society.
Gatekeeping clearly alters the channels by which patients receive care: it is associated with more first contact with a general practitioner or a primary care physician and, consequently, less self referral. Less certain is whether it changes practitioners' behaviour. There is no compelling evidence that gatekeeping modifies physicians' style of decision making or that primary care physicians apply resources any differently to patients for whom they are a gatekeeper. As regards referrals, this is not surprising, as 75% of the variation in referral rates for specific conditions is attributable to the characteristics of the presenting problem (figure).22
View larger version:In a new windowDownload as PowerPoint SlideVisits to primary care physicians for common medical conditions (yellow), surgical conditions (red), and other conditions (white). Data are from US national ambulatory medical care surveys, 1989-94; axes are on the logarithmic scale. Reprinted with permission22
Financial incentives and utilisation reviews
Healthcare organisations in the United States have used financial incentives, such as “specialty withholds” and capitation payments, to reduce referrals to specialists by gatekeepers. Withholds are a mechanism used by healthcare organisations to share financial risk for patients' use of certain types of services with the providers. Specialty withholds are proportions of payments to primary care physicians that are withheld prospectively to cover referral costs. Typically, they range from 10% to 20% of payments, and surpluses are split evenly between clinicians and insurers. In one study, a 10% withhold did not reduce rates of referral.23 Physicians considered the potential loss of income to be a cost of doing business; moreover, the financial risk applied to only a small proportion of the physicians' total practice (most US physicians contract with multiple health plans).
Withhold payments would have stronger effects if all a general practitioner's or primary care physician's patients were covered by the financial risk. The recent fundholding experiments in Britain placed increased financial responsibility for health services on general practices. Although an evaluation found fundholding had no effect on overall rates of referral, fundholding practices did have a slower rate of rise in referral rates than non-fundholding practices.24 An important conceptual problem with tying financial incentives to referral rates is that the number of referrals tells us nothing about their appropriateness, even if the results are adjusted for the health status of the population. Furthermore, incentives may provoke ethical conflicts when physicians weigh benefits to the patient against loss of income or the health services their organisation can offer.
There is little information on whether capitation fees influence the process of referral to specialists. In a national study of the referral practices of US physicians, our research group found that paying physicians by capitation fees did not influence rates of referral, although it was associated with more referrals made for discretionary indications.11 Capitation payments may act at the margins of primary care physicians' scope of practice, increasing the likelihood that health problems which could be managed either in primary care or by a specialist are referred. In recognition of these incentives, some US medical groups have developed blended payment systems that combine capitation fees to primary care physicians with fee for service payments for procedures that straddle the boundaries between primary care physicians' and specialists' practice.
In the United States, referral guidelines have not been associated with any substantive impact on physicians' referral rates. On the other hand, primary care physicians and patients have ample experience with review of referral requests (utilisation review) by health plans and in some cases by medical groups. Utilisation review programmes generally apply guidelines retrospectively. In some cases, the review leads to denying a referral request, although this is uncommon. Utilisation reviews shift some gatekeeping authority from the doctor-patient relationship to the healthcare organisation. This two tiered gatekeeping arrangement is cumbersome; it has created substantial dissatisfaction with health care on the part of both patients and physicians; and, it is not clearly associated with any cost savings. One strategy that holds great promise for altering general practitioners' and primary care physicians' referral behaviour relies on decision support—using electronic medical records to integrate referral guidelines that specify timing of referral, the investigations that should be done before referral, and the expectations of the consultant.
Conclusions
A recent editorial in the New York Times expressed a sentiment common in the United States: that gatekeeping is a failed experiment by managed care organisations.2 On the front line delivery of health care, the primary care gatekeeper has become the lightning rod for consumers' discontent with healthcare delivery. There is no question but that patients value the input of their primary care physicians into medical decisions. At issue is how to manage patients' demand for specialist care in a healthcare environment rich in specialists that promotes expectations for direct access and reliance on invasive technologies over less invasive primary care interventions.
Many UK analysts assert that gatekeeping is responsible for the country's low healthcare expenditures relative to other European nations. Although it is true that countries with gatekeeping systems spend less on health care than those without such management of referrals, gatekeeping is not directly responsible for the lower costs. Rather, gatekeeping systems have emerged in societies with scarcer healthcare resources. The lower costs are a function of supply side controls, rather than demand management at the primary care-specialty care interface. Cost arguments aside, primary care gatekeeping provides an important filter to specialist care. Patients who go directly to specialists are less likely to be ill, increasing the chances that diagnostic and therapeutic procedures will be applied inappropriately and outcomes will be threatened. Despite consumerist trends in most developed nations, patients will continue to need primary care practitioners to guide them through an increasingly complex healthcare system and to assure an equitable distribution of resources by matching services to healthcare needs.
Footnotes
This is the second of four articles in a series edited by Andrew Bindman and Azeem Majeed
Funding CBF was supported in part by an independent scientist award from the Agency for Healthcare Research and Quality, Department of Health and Human Services.
Competing interests None declared.References1.↵Research at the interface of primary and specialty care: conference summary. http://www.ahrq.gov/research/interovr.htm (accessed 24 Feb 2003)2.↵A verdict on gatekeepers [editorial]. New York Times 2001 Nov 15: 30.3.↵Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians. JAMA 1996; 275: 1693–1697OpenUrlFREE Full Text4.↵National Institute for Clinical Excellence. Referral practice—a guide to appropriate referral from general to specialist services. London: NICE, 2000. http://www.nice.org.uk/article.asp?a=1178 (accessed 24 Feb 2003).5.↵Majeed A, Malcolm L. Unified budgets for primary care groups. BMJ 1999; 318: 772–776OpenUrlFREE Full Text6.↵Kaiser Family Foundation and Health Research Education Trust. Employer health benefits: 2000 annual survey. http://www.kff.org/docs/ehbs (accessed 24 Feb 2003).7.↵Forrest CB, Weiner JP, Fowles J, Frick K, Vogeli C, Lemke K, et al. Self-referral in point-of-service plans. JAMA 2001; 285: 2223–2231OpenUrlFREE Full Text8.↵Fleming DM. The European study of referrals from primary to secondary care. Report to the Concerted Action Committee of Health Services Research for the European Community. Bristol: Royal College of General Practitioners, 1992. (No 56.)9.↵Forrest CB, Nutting P, Starfield B, von Schrader S. Family physicians' referral decisions: results from the ASPN referral study. J Fam Pract 2002; 51: 215–222OpenUrlMedlineWeb of Science10.Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Specialty referral rates in the United Kingdom versus United States. BMJ 2002; 325: 370–371OpenUrlFREE Full Text11.↵Stoddard J, Sekscenski E, Weiner J. The physician workforce: broadening the search for solutions. Health Affairs 1998; 17: 252–257OpenUrlMedline12.↵Anderson GF, Hurst J, Hussey PS, Jee-Hughes M. Health spending and outcomes: trends in OECD countries, 1960–1998. Health Affairs 2000; 19: 150–157OpenUrlFREE Full Text13.↵Boerma WG, van der Zee J, Fleming DM. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997; 47: 481–486OpenUrlMedlineWeb of Science14.↵Gervas J, Perez FM, Starfield BH. Primary care, financing and gatekeeping in western Europe. Fam Pract 1994; 11: 307–317OpenUrlFREE Full Text15.↵Forrest CB, Glade GB, Starfield B, Baker A, Kang M, Reid RJ. Gatekeeping and referral of children and adolescents to specialty care. Pediatrics 1999; 104: 28–34OpenUrlFREE Full Text16.↵Forrest CB, Nutting P, Starfield B, von Schrader S, Rohde C. Managed health plan effects on the specialty referral process: results from the ASPN referral study. Med Care 2003; 41: 242–253OpenUrlCrossRefMedlineWeb of Science17.↵Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health 1989; 79: 1628–1632OpenUrlFREE Full Text18.Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract 1991; 32: 167–174OpenUrlMedlineWeb of Science19.↵Ferris TG, Perrin JM, Manganello JA, Chang Y, Causino N, Blumenthal D. Switching to gatekeeping: changes in expenditures and utilization for children. Pediatrics 2001; 108: 283–290OpenUrlFREE Full Text20.↵Ferris TG, Chang Y, Blumenthal D, Pearson SD. Leaving gatekeeping behind—effects of opening access to specialists for adults in a health maintenance organization. N Engl J Med 2001; 345: 1312–1317OpenUrlCrossRefMedlineWeb of Science21.↵Kralewski JE, Rich EC, Feldman R, Dowd BE, Bernhardt T, Johnson C, et al. The effects of medical group practice and physician payment methods on costs of care. Heatlth Serv Res 2000; 35: 591–613OpenUrl22.↵Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians' specialty referral decisions. J Fam Pract 2001; 50: 427–432OpenUrlMedlineWeb of Science23.↵Moore SH, Martin DP, Richardson WC. Does the primary-care gatekeeper control the costs of health care? Lessons from the SAFECO experience. N Engl J Med 1983; 309: 1400–1404OpenUrlMedlineWeb of Science24.↵Surender R, Bradlow J, Coulter A, Doll H, Brown SS. Prospective study of trends in referral patterns in fundholding and non-fundholding practices in the Oxford region, 1990–4. BMJ 1995; 311: 1205–1208OpenUrlFREE Full Text
This paper presents a geographic information system (GIS) based floating catchment method for identifying physician shortage areas. The traditional designation methods are primarily regional availability measures, which use administrative boundaries such as counties as the basic spatial units for calculating physician to population ratios and designate shortage based on those ratios. Such approaches have been criticized for their inability to account for either the spatial variations of population demand and physician supply within those boundaries or for population-physician interactions across them. The floating catchment method addresses the internal spatial distribution problem by deriving population data from a smaller unit, the census tract. The potential cross border patient-physician interaction is taken into consideration by using circles of reasonable radius around each census tract centroid as the basic spatial units, which can encompass areas on either side of an administrative border. By varying the radius of the catchment circle, this paper demonstrates that the physician to population ratio is scale dependent and that the greatest variability of the ratios and shortages occur at the most local scales (< 20 miles), which argues for using finer spatial resolution data in shortage designation practice.
The recent decade has witnessed a new wave of development in the place-based accessibility theory, revolving around the two-step floating catchment area (2SFCA) method. The 2SFCA method, initially serving to evaluate the spatial inequity of health care services, has been further applied to other urban planning and facility access issues. Among these applications, different distance decay functions have been incorporated in the thread of model development, but their applicability and limitations have not been thoroughly examined. To this end, the paper has employed a place-based accessibility framework to compare the performance of twenty-four 2SFCA models in a comprehensive manner. Two important conclusions are drawn from this analysis: on a small analysis scale (e.g., community level), the catchment size is the most critical model component; on a large analysis scale (e.g., statewide), the distance decay function is of elevated importance. In sum, this comparative analysis provides the theoretical support necessary to the choice of the catchment size and the distance decay function in the 2SFCA method. Justification of model parameters through empirical evidence (e.g., field surveys about local travel activities) and model validation through sensitivity analysis are needed in future 2SFCA applications for various urban planning, service delivery, and spatial equity scenarios.
Due to the increasing pressure on resource limitations and the need for efficiency improvements, effective healthcare service planning should analyse trends in citizens’ demand for healthcare services, as well as patients’ choices of healthcare providers, which are determined not only by prestige, but also by physical accessibility and availability. The main objective of the present study is to explore the benefits of adopting the social network analysis (SNA) approach to investigate the determinants of a patient's choice of healthcare provider as a way to support better resource allocation decisions in healthcare systems. For the purpose of the analysis, administrative data was used to track the flow of patients within orthopaedic departments of the Lombardy region (Italy) in 2014. A network was developed with two types of nodes: those of orthopaedic departments in the regional hospitals (114 nodes), and those of municipalities (5092 nodes). Using the Louvain algorithm, the communities and sub-communities were determined on the basis of patients’ choices, without any prior geographical considerations or planned catchment areas. Traditional SNA measures and other novel indicators, specifically developed for this study, were applied: in particular, attractiveness (i.e. the preference that patients assign to a certain department against the others available in the same reference area) and confinement (of demand) (i.e. the degree of the unique use of a certain department). A decision support matrix based on these indicators was defined for decision makers to use in evaluating department profiles, and optimizing the location of services and allocation of resources, while preserving accessibility to care and patients’ preferences. The decision support matrix was also evaluated on the basis of real practice and decisions made by regional healthcare managers.
Limited accessibility measurements of park green spaces (PGSs) have given an account of multiple transportations when people enjoy the services. Considering the varying types and functions of PGSs, this study proposed a multi-mode method that is based on the traditional two-step floating catchment area method and relied on PGS classification to estimate spatial disparity between the supply of PGSs services and residents' demands in accessibility. Choosing the urban center of Wuhan as the study area, comparative analysis of space and statistics were conducted in accessibility between the traditional single-mode and the multi-mode methods. After a sensitive analysis of accessibility with varying travel time thresholds, underserved areas in the urban center were identified on a community level based on the PGS groups. Results indicated that the estimated accessibility average and standard deviation values by single-mode method were slimly higher than that of the multi-mode method. The average and standard deviation values of the accessibility among five time thresholds exhibited slight difference and an increasing trend. The further examination analysis of spatial accessibility in 25-min threshold demonstrated that accessibility presented spatial polarization and that most underserved areas distributed in the eastern and southwestern of the urban center in Wuhan. The findings may provide a more realistic estimation and further the knowledge of access to green spaces to help decision makers developing equal and effective planning policies and strategies.
Objective:
In recent years, the Chinese government has attached great importance to occupational health under the guidance of people-oriented concept. This paper introduces the current status and future development of occupational health in China's Thirteenth Five-Year Plan (13th FYP) period (2016-2020) to promote the cooperation and exchange on occupational health between China and other countries.
Methods:
We collected statistical data about occupational diseases and information addressing occupational diseases. We included all types of official reports, guidelines, policies, and relevant laws published by the Chinese government.
Results:
China has carried out a series of strategies and measures to reduce the incidence of occupational diseases, and has made progress in occupational health protection. However, occupational health in China still faces severe conditions and challenges for occupational diseases that have not been prevented and controlled effectively. To actively promote the future development of occupational health during the 13th FYP period, China has issued a series of important policy documents (such as the Plan for a Healthy China 2030, the 13th FYP for Occupational Disease Prevention and Control, and the 13th FYP for Occupational Health Hazard Prevention and Control) in the last two years.
Conclusion:
The overall situation condition of occupational health in China is still serious. Occupational health in China's 13th FYP period faces a series of challenges, future tasks include plans to add the employer and regulatory levels of occupational health management, and occupational health education and publicity to the current technology-dominated approaches.
Members of the family of spatial-interaction models commonly referred to as gravity models are shown to be misspecified. One result of this misspecification is the occurrence of an undesirable ‘spatial-structure effect’ in estimated distance-decay parameters and this effect is examined in detail. An alternative set of spatial-interaction models is formulated from which more accurate predictions of interactions and more accurate parameter estimates can be obtained. These new interaction models are termed competing destinations models, and estimated distance-decay parameters obtained in their calibration are shown to have a purely behavioural interpretation. The implications of gravity-model misspecification are discussed.
China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an integrated, cooperative primary health-care system, generating knowledge from practice that can support improvements, and bolstered by evidence-based performance indicators and incentives.
Measures of geographic food access overlook an important source of statistical biases, termed the edge effect. The edge effect refers to the fallacy that events contributing to the spatial pattern of an analysis unit may be outside of that unit; thus merely summarizing events within the unit may lead to distortion of the estimation. Food procurement activities can happen beyond existing administrative boundaries. Delineating food access using unit-based metrics may misrepresent the true space within which food stores are accessible. To overcome this problem, this paper proposes a gravity-based accessibility measure to improve unit-based statistical approaches in food access research. In addition, this method accounts for the spatial interaction between food supply (e.g., food items in stock) and demand (e.g., population) as well as how this interaction is mediated by the spatiotemporal separation (e.g., travel time, modality). The method is applied to the case of Franklin County, OH and has revealed the food access inequity for African Americans by modes of transport, including walking, biking, and driving. The analysis of the correlation between mode-specific food access and socioeconomic status (SES) variables reveals that using a single modality in food access research may not fully capture the travel behavior and its relationship with local food environments. With modifications, the proposed method can help evaluate food access for a target population group, such as Supplemental Nutrition Assistance Program (SNAP) users or selected ethnic minorities who may face acute difficulties in procuring economically affordable and culturally appropriate foods.
We examined the uncertainty of the contextual influences on food access through an analytic framework of the uncertain geographic context problem (UGCoP).
We first examined the compounding effects of two kinds of spatiotemporal uncertainties on people’s everyday efforts to procure food and then outlined three key dimensions (food access in real time, temporality of the food environment, and perceived nutrition environment) in which research on food access must improve to better represent the contributing environmental influences that operate at the individual level.
Guidelines to address the UGCoP in future food access research are provided to account for the multidimensional influences of the food environment on dietary behaviors.
Examines some of the many factors which influence the use of health service by consumers. In particular, the spatial aspects of health care and the ways in which the organization of health care delivery can affect utilization are discussed. Methods of analyzing the measuring accessibility to health care facilities are explained, and the effects of distance on utilization, especially in underdeveloped countries, is examined. Examples of health care systems include those from: China, Thailand, the USSR, Britain, and the USA. Particular attention is given to the place of primary health care in servicing the needs of the population, and the role of traditional medicine in some countries. Current phenomena such as privatization and rising costs in health care are also considered. -after Publishers
The two-step floating catchment area (2SFCA) method continues to be a popular measure of spatial accessibility, especially in relation to primary-level health care. Despite its popularity, most applications of the 2SFCA method are limited by the utilisation of only a single catchment size within a small geographic area. This limitation is significant to health policies which are mostly applied at the state or national scale. In this paper, a five-level dynamic catchment size was trialled within the 2SFCA method to all of Australia, with a population's remoteness used to delineate increasing catchment sizes. Initial trial results highlighted two perverse outcomes which were caused by sudden changes in catchment sizes between each level. Further refinement led to trialling an additional three-level catchment sub-type to the 2SFCA method, which created a smoother transition between remoteness levels. This study has demonstrated an effective approach to dynamically apply variable and more appropriate catchment sizes into different types of rural areas, which for the first time enables the 2SFCA method to be suitable for national-level access modelling and its potential application to health policy.
The problem of emergency facility location is a critical component in evacuation planning. The emergence of geographic information systems (GIS) has provided a useful operational platform to assist this issue. A previously overlooked facet is the consideration of a hierarchical structure in the placement of emergency shelters. Due to the fact that survivors' needs change over time during post-disaster evacuations, shelters have now been categorized on a temporal scale based on their functions at different evacuation phases. This article proposes a three-level hierarchical location model for optimizing the placement of earthquake shelters by taking into account this temporal variance. The article not only scrutinizes the modeling procedure but also implements the model in a planning area with many real-world details. Based on the optimization results derived from a GIS context, we have found that the quality of the earthquake response procedure is not only dependent on the placement strategy of shelters, but more importantly on the financial constraints imposed on the planning and construction of these shelters. A discussion has been proposed to balance the trade-off between budget planning and evacuation efficiency. As the first attempt to model the hierarchical configuration of emergency shelters with specific focus on evacuees' escalating sheltering demands, this article will be of great significance in helping policy makers consider both the spatial and financial aspects of the strategic placement of emergency shelters.
In April 2009, the Chinese government announced comprehensive reforms to the health system following more than a decade of piecemeal reform efforts. Popular complaints about high healthcare costs and access difficulties eventually received political attention following the government administration change of 2002 and the SARS outbreak of 2003. However, policy differences between ministries resulted in several years of vigorous and open policy debates involving domestic and international stakeholders as well as citizens who are active in expressing opinions virtually (netizens). The 2009 reforms signalled not only policy recognition of the need for a comprehensive and systemic approach if healthcare was to be transformed, but also charted new approaches to policy-making. While the current reforms are being rapidly implemented, the question arises as to whether the shifts in the policy-making process will continue into the future. Further evaluation of the policy process will require cooperation if not collaboration from the policy actors themselves.
Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.
Spatial accessibility measures are an important policy tool for managing healthcare provision and reducing health inequality. The two-step floating catchment area technique, in common with many alternative methodologies, requires that demand-side population be estimated using spatial interpolation techniques. This article studies the implications of adopting differing spatial representations of population on healthcare accessibility modeling outcomes. Results indicate that a dasymetric model yields lower accessibility scores than a standard pro rata model. More important, the difference is spatially disproportionate, suggesting that the degree of disadvantage experienced in rural areas may be greater than has previously been recognized.
The morphology of a city affects its ecological and socioeconomic functions, and thus how a city is spatially structured has important bearings on urban sustainability. The paper analyzes the spatial pattern of Beijing in relation to its urban functions. Our results show that the 6 concentric ring-roads in Beijing provide a basic framework for the city's overall spatial pattern, and also give its apparent resemblance to the classic concentric zone theory. The paper identifies 5 concentric zones for Beijing based on a suite of urban functions. However, there are significant differences between the urban spatial pattern of Beijing and that depicted in the classic concentric zone theory. The study sheds new light on the urban morphology of one of the major Chinese cities, and provides needed information for developing plans to diffuse urban functions in Beijing.
Government efforts designed to help improve healthcare access rely on accurate measures of accessibility so that resources can be allocated to truly needy areas. In order to capture the interaction between physicians and populations, various access measures have been utilized, including the popular two-step floating catchment area (2SFCA) method. However, despite the many advantages of 2SFCA, the problems associated with using fixed catchment sizes have not been satisfactorily addressed. We propose a new method to dynamically determine physician and population catchment sizes by incrementally increasing the catchment until a base population and a physician-to-population ratio are met. Preliminary application to the ten-county region in northern Illinois has demonstrated that the new method is effective in determining the appropriate catchment sizes across the urban to suburban/rural continuum and has revealed greater detail in spatial variation of accessibility compared to results using fixed catchment sizes.
The general practitioner is the key element within most rural health care delivery systems, virtually controlling referal to higher levels of care as well as providing basic care. In consequence of the progressive urban-based centralization of health care facilities and specialized personnel encouraged by the desire to take advantage of economies of scale in supply, the role of the general practitioner within rural health care delivery has become increasingly crucial. However, the supply of general practitioners in rural areas has not kept pace with demands, and accessibility to physicians has become a pressing issue in many rural areas. Although ‘accessibility’ is not taken to be synonymous with physical or geographical accessibility, the dispersed settlement characteristic of most rural areas elevates the latter to a position of primary importance. Following a discussion of the merits of measures of accessibility based upon utilization versus measures based upon the relative location of population and physicians, a measure on potential physical accessibility is presented and applied to a Canadian data set. The results suggest that although considerable differences in potential accessibility exist between rural areas near and far from urban centres, the smaller catchment populations of most rural general practitioners may partly compensate for isolation from major, urban concentrations of physicians.
Although social programs intend to provide equal access for all, in the final evaluation, fairness of the distribution of services is usually dictated by location. Measuring and predicting access to social services can help these programs adjust and better accommodate under-served regions. A method is proposed which delineates the service area of providers delivering social services and produces a probability metric that maps the equity of the program of services for each household. We begin with a computationally trivial method for delineating service areas, map the probability of households being served, and propose an adjustment process, an allocation, to level access to services. We argue such methods can serve to better locate service providers and insure equity when implementing social programs.
Preventive healthcare aims at reducing the likelihood and severity of potentially life-threatening illnesses by protection and early detection. The level of participation to preventive healthcare programs is a crucial factor in terms of their effectiveness and efficiency. This paper provides a methodology for designing a network of preventive healthcare facilities so as to maximize participation. The number of facilities to be established and the location of each facility are the main determinants of the configuration of a healthcare facility network. We use the total (travel, waiting and service) time required for receiving the preventive service as a proxy for accessibility of a healthcare facility, and assume that each client would seek the services of the facility with minimum expected total time. At each facility, which we model as an M/M/1 queue so as to capture the level of congestion, the expected number of participants from each population zone decreases with the expected total time. In order to ensure service quality, the facilities cannot be operated unless their level of activity exceeds a minimum workload requirement. The arising mathematical formulation is highly nonlinear, and hence we provide a heuristic solution framework for this problem. Four heuristics are compared in terms of accuracy and computational requirements. The most efficient heuristic is utilized in solving a real life problem that involves the breast cancer screening center network in Montreal. In the context of this case, we found out that centralizing the total system capacity at the locations preferred by clients is a more effective strategy than decentralization by the use of a larger number of smaller facilities. We also show that the proposed methodology can be used in making the investment trade-off between expanding the total system capacity and changing the behavior of potential clients toward preventive healthcare programs by advertisement and education.
This study evaluates the role of black residential segregation and spatial access to health care in explaining the variation in late-stage diagnosis of breast cancer in metropolitan Detroit. Data pertaining to female breast cancer from 1998 to 2002 are obtained from the Michigan Cancer Surveillance Program. An isolation index is used to assess black segregation. The 2-step floating catchment area approach integrated with a Gaussian function is used to estimate the health care access. While socioeconomic factors at ZIP code level are controlled, ordinary least squares and spatial lag models are used to explore the association between the rates of late-stage diagnosis and segregation and health care access. Results suggest that living in areas with greater black segregation and poorer mammography access significantly increases the risk of late diagnosis of breast cancer. Disadvantaged populations including those with low socioeconomic status or sociocultural barriers tend to experience high rates of late diagnosis. Findings emphasize the need for heightened screening, surveillance, and intervention programs in these areas.
In this paper the examination of the modifiable areal unit problem is extended into multivariate statistical analysis. In an investigation of the parameter estimates from a multiple linear regression model and a multiple logit regression model, conclusions are drawn about the sensitivity of such estimates to variations in scale and zoning systems. The modifiable areal unit problem is shown to be essentially unpredictable in its intensity and effects in multivariate statistical analysis and is therefore a much greater problem than in univariate or bivariate analysis. The results of this analysis are rather depressing in that they provide strong evidence of the unreliability of any multivariate analysis undertaken with data from areal units. Given that such analyses can only be expected to increase with the imminent availability of new census data both in the United Kingdom and in the USA, and the current proliferation of GIS (geographical information system) technology which permits even more access to aggregated data, this paper serves as a topical warning.
This paper presents a new technique for describing inequality of access to medical care. Access is described by the empirical relationship between need and the probability of entering the health care system for treatment. The need-entry probability relationship for one population group is compared with that for another population group to determine the extent of access differentials (differences in entry probabilities) at varying levels of need. As an illustrative application, the technique is employed to describe access differentials by economic class in six different geographic areas located in five different countries (Canada, England, Finland, Poland, United States) with differently structured health care systems. Although the findings for adults varied considerably from area to area, the access differentials among children were surprisingly consistent and unrelated to health care system structure. In particular, it appears that higher family income is associated with greater access to medical care among children at all levels of need. The paper concludes with suggestions for further applications of the proposed technique to problems of monitoring and evaluating the effectiveness of policies aimed at reducing the extent of access inequality.
The strengthening of primary health care is an important issue in health policy in The netherlands. The stimulation of co-operation and cohesion within primary health care and, in particular, the stimulation of integrated health centres is supposed to be an important mean to reduce the expansive growth of expenditures in the so-called second line (mainly medical specialists and hospitals). This article first describes recent trends in co-operation within primary health care and referral rates. For a better understanding of the issue in the context of the Dutch health care system we will also describe some of the rationale of the government policy to strengthen primary health care. In the second part results are presented of a study carried out to test if differences in referral rates among GPs in different practice settings can be explained by structural factors.
The inequitable geographic distribution of health care resources has long been recognized as a problem in the United States. Traditional measures, such as a simple ratio of supply to demand in an area or distance to the closest provider, are easy measures for spatial accessibility. However the former one does not consider interactions between patients and providers across administrative borders and the latter does not account for the demand side, that is, the competition for the supply. With advancements in GIS, however, better measures of geographic accessibility, variants of a gravity model, have been applied. Among them are (1) a two-step floating catchment area (2SFCA) method and (2) a kernel density (KD) method. This microscopic study compared these two GIS-based measures of accessibility in our case study of dialysis service centers in Chicago. Our comparison study found a significant mismatch of the accessibility ratios between the two methods. Overall, the 2SFCA method produced better accessibility ratios. There is room for further improvement of the 2SFCA method-varying the radius of service area according to the type of provider or the type of neighborhood and determining the appropriate weight equation form-still warrant further study.