Article

Towards Healthy China 2030: Modeling health care accessibility with patient referral

Authors:
  • Business Intelligence Lab, Baidu Research, Beijing, China
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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]. ...
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... 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. ...
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... 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. ...
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... 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. ...
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... 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. ...
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... 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). ...
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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. ...
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... 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. ...
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... [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). ...
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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.
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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
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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.
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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.
Article
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. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e4. doi:10.2105/AJPH.2015.302792).
Article
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
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.
Article
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.