Primary care, social inequalities and all-cause, heart disease and cancer mortality in US counties: a comparison between urban and non-urban areas

Remote health: what are the problems and what can we do about them? Insights from Australia

This article analyses three broad questions: (i) How is 'remote' different from 'rural'?; (ii) How do these differences affect the provision of health care and health outcomes, positively and negatively?; and (iii) What is needed to address these issues and systematise solutions in order to deliver parity of health outcomes?

The Role of Primary Care in Achieving Life's Essential 8: A Scientific Statement From the American Heart Association

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

Persistent Neighborhood Poverty and Breast Cancer Outcomes

IMPORTANCE

Patients with breast cancer residing in socioeconomically disadvantaged communities often face poorer outcomes (eg, mortality) compared with individuals living in neighborhoods without persistent poverty.

OBJECTIVE

To examine persistent neighborhood poverty and breast tumor characteristics, surgical treatment, and mortality.

DESIGN, Setting, and Participants

A retrospective cohort analysis of women aged 18 years or older diagnosed with stage I to III breast cancer between January 1, 2010, and December 31, 2018, and followed up until December 31, 2020, was conducted. Data were obtained from the Surveillance, Epidemiology, and End Results Program, and data analysis was performed from August 2023 to March 2024.

EXPOSURE

Residence in areas affected by persistent poverty is defined as a condition where 20% or more of the population has lived below the poverty level for approximately 30 years.

MAIN OUTCOME AND MEASURES

All-cause and breast cancer-specific mortality.

RESULTS

Among 312 145 patients (mean [SD] age, 61.9 [13.3] years), 20 007 (6.4%) lived in a CT with persistent poverty. Compared with individuals living in areas without persistent poverty, patients residing in persistently impoverished CTs were more likely to identify as Black (8735 of 20 007 [43.7%] vs 29 588 of 292 138 [10.1%]; P < .001) or Hispanic (2605 of 20 007 [13.0%] vs 23 792 of 292 138 [8.1%]; P < .001), and present with more-aggressive tumor characteristics, including higher grade disease, triple-negative breast cancer, and advanced stage. A higher proportion of patients residing in areas with persistent poverty underwent mastectomy and axillary lymph node dissection. Living in a persistently impoverished CT was associated with a higher risk of breast cancer-specific (adjusted hazard ratio [AHR], 1.10; 95% CI, 1.03-1.17) and all-cause (AHR, 1.13; 95% CI, 1.08-1.18) mortality. As early as 3 years following diagnosis, mortality risks diverged for both breast cancer-specific (rate ratio [RR], 1.80; 95% CI, 1.68-1.92) and all-cause (RR, 1.62; 95% CI, 1.56-1.70) mortality.

CONCLUSIONS AND RELEVANCE

In this cohort study of women aged 18 years or older diagnosed with stage I to III breast cancer between 2010 and 2018, living in neighborhoods characterized by persistent poverty had implications on tumor characteristics, surgical management, and mortality.

Association of Primary Care Physician Supply with Population Mortality in South Korea: A Pooled Cross-Sectional Analysis

BACKGROUND

Primary care physicians perform a comprehensive role by providing continuous, patient-centered, and accessible healthcare and establishing connections with specialized care. However, the association between the supply of primary care physicians and mortality rates in South Korea has not been thoroughly investigated.

METHODS

This study utilized data from 229 si-gun-gu in South Korea from 2016 to 2020. The densities of primary care physicians, physicians in functional primary clinics, specialists in primary care facilities, and active physicians per 100,000 people were independent variables. Age-adjusted all-cause mortality and cause-specific mortality rates per 100,000 individuals were the dependent variables. Negative binomial regression, negative binomial regression with a pseudo-panel approach, and geographically weighted regression were used to analyze the data.

RESULTS

Our study revealed a significant negative association between the density of primary care physicians and all-cause mortality. An increase in a primary care physician per 100,000 population was significantly linked to a 0.11% reduction in all-cause mortality (incidence rate ratio, 0.9989; 95% confidence interval, 0.9983-0.9995). Similar associations have been observed between mortality rates owing to cardiovascular diseases, respiratory tract diseases, and traffic accidents.

CONCLUSION

This study provides evidence that having a higher number of primary care physicians in South Korea is associated with lower mortality rates. Future research should consider better indicators that reflect the quality of primary care to better understand its impact on population health outcomes. These findings emphasize the significance of strengthening primary care in the South Korean healthcare system to improve the overall health and wellbeing.

Addressing the GP vocational training crisis in remote Australia: Lessons from the Northern Territory

OBJECTIVE

GP vocational training enrolments are declining Australia-wide and, in the Northern Territory (NT), considered by some as '…the litmus test for the national scene' the decline is precipitous. This research investigates the drivers of declining GP training uptake in the NT and identifies and ranks potential solutions.

SETTING

NT, Australia.

PARTICIPANTS

Ten senior medical students, 6 junior doctors, 11 GP registrars, 11 GP supervisors and 31 stakeholders.

DESIGN

Mixed methods: scoping review of Australian literature mapping key concepts to GP training pathway stages and marketing/communications; secondary data analyses; key informant interviews; and a stakeholder validation/prioritisation workshop. Interview data were thematically analysed. Workshop participants received summarised study findings and participated in structured discussions of potential solutions prior to nominating top five strategies in each of five categories.

RESULTS

Highly prioritised strategies included increasing prevocational training opportunities in primary care and selecting junior doctors interested in rural generalism and long-term NT practice. Also ranked highly were: [Medical School] ensuring adequate infrastructure; [Vocational Training] offering high quality, culturally sensitive, flexible professional and personal support; [General Practice] better remunerating GPs; and [Marketing] ensuring positive aspects such as diversity of experiences and expedited GP career opportunities were promoted.

CONCLUSION

Multifaceted strategies to increase GP training uptake are needed, which target different stages of GP training. Effective action is likely to require multiple strategies with coordinated action by different jurisdictional and national key stakeholder agencies. Foremost amongst the interventions required is the urgent need to expand primary care training opportunities in NT for prevocational doctors.

Disparities in access to primary care are growing wider in Canada

Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.

Comprehensive assessment of resources for prevention and control of chronic and non-communicable diseases in China: a cross-sectional study

OBJECTIVE

This study aims to comprehensively evaluate the resources for prevention and control of chronic and non-communicable diseases (NCDs) in China to provide a reference basis for optimising the resource allocation for prevention and control of NCDs.

METHODS

China Chronic Disease and Risk Factor Surveillance sites and National Demonstration Areas for Integrated Chronic and Non-communicable Disease Prevention and Control (NCDDA) were selected as investigation objects. In December 2021, the district (or county) resource allocation for NCD prevention and control was investigated through the NCDDA management information system. According to the index system of NCD prevention and control, 31 indicators of 6 dimensions were collected, and the weighted technique for order preference by similarity to an ideal solution, weighted rank-sum ratio and fuzzy comprehensive evaluation methods were used for comprehensive evaluation of resources for prevention and control of NCDs.

RESULTS

The 653 districts (or counties) in this study cover 22.96% of China's districts (or counties). The top three weights were full-time staff for NCD prevention and control (0.1066), the amount of funds for NCD prevention and control (0.0967), and the coverage rate of districts (or counties) establishing chronic obstructive pulmonary disease surveillance information system (0.0886). The comprehensive evaluation results for the resources for prevention and control of NCDs by the three methods were basically the same. The results of fuzzy comprehensive evaluation showed that the resource allocation in urban areas (0.9268) was better than that in rural areas (0.3257), the one in eastern region (0.9016) was better than that in central (0.3844) and western regions (0.3868), and the one in NCDDA (0.9625) was better than that in non-NCDDA (0.2901).

CONCLUSION

The resources in China for NCD prevention and control differ among different regions, which should be taken into account in future policymaking and resource allocation.

Income and rural-urban status moderate the association between income inequality and life expectancy in US census tracts

BACKGROUND

A preponderance of evidence suggests that higher income inequality is associated with poorer population health, yet recent research suggests that this association may vary based on other social determinants, such as socioeconomic status (SES) and other geographic factors, such as rural-urban status. The objective of this empirical study was to assess the potential for SES and rural-urban status to moderate the association between income inequality and life expectancy (LE) at the census-tract level.

METHODS

Census-tract LE values for 2010-2015 were abstracted from the US Small-area Life Expectancy Estimates Project and linked by census tract to Gini index, a summary measure of income inequality, median household income, and population density for all US census tracts with non-zero populations (n = 66,857). Partial correlation and multivariable linear regression modeling was used to examine the association between Gini index and LE using stratification by median household income and interaction terms to assess statistical significance.

RESULTS

In the four lowest quintiles of income in the four most rural quintiles of census tracts, the associations between LE and Gini index were significant and negative (p between < 0.001 and 0.021). In contrast, the associations between LE and Gini index were significant and positive for the census tracts in the highest income quintiles, regardless of rural-urban status.

CONCLUSION

The magnitude and direction of the association between income inequality and population health depend upon area-level income and, to a lesser extent, on rural-urban status. The rationale behind these unexpected findings remains unclear. Further research is needed to understand the mechanisms driving these patterns.

Access to medication-assisted treatment in the United States: Comparison of travel time to opioid treatment programs and office-based buprenorphine treatment

OBJECTIVES

Disparities in access to medication-assisted treatment are a major problem. This study estimated and compared drive time to the nearest opioid treatment program (OTP) and office-based buprenorphine treatment (OBBT) across the urban-rural continuum in the U.S.

METHODS

Drive time was calculated between the longitude and latitude of population weighted block group centroids and the longitude and latitude of the nearest OTP and OBBT. Rural-Urban Commuting Area (RUCA) codes were used for defining rurality. The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

The mean travel time to the nearest OBBT compared to OTP decreased by 7.18 min (95 % CI = 7.23-7.14) in metropolitan cores, 36.63 min (95 % CI = 37.12-36.15) in micropolitan cores, 38.84 min (95 % CI = 39.57-38.10) in small town cores, and 40.16 min (95 % CI = 40.81-39.50) in rural areas. Additionally, travel burden to the nearest OTP would be more than 60 min for 13,526,605 people and more than 90 min for 5,371,852 people. The travel burden to the nearest OBBT would be more than 60 min for 845,991 people and more than 90 min for 149,297 people.

CONCLUSIONS

The mean drive time to the closest OBBT was significantly smaller than the mean drive time to the closest OTP. Analysis of barriers to access is necessary to devising creative initiatives to improve access to critical opioid use disorder treatment services.

Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil

Objectives. To investigate the role of the Family Health Strategy (FHS) in reducing social inequalities in mortality over a 9-year follow-up period.Methods. We carried out a population-based cohort study of individuals aged 60 years and older from the city of Bagé, Brazil. Of 1593 participants at baseline (2008), 1314 (82.5%) were included in this 9-year follow-up (2017). We assessed type of primary health care (PHC) coverage and other variables at baseline. In 2017, we ascertained 579 deaths through mortality registers. Hazard ratios and their 95% confidence intervals modeled time to death estimated by Cox regression. We also tested the effect modification between PHC and wealth.Results. The FHS had a protective effect on mortality among individuals aged 60 to 64 years, a result not found among those not covered by the FHS. Interaction analysis showed that the FHS modified the effect of wealth on mortality. The FHS protected the poorest from all-cause mortality (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.36, 0.96) and avoidable mortality (HR = 0.46; 95% CI = 0.25, 0.85).Conclusions. FHS coverage reduced social inequalities in mortality among older adults. Our findings highlight the need to guarantee universal health coverage in Brazil by expanding and strengthening the FHS to promote health equity.

Disparities in Access to Opioid Treatment Programs and Office-Based Buprenorphine Treatment Across the Rural-Urban and Area Deprivation Continua: A US Nationwide Small Area Analysis

OBJECTIVES

To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States.

METHODS

Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns.

CONCLUSIONS

The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.

The southern rural health and mortality penalty: A review of regional health inequities in the United States

Rural-urban differences in morbidity and mortality across the United States have been well documented and termed the "rural mortality penalty". However, research studies frequently treat rural areas as homogeneous and often do not account for geospatial variability in rural health risks by both county, state, region, race, and sex within the United States. Additionally, people living in the rural South of the US have higher rates of morbidity and mortality compared to both their urban counterparts and other rural areas. Of those living in southern rural communities, people of color experience higher rates of death and disease compared to white populations. Although there is a wealth of research that uses individual-level behaviors to explain rural-urban health disparities, there is less focus on how community and structural factors influence these differences. This review focuses on the "southern rural health penalty", a term coined by the authors, which refers to the high rate of mortality and morbidity in southern rural areas in the USA compared to both urban areas and non-southern rural places. We use macrosocial determinants of health to explain possible reasons for the "southern rural health penalty". This review can guide future research on rural health between southern and non-southern populations in the US and examine if macrosocial determinants of health can explain health disparities within southern rural populations.

Equity and efficiency of health care resource allocation in Jiangsu Province, China

Background

Jiangsu was one of the first four pilot provinces to engage in comprehensive health care reform in China, which has been on-going for the past 5 years. This study aims to evaluate the equity, efficiency and productivity of health care resource allocation in Jiangsu Province using the most recent data, analyse the causes of deficiencies, and discuss measures to solve these problems.

Methods

Data were extracted from the Jiangsu Health/Family Planning Statistical Yearbook (2015–2019) and Jiangsu Statistical Yearbook (2015–2019). The Gini coefficient (G), Theil index (T) and health resource density index (HRDI) were chosen to study the fairness of health resource allocation in Jiangsu Province. Data envelopment analysis (DEA) and the Malmquist productivity index (MPI) were used to analyse the efficiency and productivity of this allocation.

Results

From 2014 to 2018, the total amount of health resources in Jiangsu Province increased. The G of primary resource allocation by population remained below 0.15, and that by geographical area was between 0.14 and 0.28; additionally, the G of health financial resources was below 0.26, and that by geographical area was above 0.39. T was consistent with the results for G and Lorenz curves. The HRDI shows that the allocated amounts of health care resources were the highest in southern Jiangsu, except for the number of health institutions. The average value of TE was above 0.93, and the DEA results were invalid for only two cities. From 2014 to 2018, the mean TFPC in Jiangsu was less than 1, and the values exceeded 1 for only five cities.

Conclusion

The equity of basic medical resources was better than that of financial resources, and the equity of geographical allocation was better than that of population allocation. The overall efficiency of health care resource allocation was high; however, the total factor productivity of the whole province has declined due to technological regression. Jiangsu Province needs to further optimize the allocation and increase the utilization efficiency of health care resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01320-2.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries

Background

Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare.

Methods

This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access.

Results

The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability.

Conclusions

We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people’s abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

Do financial barriers to access to primary health care increase the risk of poor health? Longitudinal evidence from New Zealand

Primary health care policies in New Zealand, as in many countries, have focused on reducing barriers to access. Financial barriers to obtaining timely health care, while not the only important barriers, are amongst the most important, and are amenable to policy reforms. There is little robust empirical evidence about the extent to which cost related barriers are associated with adverse health outcomes. Past evidence is limited to cross-sectional studies of selected groups, selected primary health care services, and to cross-sectional studies that are susceptible to unmeasured confounding bias. Using fixed effects regression modelling and data from 17,363 participants with at least two observations in three waves (2004-05, 2006-07, 2008-09) of the SoFIE-Health panel data, this study examines the impact of financial barriers to access to primary health care (general practitioner and dentist) on health status using a longitudinal national panel study of adult New Zealanders. Self-rated health (SRH), physical health (PCS) and mental health summary scores (MCS) were the health measures. The two exposures were: not seeing 1) the doctor and 2) the dentist because of cost at least once during the preceding 12 months. We also tested for interactions between the exposure (deferral of care) and age, gender, ethnicity and three health outcomes. For all outcomes, after adjusting for time-varying confounders, health deteriorated as the number of waves increased in which a non-visit was reported. Moreover, the effect size for any health deterioration was greater for deferring a dentist visit than for deferring a physician visit. Except gender and age (for MCS and doctor visits), and gender and ethnicity (for SRH and dentist visits) we did not find any evidence of interactions. These results support policy responses focussed on decreasing financial barriers to access. In the New Zealand context this finding is particularly important for dental care.

Association of primary care physician supply with maternal and child health in China: a national panel dataset, 2012-2017

Background

The Chinese government has been strengthening the primary care system since the launch of the New Healthcare System Reform in 2009. Among all endeavors, the most obvious and significant improvement lays in maternal and child health. This study was designed to explore the association of primary care physician supply with maternal and child health outcomes in China, and provide policy suggestions to the law makers.

Methods

Six-year panel dataset of 31 provinces in China from 2012 to 2017 was used to conduct the longitudinal ecological study. Linear fixed effects regression model was applied to explore the association of primary care physician supply with the metrics of maternal and child health outcomes while controlling for specialty care physician supply and socio-economic covariates. Stratified analysis was used to test whether this association varies across different regions in China.

Results

The number of primary care physicians per 10,000 population increased from 15.56 (95% CI: 13.66 to 17.47) to 16.08 (95% CI: 13.86 to 18.29) from 2012 to 2017. The increase of one primary care physician per 10,000 population was associated with 5.26 reduction in maternal mortality per 100,000 live births (95% CI: − 6.745 to − 3.774), 0.106% (95% CI: − 0.189 to − 0.023) decrease in low birth weight, and 0.419 decline (95% CI: − 0.564 to − 0.273) in perinatal mortality per 1000 live births while other variables were held constant. The association was particularly prominent in the less-developed western China compared to the developed eastern and central China.

Conclusion

The sufficient supply of primary care physician was associated with improved maternal and child health outcomes in China, especially in the less-developed western region. Policies on effective and proportional allocation of resources should be made and conducted to strengthen primary care system and eliminate geographical disparities.

Do Polish primary care physicians meet the expectations of their patients? An analysis of Polish QUALICOPC data

Background

Meeting the expectations of patients is one of the most crucial criteria when assessing the quality of a healthcare system. This study aimed to compare the expectations and experiences of patients of primary care in Poland and to identify key patient characteristics affecting these outlooks.

Methods

The study was performed within the framework of the international Quality and Costs of Primary Care in Europe (QUALICOPC) cross-sectional, questionnaire-based study. In Poland, a nationally representative sample of 2218 patients were recruited to take part in the study. As a study tool, we used data from two of four QUALICOPC questionnaires: “Patient Experience” and “Patient Values”.

Results

Patients’ expectations were fulfilled in all study areas: accessibility, continuity, quality of care, and equity. We observed that the highest-met expectations indexes were in the area of quality of care, while the lowest, but still with a positive value, were in the area of accessibility. Patient-doctor communication was the aspect most valued by study participants. Elements of the patient’s own level of engagement during the consultation were ranked as less essential.

Conclusions

Comparing patient experiences to their values allows us to identify areas for improvement that are prioritized by patients. Accessibility is recognized as the most important area by Polish patients, simultaneously showing the highest level of patient-perceived improvement potential. Interpersonal care is another domain, in which the needs of patients are satisfied but are also relatively high. Strong clinician-patient relationships seem to be a priority in patients’ expectations. The continuous efforts in interpersonal communication skills training for primary care physicians should be upgraded.

The association between the supply and utilization of community-based primary care and child health in a context of hospital-oriented healthcare system in urban districts of Guangdong, China: a panel dataset, 2014-2016

Background

Since 2009, the Chinese government has been reforming the healthcare system and has committed to reinforcing increased use of primary care. To date, however, the Chinese healthcare system is still heavily reliant on hospital-based specialty care. Studies consistently show an association between primary care and improved health outcomes, and the same association is also found among the disadvantaged population. Due to the “hukou” system, interprovincial migrants in the urban districts are put in a weak position and become the disadvantaged. Therefore, the aim of this study is to investigate whether greater supply and utilization of primary care was associated with reduced child mortality among the entire population and the interprovincial migrants in urban districts of Guangdong province, China.

Methods

An ecological study was conducted using a 3-year panel data with repeated measurements within urban districts in Guangdong province from 2014 to 2016, with 178 observations in total. Multilevel linear mixed effects models were applied to explore the associations.

Results

Higher visit proportion to primary care was associated with reductions in the infant mortality rate and the under-five mortality rate in both the entire population and the interprovincial migrants (p < 0.05) in the full models. The association between visit proportion to primary care and reduced neonatal mortality rate was significant among the entire population (p < 0.05) while it was insignificant among the interprovincial migrants (p > 0.05).

Conclusions

Our ecological study based in urban districts of Guangdong province found consistent associations between higher visit proportion to primary care and improvements in child health among the entire population and the interprovincial migrants, suggesting that China should continue to strengthen and develop the primary care system. The findings from China adds to the previously reported evidence on the association between primary care and improved health, especially that of the disadvantaged.

Cancer screening among racial/ethnic groups in health centers

Background

Underserved and low-income population are placed at a disadvantage for receiving necessary cancer screenings. This study aims to measure the rates of receiving three types of cancer screening services, Pap test, mammogram and colorectal cancer screening, among patients seen at U.S. health centers (HCs) to investigate if cancer screening among patients varies by race/ethnicity.

Methods

We analyzed data from the 2014 U.S. Health Center Patient Survey, and included samples age 21 and above. We examined three cancer screening indicators as our dependent variables including cervical, breast, and colorectal cancer screening. Logistic regressions were used to assess the racial/ethnic disparities on cancer screening, while controlling for potentially confounding factors.

Results

The rates of receiving three types of cancer screening were comparable and even higher among HC patients than those for the U.S. general population. Both bivariate and multivariate results showed there were racial/ethnic differences in the likelihood of receiving cancer screening services. However, the differences did not favor non-Hispanic Whites. African Americans had higher odds than Whites (OR: 1.92, 95% CI: 1.44–2.55, p < 0.001) of receiving Pap tests. Similar results were also found in measures of the receipt of mammogram (OR = 1.96, 95% CI: 1.46–2.64, P < 0.001) and colorectal cancer screening (OR = 1.28, 95% CI: 1.02–1.60, p < 0.05).

Conclusion

The current study presents U.S. nationally representative estimates and imply that HCs are helping fulfill an important role as a health care safety-net in reducing racial/ethnic disparities in the delivery of cancer screening services.

The disequilibrium in the distribution of the primary health workforce among eight economic regions and between rural and urban areas in China

Background

Equity is one of the major goals of China’s new medical reforms launched in 2009. This study aimed to analyze the disequilibrium in primary health care (PHC) workforce among various economic zones in China and to compare the fairness between urban and rural areas since the implementation of the new medical reforms.

Method

According to China’s 11th Five-Year Plan, China is divided into eight economic regions. The data of this study were obtained from China Statistical Yearbook 2009–2016. The Atkinson index was used to depict the trend of PHC workforce fairness; the Gini coefficient was used to compare the fairness of workforce distribution between urban and rural areas; the health resource agglomeration degree was used to analyze the distributional equity of the workforce in the eight regions; and the Theil Index was used to compare the fairness of urban and rural workforce distribution across eight regions.

Result

The Atkinson index indicated that the equity of the entire PHC workforce allocation had generally improved during the new medical reforms; the Gini coefficient indicated that the fairness of the entire workforce allocation had improved in cities, but only the nurse allocation became fairer in rural areas. The agglomeration degree and the Theil index indicated that the fairness gaps across the eight regions were still large. These analyses differed from previous studies where China was divided into western, central and eastern regions. In what was previously defined as eastern region, the northeast was under-resourced, while the eastern coastal areas were observing a resource surplus. In western region, we found that the fairness in the northwest was significantly worse than southwest.

Conclusion

In China, the distribution of healthcare workforce has been improved with continuous effort. The gaps in the distribution of PHC workforce across different economic regions and between urban and rural areas are still large, with different regions facing different problems. The government should consider the population and geographical factors in allocation of PHC workforce, especially nurses.

Access to Primary Care Physicians and Mortality in Washington State: Application of a 2-Step Floating Catchment Area

OBJECTIVE

To measure access to primary care physicians (PCPs) using a 2-step floating catchment area and explore the associations between access to PCPs and mortality related to all-causes, cancers, and heart disease in Washington State.

METHODS

An ecological study employing generalized linear regression models of access to PCPs and mortality rates in 4,761 block groups in Washington State in 2015. To measure access to PCPs, we used a 2-step floating catchment area approach, taking into account area-level population, supply of PCPs, and travel time between PCPs, as well as area-level population with a distance decay function.

RESULTS

A 1-unit increase in PCP access score was associated with a reduction of 4.2 all-cause deaths per 100,000 people controlling for socioeconomic characteristics. A 1-unit increase in PCP access score was associated with a reduction of 2.7 cancer deaths and a reduction of 2.1 heart disease deaths per 100,000 people controlling for socioeconomic characteristics.

CONCLUSIONS

Better access to PCPs was associated with lower mortality from all-causes, cancers, and heart disease. The 2-step floating catchment area approach can help with the identification of PCP shortage areas, the development of rural residency programs, and the expansion of the physician workforce in Washington State and other regions.

Development and validation of the Vietnamese Primary Care Assessment Tool - provider version

Aim:

To adapt the provider version of the Primary Care Assessment Tool (PCAT) for Vietnam and determine its internal consistency and validity.

Background:

There is a growing need to measure and explore the impact of various characteristics of health care systems on the quality of primary care. It would provide the best evidence for policy makers if these evaluations come from both the demand and supply sides of the health care sector. Comparatively more researchers have studied primary care quality from the consumer perspective than from the provider’s perspective. This study aims at the latter.

Method:

Our study translated and adapted the PCAT provider version (PCAT PE) into a Vietnamese version, after which a cross-sectional survey was conducted to examine the feasibility, internal consistency and validity of the Vietnamese PCAT provider version (VN PCAT PE). All general doctors working at 152 commune health centres in Thua Thien Hue province had been selected to participate in the survey.

Findings:

The VN PCAT PE is an instrument for evaluation of primary care in Vietnam with 116 items comprising six scales representing four core primary care domains, and three additional scales representing three derivative domains. From the translation and cultural adaptation stage, two items were combined, two items were removed and one item was added. Six other items were excluded due to problems in item-total correlations. All items have a low non-response or ‘don’t know/don’t remember’ response rate, and there were no floor or ceiling effects. All scales had a Cronbach’s alpha above 0.80, except for the Coordination scale, which still was above the minimum level of 0.70.

Conclusion:

The VN PCAT PE demonstrates adequate internal consistency and validity to be used as an effective tool for measuring the quality of primary care in Vietnam from the provider perspective.

Effect of geographic accessibility to primary care on treatment status of hypertension

Although primary care access is known to be an important factor when seeking care, its effect on individual health risk has not been evaluated by an appropriate spatial measure. This study examined whether geographic accessibility to primary care assessed by a sophisticated form of spatial measure is associated with a risk of hypertension and its treatment status among Japanese people in rural areas, where primary care is not yet established as specialization. We used an enhanced two-step floating catchment area method to calculate the neighborhood residential unit-level primary and secondary care accessibility for 52,029 subjects who participated in the 2015 annual health checkup held at 15 cities in Shimane Prefecture. Their hypertension level and treatment status were examined cross-sectionally with their neighborhood primary care and secondary care accessibility (computed with two separate distance-decay weight: slow and quick) by multivariable logistic regression controlling for demographics and neighborhood income level. The findings showed that greater geographic accessibility to primary care was associated with a decreased risk of hypertension in both slow and quick distance-decay weight, odds ratio (OR) = 0.989 (95% Confidence Interval (CI) = 0.984, 0.994), OR = 0.989 (95%CI = 0.984, 0.993), respectively. On the other hand, better secondary care accessibility was associated with an increased risk of hypertension and untreated hypertension; however, the effect of secondary care was mitigated by the effect of primary care accessibility in both slow and quick distance-decay model, hypertension: OR = 0.974 (95% CI = 0.957, 0.991), OR = 0.981 (95%CI = 0.970, 0.991), untreated hypertension: OR = 0.970 (95%CI = 0.944, 0.996), OR = 0.975 (95%CI = 0.959, 0.991), respectively. In addition, the results revealed that young and fit people were at a higher risk of untreated hypertension, which is a unique finding in the context of the Japanese healthcare system. Our findings indicate the importance of primary care even in Japan, where it is not yet established, and also emphasize the need for a culturally specific perspective in health equity.

The importance of environment: Neighborhood characteristics and parent perceptions of child health

Andersen's Behavioral Model of Health Services Use acknowledges the importance of community and environment in how individuals utilize health-care services. This article questions whether and how environment influences perceptions of health, specifically parents' perceptions of their children's health. Based on data from the 2011-2012 US National Survey of Children's Health, this study investigates how parents' views of their neighborhoods (such as safety, social support, amenities, and detracting elements) shape perceptions of their child's health. Furthermore, the analysis considers how these relationships are similar or different for minority populations. Using ordinal logistic regression, this study demonstrates that neighborhood characteristics influence parents' perceptions of their children's health. Parents who report their neighborhoods as safe, supportive, and having desirable amenities perceive their children to be healthier. Parents living in neighborhoods possessing detracting elements report their children's health as worse. These findings are largely consistent for minority and nonminority neighborhoods. The findings of this study convey the importance of environments to how parents view the health of their children. Improving safety and strengthening social supports within neighborhoods could help to address health concerns. As well, health-care organizations and public health offices should launch initiatives in disadvantaged neighborhoods to address health concerns and disparities.

Patterns of Medicare-funded primary health and specialist consultations in Aboriginal and non-Aboriginal Australians in the two years before hospitalisation for ischaemic heart disease

BACKGROUND

Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality for both Aboriginal and non-Aboriginal Australians. Patterns of primary and specialist care in patients leading up to the first hospitalisation for IHD potentially impact on prevention and subsequent outcomes. We investigated the differences in general practice (GP), specialist and emergency department (ED) consultations, and associated resource use in Aboriginal and non-Aboriginal people in the two years preceding hospitalisation for IHD.

METHODS

Linked-data were used to identify first IHD admissions for Western Australians aged 25-74 years in 2002-2007. Person-linked GP, specialist and ED consultations were obtained from the Medicare Benefits Schedule (MBS) and ED records to assess health care access and costs for the preceding 2 years.

RESULTS

Aboriginal people constituted 4.7% of 27,230 IHD patients, 3.5% of 1,348,238 MBS records, and 14% of 33,170 ED presentations. Aboriginal (vs. non-Aboriginal) people were younger (mean 50.2 vs 60.5 years), more commonly women (45.2% vs 28.4%), had more comorbidities [Charlson index≥1, 35.2% vs 26.3%], were more likely to have had GP visits (adjusted rate-ratio 1.07, 95% CI 1.02-1.12), long/prolonged (16.0% vs 11.9%) consults and non-vocationally registered GP consults (17.1% vs 3.2%), but less likely to received specialist consults (mean 1.0 vs 4.1). Mean number of urgent/semi-urgent ED presentations in the year preceding the IHD admission was higher in Aboriginal people (2.9 vs 1.9). Aboriginal people incurred 2.7% of total associated MBS expenditure (estimated at $59.7 million). Mean total cost per person was 43.3% lower in Aboriginal patients, with cost differentials being greatest in diabetic and chronic kidney disease patients.

CONCLUSIONS

Despite being over-represented in urgent/semi-urgent ED presentations and admissions for IHD, Aboriginal people were under-resourced compared with the rest of the population, particularly in terms of specialist care prior to first IHD hospitalisation. The findings underscore the need for better primary and specialist shared care delivery models particularly for Aboriginal people.

Primary care and survival among American Indian patients with diabetes in the Southwest United States: Evaluation of a cohort study at Gallup Indian Medical Center, 2009-2016

OBJECTIVES

To evaluate the role of primary care healthcare delivery on survival for American Indian patients with diabetes in the southwest United States.

METHODS

Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using a log-rank test and Cox Proportional Hazards analyses.

RESULTS

Of the 2661 patients included in analysis, 286 patients died during the study period. Having visited a primary care provider in the year prior to first admission of the study period was protective against all-cause mortality in unadjusted analysis (HR (95% CI)=0.47 (0.31, 0.73)), and after adjustment. The log-rank test indicated there is a significant difference in overall survival by primary care engagement history prior to admission (p<0.001). The median survival time for patients who had seen a primary care provider was 2322days versus 2158days for those who had not seen a primary care provider.

CONCLUSIONS

Compared with those who did not see a primary care provider in the year prior to admission, having seen a primary care provider was associated with improved survival after admission.

Racial Disparities In Geographic Access To Primary Care In Philadelphia

Primary care is often thought of as the gateway to improved health outcomes and can lead to more efficient use of health care resources. Because of primary care's cardinal importance, adequate access is an important health policy priority. In densely populated urban areas, spatial access to primary care providers across neighborhoods is poorly understood. We examined spatial variation in primary care access in Philadelphia, Pennsylvania. We calculated ratios of adults per primary care provider for each census tract and included buffer zones based on prespecified drive times around each tract. We found that the average ratio was 1,073; the supply of primary care providers varied widely across census tracts, ranging from 105 to 10,321. We identified six areas of Philadelphia that have much lower spatial accessibility to primary care relative to the rest of the city. After adjustment for sociodemographic and insurance characteristics, the odds of being in a low-access area were twenty-eight times greater for census tracts with a high proportion of African Americans than in tracts with a low proportion of African Americans.

Utilization of cardiovascular medicines and cardiovascular mortality in Lithuania, Sweden and Norway in 2003-2012

OBJECTIVE

The aim of this ecological study was to evaluate whether any changes in cardiovascular (CV) medicine utilization, population, socioeconomic and health system factors were associated with CV mortality in Lithuania, Sweden and Norway in 2003-2012.

MATERIALS AND METHODS

CV drug utilization was calculated using the Anatomical Therapeutic Chemical/Defined Daily Dose (DDD) methodology and expressed as a number of DDD per 1000 inhabitants per day (DDD/TID). The CV age-standardized death rate (CV-SDR) and risk factors data were obtained from the WHO, EUROSTAT, and FAOSTAT databases. The multiple linear regression model was used for modeling outcome measures - the relationship between the CV-SDR and CV medicine utilization including socioeconomic (GDP, unemployment and divorce rate), population (alcohol consumption, smoking and amount of kcal per day, consumption of fruit and vegetables, health status self-evaluation) and health system factors (number of hospital beds, practicing physicians and health care expenditure).

RESULTS

The higher CV medicine utilization in Sweden (307-455 DDD/TID, P<0.001) and Norway (306-394 DDD/TID, P<0.001) was associated with a definite decline in CV-SDR (in Norway from 215 to 146 and in Sweden from 233 to 174). In Lithuania, the increasing but lower consumption of CV medicines (135-360 DDD/TID, P<0.001) and twice higher CV-SDR (from 541 to 447) was registered. A significant inverse correlation was observed between CV-SDR and DDD/TID. We found a strong association between the DDD/TID and the CV-SDR (R²=0.67, P<0.001). There was a strong correlation between CV-SDR and nine factors (P<0.05), except the number of practicing physicians, amount of kcal per day. There was a strong correlation between DDD/TID and nine factors (P<0.05), except the unemployment rate and amount of kcal per day. Association between an increase in the use of medicines and a decrease in CV-SDR was stronger in the case of higher alcohol consumption, higher number of available beds in hospitals and the lower unemployment rate.

CONCLUSIONS

We confirmed the strong negative correlation between CV medicine utilization and CV mortality in all countries. The strong correlation was found between CV-SDR and nine factors, also between the use of CV medicines and nine factors. The impact of factors on the medicines induced decrease in CV-SDR showed the stronger influence in case of lower unemployment, higher alcohol consumption and higher number of beds for hospitalization.

The Role of Community Health Centers in Reducing Racial Disparities in Spatial Access to Primary Care

INTRODUCTION

Racial minorities are more likely to live in primary care shortage areas. We sought to understand community health centers' (CHCs) role in reducing disparities.

METHODS

We surveyed all primary care practices in an urban area, identified low access areas, and examined how CHCs influence spatial accessibility.

RESULTS

Census tracts with higher rates of public insurance (≥40% vs <10%, odds ratio [OR] = 31.06, P < .001; 30-39% vs 10%, OR = 7.84, P = 0.001) were more likely to be near a CHC and those with moderate rates of uninsurance (10%-19% vs <10%, OR = 0.42, P = .045) were less likely. Racial composition was not associated with proximity. Tracts close to a CHC were less likely (OR = 0.11, P < .0001) to be in a low access area. This association did not differ based on racial composition.

DISCUSSION

Although CHCs were more likely to be in areas with a greater fraction of racial minorities, location was more strongly influenced by public insurance rates. CHCs reduced the likelihood of being in low access areas but the effect did not vary by tract racial composition.

Cross-sectional study of factors associated with community health centre use in a recently urbanised community in Chengdu, China

OBJECTIVES

Public investment in community health centres (CHCs) has been increasing as a response to rapid urbanisation in China. The objectives of this study were: (1) to examine factors associated with CHC use among residents from a recently urbanised community in western China and (2) to describe satisfaction with CHC among users.

DESIGN

Cross-sectional design.

SETTING

A community recently converted to urban status with a newly constructed CHC in Southwest China.

PARTICIPANTS

A random sample of 2259 adults in the Hezuo community in Chengdu, China, completed the survey in 2013.

OUTCOME MEASURES

Trained staff interviewed study participants in their homes using structured questionnaires. The survey included questions regarding sociodemographics, health status, access to and usage of healthcare, health behaviours and CHC use. The Andersen's behavioural model of health service use was used to guide multivariable logistic regression modelling in identifying predisposing, enabling and need factors associated with the likelihood of using CHC. Descriptive statistics were used to describe residents' satisfaction with the CHC.

RESULTS

A total of 71.8% of the respondents reported using the CHC during the past year. Factors influencing adults' CHC use included: gender, marital status, education level and knowledge of one's blood pressure (predisposing factors); annual household per capita income and walking time to the CHC (enabling factors) and self-rated health as well as physical activities (need factors). CHC users reported modest satisfaction across various aspects of the CHC.

CONCLUSIONS

Neighbourhood CHC in urban areas provides important services to these residents living in a recently urbanised community. All three categories of factors in the Andersen model help explain the likelihood of CHC use. There is much room for improvement in CHC to enhance customer satisfaction. Future research is needed to improve access to CHCs and promote their use in urbanised populations with low to modest education.

Metrics for monitoring cancer inequities: residential segregation, the Index of Concentration at the Extremes (ICE), and breast cancer estrogen receptor status (USA, 1992-2012)

PURPOSE

To address the paucity of evidence on residential segregation and cancer, we explored their relationship using a new metric: the Index of Concentration at the Extremes (ICE). We focused on breast cancer estrogen receptor (ER) status, a biomarker associated with survival and, etiologically, with social and economic privilege.

METHODS

We obtained data from the 13 registry group of US Surveillance, Epidemiology, and End Results (SEER) program for 1992-2012 on all women aged 25-84 who were diagnosed with primary invasive breast cancer (n = 516,382). We appended to each case's record her annual county median household income quintile and the quintile for her annual county value for ICE measures for income (≤20th vs. ≥80th household income quintile), race/ethnicity (black vs. white), and income plus race/ethnicity (low-income black vs. high-income white). The odds of being ER+ versus ER- were estimated in relation to the county-level income and ICE measures, adjusting for relevant covariates.

RESULTS

Women in the most privileged versus deprived county quintile for household income and for all three ICE measures had a 1.1- to 1.3-fold increased odds (95 % confidence intervals excluding 1) of having an ER+ tumor. These results were robust to adjustment for age at diagnosis, cancer registry, tumor characteristics (tumor stage, size, histology, grade), and race/ethnicity.

CONCLUSION

A focus on segregation offers news possibilities for understanding how inequitable group relations contribute to cancer inequities. The utility of employing the ICE for monitoring cancer inequities should be investigated in relation to other cancer outcomes.

Racial/Ethnic Disparities in Primary Care Quality Among Type 2 Diabetes Patients, Medical Expenditure Panel Survey, 2012

INTRODUCTION

Racial and ethnic disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications and mortality rates, and the quality of diabetes care among Americans. We explored racial and ethnic disparities in primary care quality among Americans with type 2 diabetes.

METHODS

We analyzed data on adults with type 2 diabetes derived from the household component of the 2012 Medical Expenditure Panel Survey. Multiple regression and multivariate logistic regressions were used to examine the association between race/ethnicity and primary care attributes related to first contact, longitudinality, comprehensiveness, and coordination, and clusters of confounding factors were added sequentially.

RESULTS

Preliminary findings indicated differences in primary care quality between racial/ethnic minorities and whites across measures of first contact, longitudinality, comprehensiveness, and coordination. After controlling for confounding factors, these differences were no longer apparent; all racial/ethnic categories showed similar rates of primary care quality according to the 4 primary care domains of interest in the study.

CONCLUSION

Results indicate equitable primary care quality for type 2 diabetes patients across 4 key domains of primary care after controlling for socioeconomic characteristics. Additional research is necessary to support these findings, particularly when considering smaller racial/ethnic groups and investigating outcomes related to diabetes.

A Persistent Disparity: Smoking in Rural Sexual and Gender Minorities

PURPOSE

Sexual and gender minorities (SGM) smoke cigarettes at higher rates than the general population. Historically, research in SGM health issues was conducted in urban populations and recent population-based studies seldom have sufficient SGM participants to distinguish urban from rural. Given that rural populations also tend to have a smoking disparity, and that many SGM live in rural areas, it is vitally important to understand the intersection of rural residence, SGM identity, and smoking. This study analyzes the patterns of smoking in urban and rural SGM in a large sample.

METHODS

We conducted an analysis of 4280 adult participants in the Out, Proud, and Healthy project with complete data on SGM status, smoking status, and zip code. Surveys were conducted at 6 Missouri Pride Festivals and online in 2012. Analysis involved descriptive and bivariate methods, and multivariable logistic regression. We used GIS mapping to demonstrate the dispersion of rural SGM participants.

RESULTS

SGM had higher smoking proportion than the non-SGM recruited from these settings. In the multivariable model, SGM identity conferred 1.35 times the odds of being a current smoker when controlled for covariates. Rural residence was not independently significant, demonstrating the persistence of the smoking disparity in rural SGM. Mapping revealed widespread distribution of SGM in rural areas.

CONCLUSION

The SGM smoking disparity persists among rural SGM. These communities would benefit from continued research into interventions targeting both SGM and rural tobacco control measures. Recruitment at Pride Festivals may provide a venue for reaching rural SGM for intervention.

Association between Temporal Changes in Primary Care Workforce and Patient Outcomes

OBJECTIVE

To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes.

DATA SOURCES

2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims.

STUDY DESIGN/METHODS

We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models.

PRINCIPAL FINDINGS

An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p < .05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p < .05).

CONCLUSIONS

Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.

Relation between primary care physician supply and diabetes care and outcomes: a cross-sectional study

BACKGROUND

Higher primary care physician supply is associated with lower mortality due to heart disease, cancer and stroke, but its relation to diabetes care and outcomes is unknown. We examined the association between primary care physician supply and evidence-based testing and hospital visits for people with diabetes in naturally occurring multispecialty physician networks in Ontario, Canada.

METHODS

We conducted a cross-sectional analysis between Apr. 1, 2009, and Mar. 31, 2011, using linked administrative data. We included all Ontario residents over 40 years of age with a diagnosis of diabetes before Apr. 1, 2007, who were alive on Apr. 1, 2009 (N = 712 681). We tested the association between physician supply and outcomes at the network level using separate Poisson regression models for urban and nonurban physician networks. We accounted for clustering at the physician and network level and adjusted for patient characteristics.

RESULTS

Patients in physician networks with a high supply of primary care physicians were more likely to receive the optimal number of evidence-based tests for diabetes than patients in networks with low primary care physician supply (urban relative risk [RR] 1.06, 95% confidence interval [CI] 1.04-1.07; nonurban RR 1.17, 95% CI 1.14-1.21) but were no different regarding emergency department visits (urban RR 1.05, 95% CI 0.94-1.17; nonurban RR 0.96, 95% CI 0.85-1.08) or hospital admissions for diabetes complications (urban RR 1.01, 95% CI 0.89-1.14; nonurban RR 0.91, 95% CI 0.77-1.07).

INTERPRETATION

Having more primary care physicians per capita is associated with better diabetes care but not with reduced hospital visits in this setting. Further research to understand this relation and how it varies by setting is important for resource planning.

Community health centers and primary care access and quality for chronically-ill patients - a case-comparison study of urban Guangdong Province, China

Objective

Reform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the ‘gate-keeper’ CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness.

Methods

The case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients’ demographic and health status characteristics.

Results

Patients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers.

Conclusion

The study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as ‘gate-keepers’) seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients.

Factors Associated with the Competencies of Public Health Workers in Township Hospitals: A Cross-Sectional Survey in Chongqing Municipality, China

Purpose: This study aimed to explore the competencies of public health workers (PHWs) of township hospitals in Chongqing Municipality (China), and determine the related impact factors of the competencies of PHWs; Methods: A cross-sectional research was conducted on 314 PHWs from 27 township hospitals in three districts in Chongqing Municipality (China), from June to August 2014. A self-assessment questionnaire was established on the basis of literature reviews and a competency dictionary. The differences in competencies among the three districts were determined by adopting the chi-square test, t-test, analysis of variance (ANOVA) method, and the impact factors of the competencies of PHWs were determined by adopting stepwise regression analysis. Results: (1) Results of the demographic characteristics of PHWs in three sample districts of Chongqing Municipality showed that a significant difference in age of PHWs (p = 0.021 < 0.05) and the majors of PHWs (p = 0.045 < 0.05); (2) In terms of the self-evaluation competency results of PHWs in township hospitals, seven among the 11 aspects were found to have significant differences in the three districts by the ANOVA test; (3) By adopting the t-test and ANOVA method, results of the relationship between the characteristics of PHWs and their competency scores showed that significant differences were found in the economic level (p = 0.000 < 0.05), age (p = 0.000 < 0.05), years of working (p = 0.000 < 0.05) and title of PHWs (p = 0.000 < 0.05); (4) Stepwise regression analysis was used to determine the impact factors of the competencies of PHWs in township hospitals, including the economic level (p = 0.000 < 0.001), years of working (p = 0.000 < 0.001), title (p = 0.001 < 0.005), and public health major (p = 0.007 < 0.01). Conclusions: The competencies of the township hospital staff in Chongqing Municipality (China), are generally insufficient, therefore, regulating the medical education and training skills of PHWs is crucial to improve the competencies of PHWs in the township hospitals of Chongqing Municipality. The results of this study can be mirrored in other areas of China.

Associations of Provider-to-Population Ratios and Population Health by County-Level Rurality

PURPOSE

To explore the relationship between provider-to-population ratios, rurality and population health in the United States using counties as the unit of analysis.

METHOD

Population ratios for registered nurses (RNs), primary care physicians, and dentists were included in multivariable regression analyses. Population health indices assessed were premature death rate, self-rated health, teen birth rate, and mammography screening rate.

FINDINGS

County levels of health and health care providers per capita declined as rurality increased. In adjusted regression models, the highest RN-to-population ratio was associated with significantly better health measures in most urban/rural categories, with the magnitude of these associations generally increasing as rurality increased. In the smallest rural counties, the highest RN-to-population quartile was associated with 1,655 fewer years of potential life lost (YPLL), 2% lower rates of poor or fair health, 11/1,000 fewer teen births, and 6% more mammography screening relative to the lowest quartile. For primary care physicians, more significant associations were found in medium and small rural counties where the highest quartile was associated with 1,482 fewer YPLL, 3% lower rates of poor or fair health, 7/1,000 fewer teen births, and 4% more mammography screening. The highest quartile of dentist-to-population ratio was generally associated with lower rates of premature death and poor or fair health in urban, large-, and medium-sized rural counties, but not in small rural counties.

CONCLUSIONS

The consistency of the results by provider type suggests that the supply of health care professionals, particularly in rural areas, positively impacts the health of the population.

Primary care quality between Traditional Tibetan Medicine and Western Medicine Hospitals: a pilot assessment in Tibet

Introduction

This paper assesses both patients’ perspectives on the differences in primary care quality between traditional Tibetan medicine (TTM) hospitals and western medicine (WM) hospitals and the efficacy of the government’s investment in these two Prefecture-level primary care structures in Tibet.

Method

A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 692 patients aged over 18 years old, who reported the sampling site was their regular source of health care. T-tests were performed to compare the separate and total primary care attributes between WM hospitals and TTM hospitals. Multiple linear regression analysis was conducted to examine the association of the health care setting with primary care attributes while controlling for socio-demographic, health service use and health status characteristics.

Results

Compared to WM hospitals, the results showed that TTM hospitals had patients who were older (15.8 % versus 8.4 % over 60 years); with lower education levels (66.0 % versus 35.8 % with below junior high school ) and income levels (46.9 % versus 26.5 % with annual household income below 30,000RMB); more likely to be married (79.2 % versus 60.5 %); made less frequent health care visits; and had higher self-rated health status. Overall, patients assessed the primary care performance in TTM hospitals significantly higher (80.0) than WM hospitals (74.63). There were no differences in health care assessment by patient gender, age, income, education, marital status and occupation.

Conclusions

TTM patients reported better primary care experiences than patients using WM hospitals, which validated the government’s investment in traditional Tibetan medicine.

Trend in distribution of primary health care professionals in Jiangsu province of eastern China

Introduction

Since the late 1990s, the Chinese government has carried out several reforms on the primary health care, which is greatly improved but still left much to be desired, especially for the health workforces. The aim of this study was to analyze the number of health workforces and the trends in distribution of health workforces in Jiangsu province of eastern China from 2008 to 2012.

Methods

The time trends in number and distribution of health professionals were compared in study period. Lorenz curves were plotted and Gini coefficient, Atkinson index and Theil index were calculated for inequalities in the distribution of health workforces to population and area.

Results

The number of health workforces increased every year and the inequality in the distribution of health workforces showed a decline trend from 2008 to 2012. After 2009, these trends changed more rapidly. There was the disproportionality between physicians and nurses. The values of three inequality indicators based on area were larger than those based on population.

Conclusion

The health reform in 2009 might play an important role in increasing the number of health workforces and improving the distribution of health workforces in primary health care facilities. The disproportionality between physicians and nurses was related to the shortage of number of nurses.

Costs and clinical quality among Medicare beneficiaries: associations with health center penetration of low-income residents

OBJECTIVE

Determine the association between access to primary care by the underserved and Medicare spending and clinical quality across hospital referral regions (HRRs).

DATA SOURCES

Data on elderly fee-for-service beneficiaries across 306 HRRs came from CMS' Geographic Variation in Medicare Spending and Utilization database (2010). We merged data on number of health center patients (HRSA's Uniform Data System) and number of low-income residents (American Community Survey).

STUDY DESIGN

We estimated access to primary care in each HRR by "health center penetration" (health center patients as a proportion of low-income residents). We calculated total Medicare spending (adjusted for population size, local input prices, and health risk). We assessed clinical quality by preventable hospital admissions, hospital readmissions, and emergency department visits. We sorted HRRs by health center penetration rate and compared spending and quality measures between the high- and low-penetration deciles. We also employed linear regressions to estimate spending and quality measures as a function of health center penetration.

PRINCIPAL FINDINGS

The high-penetration decile had 9.7% lower Medicare spending ($926 per capita, p=0.01) than the low-penetration decile, and no different clinical quality outcomes.

CONCLUSIONS

Compared with elderly fee-for-service beneficiaries residing in areas with low-penetration of health center patients among low-income residents, those residing in high-penetration areas may accrue Medicare cost savings. Limited evidence suggests that these savings do not compromise clinical quality.

Improving outcomes in breast cancer: where should we target our efforts?

Rural-urban differences in health outcomes, including breast cancer, in the US have been studied for decades, but often with inconsistent findings. Possible reasons include methodological differences, lack of prospective investigations, small number of studies overall, and the tendency to measure rurality as a simple patient-level predictor variable. Studies have tended to assume that the same racial/ethnic cancer disparities found in the general population exist in rural regions, but this conclusion may not always be warranted. Needed are better definitions of rurality; the capability to define important predictor variables such as race, ethnicity, education, and income with greater precision than at present; and data revealing the patient's own perspective regarding care decisions. Future studies should examine whether the impact of rurality status on outcomes varies with geographic location by including the appropriate interaction terms in the outcome prediction models, as well as patient-reported reasons that might explain the outcomes observed.

Geographic and racial disparities in breast cancer-related outcomes in Georgia

OBJECTIVE

To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes.

DATA SOURCES/STUDY SETTING

Female patients in Georgia diagnosed with BC in the years 2000-2009.

STUDY DESIGN

Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level.

PRINCIPAL FINDINGS

Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death.

CONCLUSIONS

Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.

Developing a research agenda for cardiovascular disease prevention in high-risk rural communities

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

Chinese primary care physicians and work attitudes

China passed a landmark health care reform in 2009, aimed at improving health care for all citizens by strengthening the primary care system, largely through improvements to infrastructure. However, research has shown that the work attitudes of primary care physicians (PCPs) can greatly affect the stability of the overall workforce and the quality and delivery of health care. The purpose of this study is to investigate the relationship between reported work attitudes of PCPs and their personal, work, and educational characteristics. A multi-stage, complex sampling design was employed to select a sample of 434 PCPs practicing in urban and rural primary care settings, and a survey questionnaire was administered by researchers with sponsorship from the Ministry of Health. Four outcome measures describing work attitudes were used, as well as a number of personal-, work-, and practice-related factors. Findings showed that although most PCPs considered their work as important, a substantial number also reported large workloads, job pressure, and turnover intentions. Findings suggest that policymakers should focus on training and educational opportunities for PCPs and consider ways to ease workload pressures and improve salaries. These policy improvements must accompany reform efforts that are already underway before positive changes in reduced disparities and improved health outcomes can be realized in China.

Experiences with primary healthcare in Fuzhou, urban China, in the context of health sector reform: a mixed methods study

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

The impact of primary healthcare in reducing inequalities in child health outcomes, Bogotá-Colombia: an ecological analysis

BACKGROUND

Colombia is one of the countries with the widest levels of socioeconomic and health inequalities. Bogotá, its capital, faces serious problems of poverty, social disparities and access to health services. A Primary Health Care (PHC) strategy was implemented in 2004 to improve health care and to address the social determinants of such inequalities. This study aimed to evaluate the contribution of the PHC strategy to reducing inequalities in child health outcomes in Bogotá.

METHODS

An ecological analysis with localities as the unit of analysis was carried out. The variable used to capture the socioeconomic status and living standards was the Quality of Life Index (QLI). Concentration curves and concentration indices for four child health outcomes (infant mortality rate (IMR), under-5 mortality rate, prevalence of acute malnutrition in children under-5, and vaccination coverage for diphtheria, pertussis and tetanus) were calculated to measure socioeconomic inequality. Two periods were used to describe possible changes in the magnitude of the inequalities related with the PHC implementation (2003 year before - 2007 year after implementation). The contribution of the PHC intervention was computed by a decomposition analysis carried out on data from 2007.

RESULTS

In both 2003 and 2007, concentration curves and indexes of IMR, under-5 mortality rate and acute malnutrition showed inequalities to the disadvantage of localities with lower QLI. Diphtheria, pertussis and tetanus (DPT) vaccinations were more prevalent among localities with higher QLI in 2003 but were higher in localities with lower QLI in 2007. The variation of the concentration index between 2003 and 2007 indicated reductions in inequality for all of the indicators in the period after the PHC implementation. In 2007, PHC was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-5 mortality (24%), IMR (19%) and acute malnutrition (7%). PHC also contributed approximately 20% to inequality in DPT coverage, favoring the poorer localities.

CONCLUSION

The PHC strategy developed in Bogotá appears to be contributing to reductions of the inequality associated with socioeconomic and living conditions in child health outcomes.

Association of primary care characteristics with variations in mortality rates in England: an observational study

Background

Wide variations in mortality rates persist between different areas in England, despite an overall steady decline. To evaluate a conceptual model that might explain how population and service characteristics influence population mortality variations, an overall null hypothesis was tested: variations in primary healthcare service do not predict variations in mortality at population level, after adjusting for population characteristics.

Methodology/Principal Findings

In an observational study of all 152 English primary care trusts (geographical groupings of population and primary care services, total population 52 million), routinely available published data from 2008 and 2009 were modelled using negative binomial regression. Counts for all-cause, coronary heart disease, all cancers, stroke, and chronic obstructive pulmonary disease mortality were analyzed using explanatory variables of relevant population and service-related characteristics, including an age-correction factor. The main predictors of mortality variations were population characteristics, especially age and socio-economic deprivation. For the service characteristics, a 1% increase in the percentage of patients on a primary care hypertension register was associated with decreases in coronary heart disease mortality of 3% (95% CI 1–4%, p = 0.006) and in stroke mortality of 6% (CI 3–9%, p<0.0001); a 1% increase in the percentage of patients recalling being better able to see their preferred doctor was associated with decreases in chronic obstructive pulmonary disease mortality of 0.7% (CI 0.2–2.0%, p = 0.02) and in all cancer mortality of 0.3% (CI 0.1–0.5%, p = 0.009) (continuity of care). The study found no evidence of an association at primary care trust population level between variations in achievement of pay for performance and mortality.

Conclusions/Significance

Some primary healthcare service characteristics were also associated with variations in mortality at population level, supporting the conceptual model. Health care system reforms should strengthen these characteristics by delivering cost-effective evidence-based interventions to whole populations, and fostering sustained patient-provider partnerships.

Influence of primary care on breast cancer outcomes among Medicare beneficiaries

PURPOSE

We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes.

METHODS

Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations.

RESULTS

Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis.

CONCLUSIONS

Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.