How many miles to the doctor?

Assessing health disparities in breast cancer incidence burden in Tennessee: geospatial analysis

Background

Tennessee women experience the 12th highest breast cancer mortality in the United States. We examined the geographic differences in breast cancer incidence in Tennessee between Appalachian and non-Appalachian counties from 2005 to 2015.

Methods

We used ArcGIS 10.7 geospatial analysis and logistic regression on the Tennessee Cancer Registry incidence data for adult women aged ≥ 18 years (N = 59,287) who were diagnosed with breast cancer from 2005 to 2015 to evaluate distribution patterns by Appalachian county designation. The Tennessee Cancer Registry is a population-based, central cancer registry serving the citizens of Tennessee and was established by Tennessee law to collect and monitor cancer incidence. The main outcome was breast cancer stage at diagnosis. Independent variables were age, race, marital status, type of health insurance, and county of residence.

Results

Majority of the sample were White (85.5%), married (58.6%), aged ≥ 70 (31.3%) and diagnosed with an early stage breast cancer (69.6%). More than half of the women had public health insurance (54.2%), followed by private health insurance coverage (44.4%). Over half of the women resided in non-Appalachian counties, whereas 47.6% were in the Appalachian counties. We observed a significant association among breast cancer patients with respect to marital status and type of health insurance coverage (p =  < 0.0001). While the logistic regression did not show a significant result between county of residence and breast cancer incidence, the spatial analysis revealed geographic differences between Appalachian and non-Appalachian counties. The highest incidence rates of 997.49–1164.59/100,000 were reported in 6 Appalachian counties (Anderson, Blount, Knox, Rhea, Roane, and Van Buren) compared to 3 non-Appalachian counties (Fayette, Marshall, and Williamson).

Conclusions

There is a need to expand resources in Appalachian Tennessee to enhance breast cancer screening and early detection. Using geospatial techniques can further elucidate disparities that may be overlooked in conventional linear analyses to improve women’s cancer health and associated outcomes.

Differences in Travel Time to Cancer Surgery for Colon versus Rectal Cancer in a Rural State: A New Method for Analyzing Time-to-Place Data Using Survival Analysis

PURPOSE

Rectal cancer is rarer than colon cancer and is a technically more difficult tumor for surgeons to remove, thus rectal cancer patients may travel longer for specialized treatment compared to colon cancer patients. The purpose of this study was to evaluate whether travel time for surgery was different for colon versus rectal cancer patients.

METHODS

A secondary data analysis of colorectal cancer (CRC) incidence data from the Iowa Cancer Registry data was conducted. Travel times along a street network from all residential ZIP Codes to all cancer surgery facilities were calculated using a geographic information system. A new method for analyzing "time-to-place" data using the same type of survival analysis method commonly used to analyze "time-to-event" data is introduced. Cox proportional hazard model was used to analyze travel time differences for colon versus rectal cancer patients.

RESULTS

A total of 5,844 CRC patients met inclusion criteria. Median travel time to the nearest surgical facility was 9 minutes, median travel time to the actual cancer surgery facilities was 22 minutes, and the median number of facilities bypassed was 3. Although travel times to the nearest surgery facilities were not significantly different for colon versus rectal cancer patients, rectal cancer patients on average traveled 15 minutes longer to their actual surgery facility and bypassed 2 more facilities to obtain surgery.

DISCUSSION

In general, the survival analysis method used to analyze the time-to-place data as described here could be applied to a wide variety of health services and used to compare travel patterns among different groups.

Lung Cancer Surgical Regionalization Disproportionately Worsens Travel Distance for Rural Patients

PURPOSE

Major cancer surgeries have regionalized to fewer and higher-volume hospitals, with the goal of improving the quality of surgical care. However, regionalization may have negative effects on geographic access to care. We hypothesize that lung cancer patients have been traveling further for surgery over time as regionalization has occurred, and this increased travel has primarily impacted rural patients.

METHODS

A North Carolina all-payer state discharge database was used to capture discharges from 2005 to 2015 for patients undergoing lung cancer resection. Changes in patterns of care over time in high-volume centers (HVC) were examined. Adjusted patient straight-line travel distance was estimated over time and stratified by rural-urban location.

FINDINGS

The number of hospitals performing lung cancer resections decreased from 49 to 31 over the study period (P = .0006), and the proportion of patients receiving care at HVC increased from 23% to 44% (P < .0001). Rural patient travel distance increased over time by 8.5 miles (95% CI: 0.56-17.10, P = .048), from 45.1 to 53.6 miles. There was no change in urban patient travel distance. The difference in adjusted travel distance between rural and urban patients nearly doubled from 2005 to 2015 (9.6 to 17.9 miles,P < .0001).

CONCLUSION

In North Carolina, lung cancer surgical regionalization occurred over the study period and was accompanied by increases in travel distance for rural patients only. Further work is needed to determine the effects of greater travel distance on patterns of cancer care for rural patients.

Comparison of survival of stage I-III colon cancer by travel distance and hospital volume

BACKGROUND

Previous studies have demonstrated improved outcomes at high-volume colorectal surgery centers; however, the benefit for patients who live far from such centers has not been assessed relative to local, low-volume facilities.

METHODS

The 2010-2015 National Cancer Database (NCDB) was queried for patients with stage I-III colon adenocarcinoma undergoing treatment at a single center. A 'local, low-volume' cohort was constructed of 12,768 patients in the bottom quartile of travel distance at the bottom quartile of institution surgical volume and a 'travel, high-volume' cohort of 11,349 patients in the top quartile of travel distance at the top quartile of institution surgical volume.

RESULTS

In unadjusted analysis, patients in the travel cohort had improved rates of positive resection margins (3.7% vs. 5.5%, p < 0.001), adequate lymph-node harvests (92% vs. 83.6%, p < 0.001), and 30- (2.2% vs. 3.9%, p < 0.001) and 90-day mortality (3.7% vs. 6.4%, p < 0.001). On multivariable logistic regression analysis adjusting for patient demographic, tumor, and facility characteristics, the cohorts demonstrated equivalent overall survival (HR: 0.972, p = 0.39), with improved secondary outcomes in the 'travel' cohort of adequate lymph-node harvesting (OR: 0.57, p < 0.001), and 30- (OR 0.79, p = 0.019) and 90-day mortality (OR 0.80, p = 0.004).

CONCLUSIONS

For patients with stage I-III colon cancer, traveling to high-volume institutions compared to local, low-volume centers does not convey an overall survival benefit. However, given advantages including 30- and 90-day mortality and adequate lymph-node harvest, nuanced patient recommendations should consider both these differences and the unquantified benefits to local care, including cost, travel time, and support systems.

Clair CM, Hou JY, Khoury-Collado F, Ananth CV, Neugut AI, Hershman DL, Wright JD. Effect of regionalization of endometrial cancer care on site of care and patient travel

BACKGROUND

Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.

OBJECTIVE

To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.

STUDY DESIGN

We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.

RESULTS

We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both).

CONCLUSION

The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance

As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective

To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants

This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures

Active US dermatologist and physician density.

Results

In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance

Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

Tackling Climate Change Close to Home: Mobile Breast Screening as a Model

Objective

Health services contribute significantly to carbon dioxide (CO2) emissions and, while services in the UK are beginning to address this, the focus has been on reducing energy consumption rather than road transport, a major component of emissions. We aimed to compare the distances travelled by patients attending mobile breast screening clinics compared to the distance they would need to travel if screening services were centralized.

Methods

Anonymized postcode records were analysed to determine driving distances potentially saved through attendance at 20 mobile breast screening clinics rather than at two centralized locations. Based on assumptions for the typical car used, the CO2 emissions were calculated for the current case of decentralized service through mobile clinics compared to a hypothetical case where only centralized services are available over one complete three-year cycle of breast screening invitations.

Results

The availability of mobile breast screening clinics for the 60,675 women who underwent screening over a three-year cycle led to a return journey distance savings of 1,429,908 km. Taking into account the CO2 emissions of the tractor unit used for moving the mobile clinics around, this equates to approximately 75 tonnes of CO2 saved in any one year.

Conclusions

Decentralizing health care delivery can potentially provide substantial reductions in emissions at the same time as improving the patient experience. Thus, the ‘care close to home’ agenda can simultaneously improve health outcomes and the environment.

The geographic distribution of the otolaryngology workforce in the United States

OBJECTIVES

To describe the deployment of otolaryngologists and evaluate factors associated with the geographic distribution of otolaryngologists in the United States.

STUDY DESIGN

Cross-sectional study.

METHODS

The otolaryngology physician supply was defined as the number of otolaryngologists per 100,000 in the hospital referral region (HRR). The otolaryngology physician supply was derived from the American Medical Association Masterfile or from the Medicare Enrollment and Provider Utilization Files. Multiple linear regression tested the association of population, physician, and hospital factors on the supply of Medicare-enrolled otolaryngologists/HRR.

RESULTS

Two methods of measuring the otolaryngology workforce were moderately correlated across hospital referral regions (Pearson coefficient 0.513, P = .0001); regardless, the supply of otolaryngology providers varies greatly over different geographic regions. Otolaryngologists concentrate in regions with many other physicians, particularly specialist physicians. The otolaryngology supply also increases with regional population income and education levels. Using AMA-derived data, there was no association between the supply of otolaryngologists and staffed acute-care hospital beds and the presence of an otolaryngology residency-training program. In contrast, the supply of otolaryngology providers enrolled in Medicare independently increases for each HRR by 0.8 per 100,000 for each unit increase in supply of hospital beds (P < .0001) and by 0.49 per 100,000 in regions with an otolaryngology residency-training program (P = .006), accounting for all other factors.

CONCLUSION

Irrespective of methodology, the supply of otolaryngologists varies widely across geographic regions in the United States. For Medicare beneficiaries, regional hospital factors-including the presence of an otolaryngology residency program-may improve access to otolaryngology services.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:95-101, 2017.

Implementing primary prevention programs for adolescents in rural environments

Lifestyle behaviors generally are established during adolescence and these habits can increase or decrease a person's chance for a healthful and productive life. Thus, it is important that primary prevention and health promotion begin during those early years. A number of deterrents to the use of health promoting programs are identified but for rural residents there may be other barriers associated with demographic, social, geographic, cultural, economic, educational and political factors. Those environmental factors must be considered when planning, implementing and evaluating programs. In turn, provider-community partnerships are an effective strategy to provide services in rural communities within the constraints of limited resources.

Geographic information systems and chronic kidney disease: racial disparities, rural residence and forecasting

The dynamics of health and health care provision in the United States vary substantially across regions, and there is substantial regional heterogeneity in population density, age distribution, disease prevalence, race and ethnicity, poverty and the ability to access care. Geocoding and geographic information systems (GIS) are important tools to link patient or population location to information regarding these characteristics. In this review, we provide an overview of basic GIS concepts and provide examples to illustrate how GIS techniques have been applied to the study of kidney disease, and in particular to understanding the interplay between race, poverty, rural residence and the planning of renal services for this population. The interplay of socioeconomic status and renal disease outcomes remains an important area for investigation and recent publications have explored this relationship utilizing GIS techniques to incorporate measures of socioeconomic status and racial composition of neighborhoods. In addition, there are many potential challenges in providing care to rural patients with chronic kidney disease including long travel times and sparse renal services such as transplant and dialysis centers. Geospatially fluent analytic approaches can also inform system level analyses of health care systems and these approaches can be applied to identify an optimal distribution of dialysis facilities. GIS analysis could help untangle the complex interplay between geography, socioeconomic status, and racial disparities in chronic kidney disease, and could inform policy decisions and resource allocation as the population ages and the prevalence of renal disease increases.

Trends in radical prostatectomy: centralization, robotics, and access to urologic cancer care

BACKGROUND

Robotic surgery has been widely adopted for radical prostatectomy. We hypothesized that this change is rapidly shifting procedures away from hospitals that do not offer robotics and consequently increasing patient travel.

METHODS

A population-based observational study of all prostatectomies for cancer in New York, New Jersey, and Pennsylvania from 2000 to 2009 was performed using hospital discharge data. Hospital procedure volume was defined as the number of prostatectomies performed for cancer in a given year. Straight-line travel distance to the treating hospital was calculated for each case. Hospitals were contacted to determine the year of acquisition of the first robot.

RESULTS

From 2000 to 2009, the total number of prostatectomies performed annually increased substantially. The increase occurred almost entirely at the very high-volume centers (≥ 106 prostatectomies/year). The number of hospitals performing prostatectomy fell 37% from 2000 to 2009. By 2009, the 9% (21/244) of hospitals that had very high volume performed 57% of all prostatectomies, and the 35% (86/244) of hospitals with a robot performed 85% of all prostatectomies. The median travel distance increased 54% from 2000 to 2009 (P<.001). The proportion of patients traveling ≥ 15 miles increased from 24% to 40% (P < .001).

CONCLUSIONS

Over the past decade, the number of radical prostatectomies performed has risen substantially. These procedures have been increasingly centralized at high-volume centers, leading to longer patient travel distances. Few prostatectomies are now performed at hospitals that do not offer robotic surgery.

A probabilistic sampling method (PSM) for estimating geographic distance to health services when only the region of residence is known

Background

The need to estimate the distance from an individual to a service provider is common in public health research. However, estimated distances are often imprecise and, we suspect, biased due to a lack of specific residential location data. In many cases, to protect subject confidentiality, data sets contain only a ZIP Code or a county.

Results

This paper describes an algorithm, known as "the probabilistic sampling method" (PSM), which was used to create a distribution of estimated distances to a health facility for a person whose region of residence was known, but for which demographic details and centroids were known for smaller areas within the region. From this distribution, the median distance is the most likely distance to the facility. The algorithm, using Monte Carlo sampling methods, drew a probabilistic sample of all the smaller areas (Census blocks) within each participant's reported region (ZIP Code), weighting these areas by the number of residents in the same age group as the participant. To test the PSM, we used data from a large cross-sectional study that screened women at a clinic for intimate partner violence (IPV). We had data on each woman's age and ZIP Code, but no precise residential address. We used the PSM to select a sample of census blocks, then calculated network distances from each census block's centroid to the closest IPV facility, resulting in a distribution of distances from these locations to the geocoded locations of known IPV services. We selected the median distance as the most likely distance traveled and computed confidence intervals that describe the shortest and longest distance within which any given percent of the distance estimates lie. We compared our results to those obtained using two other geocoding approaches. We show that one method overestimated the most likely distance and the other underestimated it. Neither of the alternative methods produced confidence intervals for the distance estimates. The algorithm was implemented in R code.

Conclusions

The PSM has a number of benefits over traditional geocoding approaches. This methodology improves the precision of estimates of geographic access to services when complete residential address information is unavailable and, by computing the expected distribution of possible distances for any respondent and associated distance confidence limits, sensitivity analyses on distance access measures are possible. Faulty or imprecise distance measures may compromise decisions about service location and misdirect scarce resources.

Centralization of cancer surgery: implications for patient access to optimal care

PURPOSE

The volume-outcomes relationship has led many to advocate centralization of cancer procedures at high volume hospitals (HVH). We hypothesized that in response cancer surgery has become increasingly centralized and that this centralization has resulted in increased travel burden for patients.

PATIENTS AND METHODS

Using 1996 to 2006 discharge data from NY, NJ, PA, all patients > or = 18 years old treated with extirpative surgery for colorectal, esophageal, or pancreatic cancer were examined. Patients and hospitals were geocoded. Annual hospital procedure volume for each tumor site was examined, and multiple quantile and logistic regressions were used to compare changes in centralization and distance traveled.

RESULTS

Five thousand two hundred seventy-three esophageal, 13,472 pancreatic, 202,879 colon, and 51,262 rectal procedures were included. A shift to HVH occurred to varying degrees for all tumor types. The odds of surgery at a low volume hospital decreased for esophagus, pancreas and colon: per year odds ratios (ORs) were 0.87 (95% CI, 0.85 to 0.90), 0.85 (95% CI, 0.84 to 0.87), and 0.97 (95% CI, 0.97 to 0.98). Median travel distance increased for all sites: esophagus 72%, pancreas 40%, colon 17%, and rectum 28% (P < .0001). Travel distance was proportional to procedure volume (P < .0001). The majority of the increase in distance was attributable to centralization.

CONCLUSION

There has been extensive centralization of complex cancer surgery over the past decade. While this process should result in population-level improvements in cancer outcomes, centralization is increasing patient travel. For some subsets of the population, increasing travel requirements may pose a significant barrier to access to quality cancer care.

Disparities in geographic access to pediatric subspecialty care

PURPOSE

To identify correlates of geographic access to pediatric medical subspecialists in the United States and identify characteristics of populations at risk for poor geographic access.

METHODS

Geographic access was operationalized as distance to care. Using data from the American Board of Pediatrics and the Claritas' Pop-Facts Database, the straight-line distance between each zip code in the United States and the nearest subspecialist was calculated for each pediatric subspecialty using zip code centroids. Using 16 specialty-specific, random-effects multiple regression models, zip code characteristics associated with being farther from a subspecialty provider were identified.

RESULTS

Under-18 population, metropolitan status, and presence of a nearby teaching facility were associated with shorter distances to care across pediatric subspecialties. The proportion of the population below the federal poverty level was positively associated with greater distances to care. Zip codes in the Mountain and West North Central regions, likewise, were significantly farther from pediatric subspecialists, even when statistically controlling for other factors.

CONCLUSIONS

Pediatric populations at risk for poor geographic access to pediatric subspecialty care include those who reside in zip codes with high concentrations of poverty, in rural and small metropolitan areas, and in the Mountain and West North Central regions. The extent to which these distances create barriers to receipt of care is not established.

[Geographic distribution of physicians in Brazil: an analysis based on a locational choice model]

The primary aim of this study was to analyze the geographic distribution of physicians among the Regions and States of Brazil using a locational choice model. Our individual data analysis showed a positive relationship between the number of physicians per 1,000 inhabitants in a State and the number of places in residency programs. Thus, the concentration of residency programs in some States has contributed to the unequal distribution of physicians in Brazil. There are also significant differences in physicians' income between Regions.

Geographic access to health care for rural Medicare beneficiaries

CONTEXT

Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care.

PURPOSE

To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington.

METHODS

Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes.

FINDINGS

There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists.

CONCLUSIONS

Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.

The geographic distribution of physicians revisited

CONTEXT

While there is debate over whether the U.S. is training too many physicians, many seem to agree that physicians are geographically maldistributed, with too few in rural areas.

OBJECTIVE

Official definitions of shortage areas assume the market for physician services is based on county boundaries. We wished to ascertain how the picture of a possible shortage changes using alternative measures of geographic access. We measure geographic access by the number of full-time equivalent physicians serving a community divided by the expected number of patients (possibly both from within the community and outside) receiving care from those physicians. Moreover, we wished to determine how the geographic distribution of physicians had changed since previous studies, in light of the large increase in physician numbers.

DESIGN

Cross-sectional data analyses of alternative measures of geographic access to physicians in 23 states with low physician-population ratios.

RESULTS

Between 1979 and 1999, the number of physicians doubled in the sample states. Although most specialties experienced greater diffusion everywhere, smaller specialties had not yet diffused to the smallest towns. Multiple measures of geographic access, including physician-to-population ratios, average distance traveled to the nearest physician, and projected average caseload per physician, confirm that residents of metropolitan areas have better geographic access to physicians. Physician-to-population ratios exhibit the largest degree of geographic disparity, but ratios in rural counties adjacent to metropolitan areas are smaller than in those not adjacent to metropolitan areas. Distance-traveled and caseload models that allow patients to cross county lines show less disparity and indicate that residents of isolated rural counties have less access than those living in counties adjacent to metropolitan areas.

CONCLUSION

Geographic access to physicians has continued to improve over the past two decades, although some smaller specialties have not diffused to the most rural areas. While substantial variation in the supply of physicians across communities remains, current measures of geographic access to physicians overstate the extent of maldistribution and yield an incorrect ranking of areas according to geographic accessibility of physicians.

Geocoding in cancer research: a review

There is now widespread agreement that geographic identifiers (geocodes) should be assigned to cancer records, but little agreement on their form and how they should be assigned, reported, and used. This paper reviews geocoding practice in relation to major purposes and discusses methods to improve the accuracy of geocoded cancer data. Differences in geocoding methods and materials introduce errors of commission and omission into geocoded data. A common source of error comes from the practice of using digital boundary files of dubious quality to place addresses into areas of interest. Geocoded data are linked to demographic, environmental, and health services data, and each data type has unique accuracy considerations. In health services applications, the accuracy of distances computed from geocodes can differ markedly. Privacy and confidentiality issues are important in the use and release of geocoded cancer data. When masking methods are used for disclosure limitation purposes, statistical methods must be adjusted for the locational uncertainty of geocoded data. We conclude that selection of one particular type of geographic area as the geocode may unnecessarily constrain future work. Therefore, the longitude and latitude of each case is the superior basic geocode; all other geocodes of interest can be constructed from this basic identifier.

Potential access and revealed access to pain management medications

The area configuration of healthcare resources, such as the number of hospitals per hundred thousand population, has often been used in healthcare planning and policy making to estimate the global access (potential access) of health services to a local population. However, the actual utilization of the "available" healthcare resources (revealed access) is usually much more limited. The objectives of this study were to examine the availability of healthcare resources by measuring the potential access and the revealed access for outpatients who need to access pharmacies to fill prescriptions of Schedule II (CII) opioids for pain management, and to explore the difference between rural and urban residents in these two types of access. About 191,700 prescriptions for CII opioids dispensed in 1997 in the state of Michigan, USA were analyzed. Revealed accessibility was measured by the distance between the paired zip codes of the pharmacy and the patient listed on each prescription. Potential accessibility was measured by the distance from a patient's zip code to that of the nearest community pharmacy that could dispense the opioid prescriptions. The analyses on revealed access showed that 50% of the CII prescriptions were dispensed by pharmacies located within a 5-mile radius of patients' residences, 75% of prescriptions were dispensed within about a 10-mile radius, and 90% were within 20 miles. If patients were free to access the nearest pharmacy for dispensing (a hypothetical situation under potential access), the median, 75th percentile, and 90th percentile distances could reduce to 2, 3, and 5 miles, respectively. Similar differences between revealed and potential access were observed in both rural and urban areas and for every major opioid drug group. We conclude that policymakers should recognize the discrepancy between potential and revealed accessibility and move beyond only considering area configuration of healthcare resources to evaluating and improving access to care.

The influence of attractiveness factors and distance to general practice surgeries by level of social disadvantage and global access in Perth, Western Australia

The impact on attendance of the distance to general practice surgeries, and the attributes offered by those surgeries, was investigated. One thousand and forty four subjects, selected at random from the metropolitan area of Perth, Western Australia, responded to a household interview survey concerning which attributes of general practice (GP) surgeries they found attractive and the identity of the surgery they preferred to attend. The sample was stratified by different levels of social disadvantage and by good and poor global levels of spatial accessibility of GP surgeries. In separate fieldwork, interviewers collected detailed environmental data from practice staff at 466 GP surgeries available to the community survey respondents within metropolitan Perth. Respondents living in areas of poor global access were more likely to attend their nearest surgery (25% vs. 6%) and to bypass fewer surgeries to attend a preferred surgery (median 2 vs. 20). Those who were most socially disadvantaged were less likely than those who were better off to bypass surgeries where global access was poor, but more likely to bypass nearby surgeries and to seek out a surgery that bulk billed in areas where global access was good. A number of attractiveness factors had an important influence on choice of surgery, including: 'easy to make an appointment'; 'generally sees patients on time'; 'pharmacy nearby'; 'bulk bills' and 'open at all on Sundays'. Respondents attending their nearest surgery were more likely to have all of their nominated 'very important' attributes satisfied at that surgery than non-attenders (40% vs. 16%). A logistic regression model, adjusting for distance effects and size of surgery, showed within each level of global access and social disadvantage a consistent increase in the odds of attending a surgery that satisfied the attributes desired by respondents.

Developing policies responsive to barriers to health care among rural residents: what do we need to know?

A substantial body of research has been devoted to the subject of access to health care services for rural residents, much with the intention of shaping government policies to remove barriers or equalize the distribution of health care services. A number of programs and policies have grown out of or been affected by access research, yet despite identifiable successes of the policy research process, barriers to health care services still exist in rural areas. This article attempts to stimulate discussion about ways that rural health researchers can build on past research on access to care. A framework for posing access questions is proposed, suggesting that access research focus on the following areas: factors that drive differences in utilization, availability, and acceptability; consumer satisfaction and an understanding of why rural consumer satisfaction has been found to be high; factors that impede access that are mutable; and services that can be shown to improve outcomes.

The effects of physician in-migration to rural Colorado (1992 to 1995)

This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants.

Multi-method assessment of access to primary medical care in rural Colorado

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Rural hospital inpatient surgical volume: cutting-edge service or operating on the margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.

Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection

BACKGROUND

Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma.

METHODS

From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients' age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance.

RESULTS

Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P =.010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P <.001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P =.009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis.

CONCLUSIONS

Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study.

The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California

CONTEXT

Managed care plans aggressively seek to contain costs, but few data are available regarding their impact on access to high quality care for their members.

OBJECTIVE

To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in California.

DESIGN

Retrospective cohort study using state-mandated hospital discharge datasets.

SETTING

Pediatric cardiovascular surgical centers in California.

PATIENTS

Five thousand seventy-one children admitted for open cardiac surgical procedures during 1992-1994.

RESULTS

Hospitals were divided into lower- and higher-mortality groups according to adjusted surgical mortality. Using multivariate logistic regression analysis to control for medical, socioeconomic, demographic, and distance factors, children with managed care insurance were less likely to be admitted to a lower-mortality hospital for surgery relative to children with indemnity insurance (odds ratio:.53; 95% confidence interval:.45,.63). Similar findings resulted when the analysis was stratified by race/ethnicity. In addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher-mortality centers (adjusted difference:.54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,. 41).

CONCLUSIONS

During this study, children with managed care insurance had significantly reduced use of lower-mortality hospitals for pediatric heart surgery in California compared with children with indemnity insurance. Further study is necessary to determine the mechanisms of this apparent insurance-specific inequity.

Hills, ridges, mountains, and roads: geographical factors and access to care in rural Kentucky

Access to health care remains an important issue facing many individuals. Barriers to health care include financial factors, characteristics of the individuals and of the health care delivery system, as well as geographical factors. Using a telephone survey of Kentucky residents, this study investigated the relationship between the road quality and county elevation and access to health care for individuals in rural and urban areas of the state. Controlling the comparison for known individual characteristics, community characteristics, and medical infrastructure characteristics, this study uncovered that worse road conditions, measured by a road "rideability" index, were associated with longer times to reach medical care. It also found an association between higher county elevations and shorter times to reach medical care.

Entrance and exit of obstetrics providers in rural Alabama

In Alabama between 1985 and 1989, a total of 94 physicians outside of the four largest cities in the state dropped the obstetrics portion of their practices or left practice in their communities altogether. During the same period 82 physicians entered obstetrics practice in this area. The study presented here used survey and archival data to compare practice characteristics of generalists and specialists in rural and town counties who made different decisions about providing obstetrics care. More generalists left and more specialists entered practice both in town and in rural counties. Rural counties lost more obstetrics providers because more generalists provided the obstetrics care in these areas. Across both specialty and county categories, physicians in group practice who accepted Medicaid and had local access to larger numbers of patients were more likely to remain or begin new obstetric practices. During this period, some obstetrics specialists moved into rural communities that had previously supported only generalist physicians. These findings suggest that the options for organizing successful obstetrics practices have narrowed, putting solo and generalist physicians who operate small-scale obstetrics practices at a disadvantage. These physicians also face competition from obstetrics specialists who are beginning to enter practice in the rural areas of the state. Designing policies that effectively improve geographic access to care requires a realistic understanding of the practice constraints faced by obstetrics providers. For example, as centralized specialist group practices serve residents from surrounding rural areas, programs that facilitate linkages, such as satellite clinics and use of mid-level practitioners, can be promoted.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital choice of Medicare beneficiaries in a rural market: why not the closest?

As part of a larger study of hospital choice, the travel patterns of more than 12,000 Medicare beneficiaries residing in three overlapping rural areas were examined. During 1986 these Medicare beneficiaries were admitted to one of 53 hospitals in an area that encompassed parts of Minnesota, North Dakota, and South Dakota. Information on ZIP code of residence, closest hospital, and hospital of admission were used to analyze hospital choices of the Medicare rural elderly residing in this area. To summarize their travel patterns, the admitting hospital was categorized based on whether it was urban or rural, its size and whether or not it was the closest facility. Findings indicated that 60 percent of these rural Medicare beneficiaries used hospital services at their closest rural hospital, regardless of its size. However, 79 percent of those whose closest hospital was larger than 75 beds used it, while only 54 percent of those whose closest rural hospital was fewer than 75 beds obtained services there. Overall, 30 percent of those residing in this rural market area went to an urban hospital. These patterns appeared to reflect an evaluation by the physician and/or individual of the relative attractiveness of the local hospital versus alternatives available, as well as the individual's characteristics. Travel patterns varied by the beneficiary's age as well as his or her relative complexity of illness, as measured by a Disease Staging methodology. Findings have implications for the provision and financing of hospital services in rural areas.

Geographic barriers to child health services in rural northern New England: 1980 to 1989

Despite substantial recent increases in the number of rural physicians, it is unknown whether rural children still face significant barriers to medical care. To address this question, we determined travel times in 1980 and in 1989 to child health services for the rural pediatric population of northern New England--the area with the highest per-capita primary care physician supply of any non-metropolitan region in the United States. The study population in 1989 included 363,443 children living in 936 nonmetropolitan towns. The study revealed important spatial relationships in health service supply and demand not identified using other methods of assessing physician availability. Although travel times to physicians decreased slightly during the decade, we found that 15.5 percent of the children in our population were more than 30 minutes from pediatricians in 1989, and travel time to emergency rooms was more than 30 minutes for 9.9 percent of the children. In contrast, only 1.8 percent of children faced excessive travel times to family/general practitioners. While towns with pediatricians were likely to also have a family physician or an emergency room, the majority of towns with family physicians had neither a pediatrician nor an emergency room. Towns with poor geographic access to pediatricians and emergency rooms had low population densities and were distant from metropolitan areas. The analysis indicates that even in rural areas of high physician supply, access to pediatricians and emergency rooms for many children remains limited, and family physicians are the dominant medical providers for children.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of measures of access to child health clinics and the implications for modelling the location of new clinics

OBJECTIVE

To determine whether measurement of access to existing child health clinics, and modelled location of new clinics, was affected by the spatial definitions of the target population.

METHOD

Populations requiring childhood screening services were defined as located at individual households, and at geographic and population-weighted centroids of small and large areas. Straight-line and network distances were measured and compared from these origins to varying numbers of existing clinics. The same origins were used to model sets of locations for new clinics, and access levels were again compared.

RESULTS

Travel distances for 82,499 annual baby-visits to 140 existing clinics were between 136,000 km and 84,000 km, depending on origin definition. An analysis based on small area centroid data was as accurate as one based on household data. Planning solutions for new clinics located on the basis of few large areas, with populations centred at spatially defined centroids, resulted in poorer access for the population (231,000 km of travel) than one based on many small areas with populations centred at population weighted centroids (194,000 km of travel).

IMPLICATIONS

Public access to health facilities will be improved if decisions about their locations are aided by the application of spatial analysis techniques based on small area definitions.

The distance to community medical care and the likelihood of hospitalization: is closer always better?

OBJECTIVES

This study examined the influence that distance from residence to the nearest hospital had on the likelihood of hospitalization and mortality.

METHODS

Hospitalizations were studied for Maine. New Hampshire, and Vermont during 1989 (adults) and for 1985 through 1989 (children) and for mortality (1989) in Medicare enrollees.

RESULTS

After other known predictors of hospitalization (age, sex, bed supply, median household income, rural residence, academic medical center, and presence of nursing home patients) were controlled for, the adjusted rate ratio of medical hospitalization for residents living more than 30 minutes away was 0.85 (95% confidence interval [CI] = 0.82, 0.88) for adults and 0.78 (95% CI = 0.74, 0.81) for children, compared with those living in a zip code with a hospital. Similar effects were seen for the four most common diagnosis-related groups for both adults and children. The likelihood of hospitalization for conditions usually requiring hospitalization and for mortality in the elderly did not differ by distance.

CONCLUSIONS

Distance to the hospital exerts an important influence on hospitalization rates that is unlikely to be explained by illness rates.

A macro approach to the explanation of physician distribution in Canada

Physician distribution is influenced by complex factors. It is generally argued that the probability of physician increase will be greater in areas that have more to offer in the way of social and economic advantages, This study examines the effects of selected demographic, socioeconomic, and environmental factors (e.g., population size, percent university educated, and hospital bed/population ratio) on the spatial distribution of physicians, using data for "active" civilian physicians obtained from Health and Welfare Canada. The findings indicate that the variable "percentage university educated" is the most important factor influencing physician distribution, once demographic and environmental factors are controlled. The higher the educational level of the population, the higher the physician/population ratio and the higher the proportion of children under age 5, the lower the physician/population ratio. Findings provide evidence of a concentration of physicians in high-status areas. A pattern of larger relative dispersion was also observed for physician/population ratios across areas for suburban dwellers.

Correlation of travel time on roads versus straight line distance

Studies of hospital demand and choice of hospital have used straight line distance from a patient's home to hospitals as a measure of geographic access, but there is the potential for bias if straight line distance does not accurately reflect travel time. Travel times for unimpeded travel between major intersections in upstate New York were compared with distances between these points. The correlation between distance and travel time was 0.987 for all observations and 0.826 for distances less than 15 miles. These very high correlations indicate that straight line distance is a reasonable proxy for travel time in most hospital demand or choice models, especially those with large numbers of hospitals. The authors' outlier analyses show some exceptions, however, so this relationship may not hold for studies focusing on specific hospitals, very small numbers of hospitals, or studies in dense urban areas with high congestion and reliance on surface streets.

Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics

OBJECTIVES

This study assessed the impact of mother's race, insurance status, and use of prenatal care on very low birthweight infant delivery in or transfer to hospitals with neonatal intensive care units (ICUs).

METHODS

Multivariate analysis of Alabama vital statistics records between 1988 and 1990 for infants weighing 500 to 1499 g was conducted, comparing hospital of birth and maternal and infant transfer status, and controlling for infant birthweight and for maternal pregnancy history and demographic characteristics.

RESULTS

With other factors adjusted for, non-White mothers with early prenatal care were more likely than White mothers to deliver their very low birthweight infants in hospitals with neonatal ICUs without transfer. Among the mothers who presented first at hospitals without such facilities, those who had late prenatal care were less likely than those with early care to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for White women. Likelihood of infant transfer was not associated with these maternal characteristics.

CONCLUSIONS

Maternal race, prenatal care use, and insurance status may influence the likelihood that very low birthweight infants will have access to neonatal intensive care. Interventions to improve perinatal regionalization should address individual and system barriers to the timely referral of high-risk mothers.

Deviation from the carrying capacity for physicians and growth rate of physician supply: the Taiwan case

This study applies the theory of carrying capacity to examine the effects of market forces on the location pattern of physicians in Taiwan between 1974 and 1982. The data for the analysis were collected from governmental publications. The township was selected as the geographic unit of analysis. By using a regression model of physician supply, this study developed a proxy for physician carrying capacity and a deviation indicator to classify townships as attractive or unattractive. The results of this study indicate that: (1) within attractive townships, the greater the deviation from physician carrying capacity, the faster the growth rate of the physician-population ratio; (2) the overall pattern of the growth rate is quite similar across different sizes of townships; and (3) due to a loss of population, unattractive townships do not necessarily have the lowest growth rates of the physician-population, unattractive they gain few physicians. This study thus concludes that market forces are powerful in determining the physician distribution.

The effect of distance to VA facilities on the choice and level of utilization of VA outpatient services

The 1987 survey of Veterans is used to explain the effects of distance to VA facilities on the choice and level of utilization of VA outpatient services by U.S. veterans. A two part discrete/continuous model is used to separate two elements of the decision to seek outpatient services from federally operated VA facilities. First, a discrete choice is made to seek care from the VA. Second, a continuous choice is made to seek a particular level of utilization. Distance is found to affect the initial discrete choice significantly for measured distances up to 60 miles at a decreasing rate. Once some VA outpatient contact is made, distance is a major factor only for the elderly in determining the amount of utilization. Disturbingly, elderly veteran users living more than 30-40 miles from the nearest VA are expected to make fewer visits in a year than younger veterans.

Using Gini-style indices to evaluate the spatial patterns of health practitioners: theoretical considerations and an application based on Alberta data

The paper analyzes how Gini-style indices are optimally used in the evaluation of economic spatial models designed to predict where health care practitioners are likely to locate under competitive market conditions. At a conceptual level, the analysis establishes that Gini-style indices can be brought to bear on economic models, only if the ordering of geographic areas required to give Gini-coefficient values internal technical coherence also has meaning in terms of the conceptual predictions of the modelling. This, in turn, implies that Gini-indices are most likely to prove useful for fairly aggregated forms of economic analysis, involving relatively few and large geographic divisions. At an applied level, the analysis establishes that one particular geographic distribution of health practitioners is empirically dominant, and that is the distribution which involves the lowest practitioner:population ratio in rural areas, and the highest ratio in large urban areas, with the ratio for small urban areas in between. The empirical evidence also suggests that the spatial practitioner distributions are highly stable for most kinds of health personnel, making it problematic whether these distributions can be changed through normal types of public policy interventions.

When your client lives in a rural area. Part I: Rural health care delivery issues

In the past 2 years there has been increased emphasis on health care delivery concerns in rural environments. Research monies also target the health care needs of vulnerable populations living in areas with a shortage of health professionals; many of these populations are located in rural areas. There is, however, a paucity of information about populations and mental health nursing in rural environment. Part I of this two-part article summarizes pertinent definitions and characteristics of rural environments. The health care delivery system in rural settings is considered within a framework of availability, accessibility, and acceptability of services. Traditional belief systems are highlighted, and the impact of these on health care-seeking behaviors of rural people are discussed.

Using qualitative methods to evaluate health service delivery in three rural Colorado communities

Qualitative and quantitative methods can be used simultaneously for hypothesis generation and testing. A pilot study was conducted in 1991 in three rural Colorado communities to clarify health service delivery problems related to cancer. The analysis focused on the perceptions of three types of respondents in each community related to whether cancer was a major problem, whether health services were adequate in their community, and what perceived solutions could be implemented. Respondents included community influentials, health care providers, and cancer patients or family members. Semistructured phone interviews were used to collect perceptions of these community members. Transcripts from the three communities were combined, coded, and tallied. Several distinct themes emerged from the analysis. These included: cancer was a major problem; public and provider education was needed; community systems and support to identify and solve health problems were lacking; medical networking needed to be expanded; transportation was a problem for remote communities; inability to pay for services was a problem for rural communities. Most respondents identified the problems as relevant to other chronic and acute diseases as well as cancer. This method identified the critical problems for the majority of the people without losing sight of the outlier responses.

The geographical distribution of psychiatrists in Canada: unmet needs and remedial strategies

Many efforts are underway to rationalize the process of manpower planning in psychiatry. A wide variation in the geographic distribution of psychiatrists remains. A multidimensional assessment of the needs of a population is recommended, based on the epidemiology of mental disorders, professional and institutional needs, consumer estimates, and the requirements of subgroups. Counting the number of vacant positions for psychiatrists can be misleading. Professional norms for the optimal access of a population to psychiatric services and standards for the quantity and/or quality of services provided need to be developed. Potential outcome measures are suggested, along with a three-tiered system of estimating geographic needs. Deterrent factors to an optimal geographic distribution of most professionals are reviewed, along with factors specific to our residency training programs. In the short term, the benefits and limitations of recruiting foreign-trained psychiatrists are compared with those of recruiting Canadian specialists. Complementary long term strategies include the provision of financial incentives, optimal working conditions, relevant training and maintenance of competence issues, and community support.

Allocating medical resources in rural America: alternative perceptions of justice

In national debates concerning the allocation of medical resources rural America is a neglected topic, and the voices of rural health professionals are seldom heard. This paper highlights the special problems encountered in allocating medical resources within the rural setting and indicates the strategies that rural residents compose for dealing with them. Our findings are based on a study consisting of in-depth open-ended interviews with family physicians in the rural northwest United States. We contrast the approach to justice expressed by these rural physicians with the conception of justice that dominates Western philosophy and bioethics. In the course of our discussion, the diversity within Western culture becomes apparent. We discuss strategies for incorporating different perspectives into local and national allocation debates, clarify the reasons why a more encompassing approach to justice is necessary, and review the implications of our work for future research.

The increasing supply of physicians in US urban and rural areas, 1975 to 1988

BACKGROUND

Despite the rapid growth of the US physician supply since the mid-1970s, it remains unclear whether physicians have spread into the most rural areas of the country. This report examines the urban-rural distribution of physicians between 1975 and 1988.

METHODS

A county-based typology of the urban-rural continuum was employed to examine trends in the supply of nonfederal primary care physicians, specialist physicians, and osteopaths.

RESULTS

All urban and rural areas gained physicians during the late 1970s and 1980s. The supply of physicians increased most rapidly in metropolitan counties. Within nonmetropolitan areas, urbanized remote counties became more prominent centers of the physician supply. Osteopaths were more likely to locate in the most rural areas than allopaths. The physician supply in all areas also became more specialized over time.

CONCLUSIONS

The rapid growth of the US physician supply was associated with the spread of more practitioners into all parts of the country. However, the supply of physicians increased most rapidly in urban areas, widening urban-rural differences in the availability of physicians.

The optimal psychiatrist-to-population ratio: a Canadian perspective

A systematic effort is underway to rationalize the planning of physician supply. This paper summarizes the current methodologies available and focuses on the attempts to determine the optimal psychiatrist-to-population ratio in Canada. The impact of several variables influencing this ratio is discussed. An outline of the correlation between target physician supply and requirements of future trainees is presented. While the relevant methodology is rapidly evolving, an improved process of data collection is urgently required. A number of challenges for our profession lay ahead, such as the need for sensitive and reliable measures of the adequacy of psychiatrist and subspecialist supply and public issues arising from the poor geographic distribution of psychiatric manpower.

Availability and accessibility of rural health care

The 1980s saw a retrenchment of the ideology that government intervention could solve the problems of inadequate access to health services in rural areas. Increased emphasis was placed on an ideology that promoted deregulation and competitive market solutions. During the 1980s, the gap in the availability of physicians in metropolitan versus nonmetropolitan areas widened. Also during that time period, the gap between metropolitan and nonmetropolitan populations' utilization of physician services widened. In addition, many indicators of the health status of nonmetropolitan residents versus metropolitan residents worsened during the 1980s. As we enter the 1990s, concern about equitable access to needed health care services and for the vulnerability and fragility of rural health systems has resurfaced. A number of national policies and a research agenda to improve accessibility and availability of health services in rural areas are being considered.

Physician use of hospitals: effects of physician, patient, and hospital characteristics

This paper examines the determinants of hospital utilisation in one county. In contrast to previous studies, the paper examines the physician rather than the patient as the key decision-maker. Specifically, the paper assesses the impact of several physician, patient, and hospital characteristics on the probability of admitting to a hospital, the volume of the physician's admissions at the hospital, and the concentration of the physician's admissions at the hospital. Distance from the physician's office to the hospital exerts the strongest and most consistent effects. The results are interpreted in light of several theoretical and research perspectives on physician behaviour.

The impact of obstetrical liability on access to perinatal care in the rural United States

Liability issues have caused large numbers of obstetrical providers, particularly family and general practitioners, to discontinue offering perinatal care in rural areas. Losses of even small numbers of rural obstetrical providers can severely limit access to care for large geographic areas. A lack of access to local obstetrical care can result in less than adequate prenatal care and in potential delays in the diagnosis and care of acute perinatal complications. Women who live in these underserved rural communities suffer increased adverse birth outcomes, leading to significantly higher medical costs. Proposed solutions to the problem include risk management programs associated with reduced liability premiums; increased Medicaid reimbursement for obstetrical care; health department subsidies to offset insurance premiums for rural obstetrical care; and programs in predoctoral and residency training designed to identify, assess and address the health care needs of rural areas. Although some measure of success has resulted from these efforts, more systematic and comprehensive policy changes are needed to meet the challenge of this crisis.