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Background and Purpose: Investigating the cost-effectiveness of future mobile stroke unit (MSU) services with respect to local idiosyncrasies is essential for enabling large-scale implementation of MSU services. The aim of this study was to assess the cost-effectiveness for varying urban German settings and modes of operation., Methods: Costs of different operating times together with different personnel configurations were simulated. Different possible catchment zones, ischemic stroke incidence, circadian distribution, rates of alternative diagnoses, as well as missed cases were incorporated to model case coverage and patient numbers. Based on internationally reported clinical outcomes of MSUs, a 5-year Markov model was applied to analyze the cost-effectiveness for the different program setups., Results: Compared with standard stroke care, MSUs achieved an additional 0.06 quality-adjusted life years (QALYs) over a 5-year time horizon. Assuming a catchment zone of 750,000 inhabitants and 8 h/7 day operation resulted in an incremental cost-effectiveness ratio (ICER) of €37,182 per QALY from a societal perspective and €45,104 per QALY from a healthcare perspective. Lower ICERs were possible when coverage was expanded to 16 h service on 7 days per week and larger populations. Sensitivity analyses revealed that missing ischemic strokes significantly deteriorated economic performance of MSU., Conclusions: Major determinants of cost-effectiveness should be addressed when setting up novel MSU programs. Catchment zones of more than 500,000-700,000 inhabitants and operating times of at least 12-16 h per day, 7 days per week could enable the most cost-effective MSU services in the German healthcare system., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background: Pharmacy deserts represent areas where residents face notable challenges to accessing pharmacies. North Carolina (NC) presents an intriguing case study due to its diverse geographic landscape yet lacks extensive research regarding its pharmacy deserts., Objectives: This study aims to map pharmacy deserts in NC using pharmacy location and social determinants of health (SDOH) data measured using the social vulnerability index (SVI) and descriptively characterize health care utilization statistics for University of North Carolina (UNC) Health's catchment population., Methods: Pharmacy location data was compiled from the NC Board of Pharmacy. Pharmacy deserts were defined based on SVI > 0.75 and distance thresholds aligned to United States Department of Agriculture standards. Residential characteristics were retrieved from PolicyMap and Social Explorer databases. UNC Health patient utilization data were collected by UNC Pharmacy Data Analytics group for 3 NC counties., Results: Two thousand and two NC pharmacies met inclusion criteria. 17.2% urban tracts (1.3M residents) and 4.25% rural tracts (0.14M residents) were identified as pharmacy deserts (adj. P < 0.001). Those residing in deserts had significantly less internet access, annual medical cost per capita, and access to homeless relief services as well as significantly higher food insecurity rates and Medicare cost per capita (adj. P < 0.001). UNC-specific health care utilization statistics for the 3 assessed counties were all poorer in deserts compared to nondeserts within the same counties (P > 0.05)., Conclusion: A geospatial map with the location of pharmacy deserts in NC was created to highlight differences in patient health care utilization, affecting rural and urban areas. By incorporating SDOH predictors, this study provides a more nuanced map of NC pharmacy deserts compared to reviewing distance to pharmacies alone. Higher rates of emergency department and inpatient visits in counties with more residents in pharmacy deserts suggests potential health outcomes associated with limited pharmacy access., Competing Interests: Disclosure The authors declare no relevant conflicts of interest or financial relationships., (Published by Elsevier Inc.)

Background: The University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center has developed a novel data resource, the Cancer Information and Population Health Resource (CIPHR), for conducting catchment area evaluation and cancer population health research that links the North Carolina Central Cancer Registry (NCCCR) to medical and pharmacy claims data from Medicare, Medicaid, and private plans operating within North Carolina. This study's aim was to describe the CIPHR data and provide examples of potential cohorts available in those data., Methods: We present the underlying populations included in the NCCCR and claims data before linkage and demonstrate estimated sample sizes when these data are linked and commonly used insurance enrollment criteria are applied., Results: Data for the years 2003-2020 are present in CIPHR and include 947 977 cancer cases from the NCCCR and 21.6 million enrollees in public and private health insurance (cancer and noncancer cases). When limited to first or only cancers (n = 672 377), 86% could be linked to insurance enrollment for at least 1 month during 2003-2020 (n = 582 638), with 62% of individuals linking to enrollment during the month of cancer diagnosis. Among all registry cancer cases, 47% (n = 317 898) had continuous insurance enrollment for at least 12 months before and after cancer diagnosis., Conclusion: CIPHR illustrates the utility of establishing and maintaining a statewide, comprehensive cancer population health database. This resource serves to characterize the cancer center catchment area and aids in tracking cancer outcomes and trends in care delivery as well as identifying disparities that require intervention and policy focus., (© The Author(s) 2024. Published by Oxford University Press.)

Background: Population-based linked datasets are vital to generate catchment area and population health research. The novel Cancer Information and Population Health Resource (CIPHR) links statewide cancer registry data, public and private insurance claims, and provider- and area-level data, representing more than 80% of North Carolina's large, diverse population of individuals diagnosed with cancer. This scoping review of articles that used CIPHR data characterizes the breadth of research generated and identifies further opportunities for population-based health research., Methods: Articles published between January 2012 and August 2023 were categorized by cancer site and outcomes examined across the care continuum. Statistically significant associations between patient-, provider-, system-, and policy-level factors and outcomes were summarized., Results: Among 51 articles, 42 reported results across 23 unique cancer sites and 13 aggregated across multiple sites. The most common outcomes examined were treatment initiation and/or adherence (n = 14), mortality or survival (n = 9), and health-care resource utilization (n = 9). Few articles focused on cancer recurrence (n = 1) or distance to care (n = 1) as outcomes. Many articles discussed racial, ethnic, geographic, and socioeconomic inequities in care., Conclusions: These findings demonstrate the value of robust, longitudinal, linked, population-based databases to facilitate catchment area and population health research aimed at elucidating cancer risk factors, outcomes, care delivery trends, and inequities that warrant intervention and policy attention. Lessons learned from years of analytics using CIPHR highlight opportunities to explore less frequently studied cancers and outcomes, motivate equity-focused interventions, and inform development of similar resources., (© The Author(s) 2024. Published by Oxford University Press.)

Background: An equal distribution of hospital structures represents an important factor to achieve Universal Health Coverage. Generally, the most diffused approach to measure the potential availability to healthcare is the provider-to-population ratio based on the number of beds or professionals. However, this approach considers only the availability of resources provided at regional or local level ignoring the spatial accessibility of interregional facilities that are particularly accessed by patients living at the borders. Aim of this study is to outline the distribution of the intra and interregional services in Italy to capture the level of equity across the country. Moreover, it explores the impact of the accessibility to these resources on interregional patient's mobility to receive care., Methods: To compute spatial accessibility, we propose an alternative approach that applies the enhanced two-step floating catchment area (ESFCA) to capture the level of attraction of intra and interregional hospitals to a given population. Moreover, the adoption of process and outcome indices captured to what extent the quality of structures influenced patients in choosing services located inside or outside their region of residence., Results: The study confirms that there is an unequal distribution of high-quality resources at regional and national level with a high level of inequality in the availability and accessibility of quality resources between the north and south part of Italy. This is particularly true considering the accessibility of intraregional resources in the southern part of the country that clearly influences patient choice and contribute to a significant cross border passive mobility to northern regions. This is confirmed by an econometric model that showed a significant effect of spatial accessibility with the propensity of patients of travel from the region of residence to receive care., Conclusions: The analysis of intra and interregional components of spatial accessibility may contribute to identify to what extent patients are willing to travel outside their region of residence to access to care services. Moreover, it can contribute to gain a deeper understanding of the allocation of health resources providing input for policy makers on the basis of the principles of service accessibility in order to contain patient mobility., (© 2024. The Author(s).)

Background: The U.S. Preventive Services Task Force recently issued an updated draft recommendation statement to initiate breast cancer screening at age 40, reflecting well-documented disparities in breast cancer-related mortality that disproportionately impact younger Black women. This study applied a novel approach to identify hotspots of breast cancer diagnosed before age 50 and/or at an advanced stage to improve breast cancer detection within these communities., Methods: Cancer registry data for 3,497 women with invasive breast cancer diagnosed or treated between 2012 and 2020 at the Helen F. Graham Cancer Center and Research Institute (HFGCCRI) and who resided in the HFGCCRI catchment area, defined as New Castle County, Delaware, were geocoded and analyzed with spatial intensity. Standardized incidence ratios stratified by age and race were calculated for each hotspot., Results: Four hotspots were identified, two for breast cancer diagnosed before age 50, one for advanced breast cancer, and one for advanced breast cancer diagnosed before age 50. Younger Black women were overrepresented in these hotspots relative to the full-catchment area., Conclusions: The novel use of spatial methods to analyze a community cancer center catchment area identified geographic areas with higher rates of breast cancer with poor prognostic factors and evidence that these areas made an outsized contribution to racial disparities in breast cancer., Impact: Identifying and prioritizing hotspot breast cancer communities for community outreach and engagement activities designed to improve breast cancer detection have the potential to reduce the overall burden of breast cancer and narrow racial disparities in breast cancer., (©2024 American Association for Cancer Research.)

Importance: The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas., Objective: To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses., Design, Setting, and Participants: This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023., Exposures: Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison., Main Outcomes and Measures: The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis., Results: This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis., Conclusions and Relevance: In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Objective: To compare measures of spatial access to care commonly used by policy makers and researchers with the more comprehensive enhanced two-step floating catchment area (E2SFCA) method., Study Setting: Fourteen southwestern Pennsylvania counties., Study Design: We estimated spatial access to buprenorphine-waivered prescribers using three commonly used measures-Euclidean travel distance to the closest prescriber, travel time to the closest provider, and provider-to-population ratios-and the E2SFCA. Unlike other measures, the E2SFCA captures provider capacity, potential patient volume, and travel time to prescribers., Data Collection/extraction Methods: We measured provider capacity as the number of buprenorphine prescribers listed at a given address in the Drug Enforcement Agency's 2020 Controlled Substances Act Registrants Database, and we measured potential patient volume as the number of nonelderly adults in a given census tract as reported by the 2018 American Community Survey. We estimated travel times between potential patients and prescribers with Bing Maps and Mapbox application programming interfaces. We then calculated each spatial access measure using the R programming language. We used each measure of spatial access to identify census tracts in the lowest quintile of spatial access to prescribers., Principal Findings: The Euclidean distance, travel time, and provider-to-population ratio measures identified 48.3%, 47.2%, and 69.9% of the census tracts that the E2SFCA measure identified as being in the lowest quintile of spatial access to care, meaning that these measures misclassify 30%-52% of study area census tracts as having sufficient spatial access to buprenorphine prescribers., Conclusions: Measures of spatial access commonly used by policy makers do not sufficiently accurately identify geographic areas with relatively low access to prescribers of buprenorphine. Using the E2SFCA in addition to the commonly used measures would allow policy makers to precisely target interventions to increase spatial access to opioid use disorder treatment and other types of health care services., (© 2021 Health Research and Educational Trust.)

Introduction: The first case of COVID-19 in Sweden was diagnosed in late January 2020, the first recommendations against the spread of the virus were released in mid-March, and the peak of the first wave of the pandemic was reached in March-June. The aim of this cross-sectional study was to assess the short-term effects of the first wave of the COVID-19 pandemic on prostate cancer (PCa) diagnosis, staging, and treatment., Materials and Methods: Data in the National Prostate Cancer Register (NPCR) of Sweden on newly diagnosed PCa cases and on the number of diagnostic and therapeutic procedures performed between 18 March 2020 and 2 June 2020 were compared with those in the corresponding time periods in 2017-2019, as reported until January 31 of the year after each study period., Results: During the study period in 2020, 36% fewer PCa cases were registered in NPCR compared with the corresponding time period in previous years: 1458 cases in 2020 vs a mean of 2285 cases in 2017-2019. The decrease in new PCa registrations was more pronounced in men above age 75 years, down 51%, than in men aged 70-75, down 37%, and in men below age 70, down 28%. There was no decrease in the number of radical prostatectomies and number of radical radiotherapy courses increased by 32%., Conclusions: During the peak of the first phase of the COVID-19 pandemic, the number of men diagnosed with PCa in Sweden decreased by one third compared with previous years, whereas there was no decrease in the number of curative treatments.

Importance: Limited information on the transmission and dynamics of SARS-CoV-2 at the city scale is available., Objective: To describe the local spread of SARS-CoV-2 in Valencia, Spain., Design, Setting, and Participants: This single-center epidemiological cohort study of patients with SARS-CoV-2 was performed at University General Hospital in Valencia (population in the hospital catchment area, 364 000), a tertiary hospital. The study included all consecutive patients with COVID-19 isolated at home from the start of the COVID-19 pandemic on February 19 until August 31, 2020., Exposures: Cases of SARS-CoV-2 infection confirmed by the presence of IgM antibodies or a positive polymerase chain reaction test result on a nasopharyngeal swab were included. Cases in which patients with negative laboratory results met diagnostic and clinical criteria were also included., Main Outcomes and Measures: The primary outcome was the characterization of dissemination patterns and connections among the 20 neighborhoods of Valencia during the outbreak. To recreate the transmission network, the inbound and outbound connections were studied for each region, and the relative risk of infection was estimated., Results: In total, 2646 patients were included in the analysis. The mean (SD) age was 45.3 (22.5) years; 1203 (46%) were male and 1442 (54%) were female (data were missing for 1); and the overall mortality was 3.7%. The incidence of SARS-CoV-2 cases was higher in neighborhoods with higher household income (β2 [for mean income per household] = 0.197; 95% CI, 0.057-0.351) and greater population density (β1 [inhabitants per km2] = 0.228; 95% CI, 0.085-0.387). Correlations with meteorological variables were not statistically significant. Neighborhood 3, where the hospital and testing facility were located, had the most outbound connections (14). A large residential complex close to the city (neighborhood 20) had the fewest connections (0 outbound and 2 inbound). Five geographically unconnected neighborhoods were of strategic importance in disrupting the transmission network., Conclusions and Relevance: This study of local dissemination of SARS-COV-2 revealed nonevident transmission patterns between geographically unconnected areas. The results suggest that tailor-made containment measures could reduce transmission and that hospitals, including testing facilities, play a crucial role in disease transmission. Consequently, the local dynamics of SARS-CoV-2 spread might inform the strategic lockdown of specific neighborhoods to stop the contagion and avoid a citywide lockdown.

Background: Individual patient characteristics, social determinants, and geographic access may be associated with patients engaging in appropriate health behaviors., Objective: To assess the relationship between statin adherence, geographic accessibility to pharmacies, and neighborhood sociodemographic characteristics in Michigan., Methods: The proportion of days covered (PDC) was calculated from pharmacy claims of a large insurer of adults who had prescriptions for statins between July 2009 and June 2010. A PDC ≥0.80 was defined as adherent. The predictor of interest was a ZIP code tabulation area (ZCTA)-level measure of geographic accessibility to pharmacies, measured using a method that integrates availability and access into a single index. We fit unadjusted models as well as adjusted models controlling for age, sex, and ZCTA-level measures of socioeconomic status (SES), racial isolation (RI) of non-Hispanic blacks, and urbanicity., Results: More than 174 000 patients' claims data were analyzed. In adjusted models, pharmacy access was not associated with adherence (0.99; 95% CI: 0.96, 1.03). Greater RI (0.87; 95% CI: 0.85, 0.88) and urban status (0.93; 95% CI: 0.89, 0.96) were associated with lower odds of adherence. Individuals in ZCTAs with higher SES had higher odds of adherence, as were men and older age groups., Conclusion and Relevance: Adherence to statin prescriptions was lower for patients living in areas characterized as being racially segregated or lower income. Initiating interventions to enhance adherence, informed by understanding the social and systematic barriers patients face when refilling medication, is an important public health initiative that pharmacists practicing in these areas may undertake.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing the coronavirus disease 2019 (COVID-19) pandemic, has infected millions of people and caused hundreds of thousands of deaths. While COVID-19 has overwhelmed healthcare resources (e.g., healthcare personnel, testing resources, hospital beds, and ventilators) in a number of countries, limited research has been conducted to understand spatial accessibility of such resources. This study fills this gap by rapidly measuring the spatial accessibility of COVID-19 healthcare resources with a particular focus on Illinois, USA., Method: The rapid measurement is achieved by resolving computational intensity of an enhanced two-step floating catchment area (E2SFCA) method through a parallel computing strategy based on cyberGIS (cyber geographic information science and systems). The E2SFCA has two major steps. First, it calculates a bed-to-population ratio for each hospital location. Second, it sums these ratios for residential locations where hospital locations overlap., Results: The comparison of the spatial accessibility measures for COVID-19 patients to those of population at risk identifies which geographic areas need additional healthcare resources to improve access. The results also help delineate the areas that may face a COVID-19-induced shortage of healthcare resources. The Chicagoland, particularly the southern Chicago, shows an additional need for resources. This study also identified vulnerable population residing in the areas with low spatial accessibility in Chicago., Conclusion: Rapidly measuring spatial accessibility of healthcare resources provides an improved understanding of how well the healthcare infrastructure is equipped to save people's lives during the COVID-19 pandemic. The findings are relevant for policymakers and public health practitioners to allocate existing healthcare resources or distribute new resources for maximum access to health services.

Objective: ANCA-associated vasculitides (AAV) have increased in prevalence since the 1980s. We aimed to investigate the incidence and prevalence of AAV during a 15-year period from 1999 to 2013 in Northern Norway, looking for variations during this period., Methods: Patient records were retrieved from The Northern Norwegian Vasculitis Registry; in addition we searched all regional hospital databases. Patients diagnosed with AAV from 1999 through to 2013 were included. For prevalence data, patients residing in the area, but with AAV diagnosis prior to 1999, were also included. The diagnosis of AAV was based on the European Medicines Agency algorithm., Results: We identified 140 cases; 88 were classified as granulomatosis with polyangiitis (GPA), 37 as microscopic polyangiitis (MPA) and 15 as eosinophilic granulomatosis with polyangiitis (EGPA). Adult (age ≥15 years) annual incidence rates per million were as follows: for GPA 15.6 (95% CI: 12.5, 19.2), MPA 6.5 (95% CI: 4.6, 9.0), EGPA 2.7 (95% CI: 1.5, 4.5) and overall AAV 24.7 (95% CI: 20.8, 29.2). Incidences of MPA and overall AAV showed an increasing trend (P < 0.05). Adult point prevalence rates per million in 2013 were 261 (95% CI: 213, 316) for GPA, 58.2 (95% CI: 36.9, 87.3) for MPA, 32.9 (95% CI: 17.5, 56.3) for EGPA and 351 (95% CI: 296, 416) for overall AAV., Conclusion: The incidence rate of GPA and the prevalence rates of GPA and EGPA are currently the highest reported. MPA increased significantly from a prior low incidence. The overall AAV annual incidence and prevalence are still increasing., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The increasing inequality in spatial accessibility to hospitals in developing countries has been attracting attention from researchers and politicians. The situation seems to be worse in growing megacities where more than 10 million people live and rapid urban sprawl has caused serious problems with the supply of health and public transport services. The recent global COVID-19 pandemic calls for particular attention to be afforded to the matter of equal access to basic medical facilities and services for people across different neighborhoods. Although some studies have already been undertaken into the subject of health-focused inequality in the cities of developing countries, the spatial inequity in hospital accessibility has rarely been discussed to date. In this paper, I aim to provide new evidence by considering Beijing as a case study. With the results of my analysis, I show that low-income neighborhoods have experienced lower levels of accessibility not only to high-tier hospitals (secondary and tertiary hospitals) but also to primary healthcare services (primary hospital and neighborhood clinics). The rate at which high-income neighborhoods access secondary and tertiary hospitals is approximately 4 times and 1.5 times as high as that of low-income neighborhoods. Low-income face nearly twice the travel time of those from high-income neighborhoods to reach the nearest primary hospital or neighborhood clinics. Suburban neighborhoods have less access to medical services than neighborhoods that are located in the central urban areas. It seems that the rapid urban sprawl has been worsening spatial inequality in the context of access to medical services in the growing megacity of Beijing. Equal access to healthcare services should be prioritized in future policy discussions, especially in relation to the urban growth management of megacities in developing countries in order to ensure that fair and inclusive urbanization processes are undertaken. Equal access to healthcare services would also be widely beneficial in the context of managing the COVID-19 pandemic., (Copyright © 2020. Published by Elsevier Ltd.)

Rural health services, and the workforces that provide those services, are under unprecedented pressure due to insufficient health workforce numbers and distribution of health workforce weighted to urban areas. This creates health service access issues in rural areas, compounding existing health inequalities between rural and urban people. Many approaches to date have aimed to rectify these issues, with moderate success. In this article we present a call to action to pursue a complementary approach: supporting the capability of the rural health workforce. We hypothesise that further exploring what it means to be a 'capable' rural health professional and what processes or conditions support or erode capability may additionally bolster efforts toward strong rural and remote health systems. The Capability Approach is a theory proposed by Amartya Sen, who was awarded the Nobel Memorial Prize in Economic Sciences in 1998 for this work. Although the Capability Approach inspired, for instance, the UN's Human Development Index, it has not been deeply explored in the context of rural health workforce. While still untested, a focus on capability may assist us in taking a broader view, which encompasses functioning and the freedom to pursue different functioning combinations. The feasible freedom and opportunities are paramount to the concept of capability. We posit that competence is static and the responsibility of the practitioner (and their education), but that capability is fluid and multi-dimensional and the responsibility of the practitioner, community and system. Therefore, we hypothesise that a focus on a Capability Approach, which modulates the relation between the contextual factors and outcomes, may provide us with greater understanding and avenues for action when we aim to improve outcomes such as rural health service sustainability. Developing a list of appropriate capabilities and setting strategies to support capability and its more nuanced domains may present unique opportunities for influence, and these may have positive effects on the rural health workforce. Of course it will need to be determined if improving rural primary health professionals' capability has positive impacts upon quality and access to care, and whether supporting capability is sustainable and worthy of investment.

Objective: To develop an automated, reproducible method for delineating hospital service areas (HSAs)., Data Sources/setting: Discharge data from all Swiss acute care hospitals for the years 2013 to 2016., Study Design: We derived HSAs and hospital referral regions for Switzerland using a newly developed flow-based, automated, objective, and reproducible method using all discharge data. We compared our method to the classical, partially subjective approach used to delineate the Swiss Health Care Atlas by delineating four sets of intervention-specific HSAs., Principal Findings: Based on 4 105 885 discharges, the fully automated method delineated 63 HSAs. Comparison with existing HSAs reveals good overlap and comparable measures of health utilization between the methods and shows that in the Swiss setting, our method outperforms a cluster-based approach to defining HSAs. While the classical method potentially takes an entire day to delineate the regions, our method took approximately 10 minutes., Conclusions: Hospital service areas are used to analyze differences in use of health care that may indicate underuse and overuse. Our new, fully automated, objective, and reproducible method provides a useful tool for hospital services researchers that will enable them to delineate and update patient-flow-based HSAs., (© Health Research and Educational Trust.)

Importance: Social determinants of health, such as income, education, housing quality, and employment, are associated with disparities in Alzheimer disease and health generally, yet these determinants are rarely incorporated within neuropathology research., Objective: To establish the feasibility of linking neuropathology data to social determinants of health exposures using neighborhood disadvantage metrics (the validated Area Deprivation Index) and to evaluate the association between neighborhood disadvantage and Alzheimer disease-related neuropathology., Design, Setting, and Participants: This cross-sectional study consisted of decedents with a known home address who donated their brains to 1 of 2 Alzheimer disease research center brain banks in California and Wisconsin between January 1, 1990, and December 31, 2016. Neither site had preexisting social metrics available for their decedents. Neuropathologic features were obtained from each site for data collected using the standardized Neuropathology Data Set form and from autopsy reports. Data were analyzed from June 7 to October 10, 2019., Exposures: Geocoded decedent addresses linked to neighborhood disadvantage as measured by the Area Deprivation Index calculated for the year of death., Main Outcomes and Measures: Presence of Alzheimer disease neuropathology. The association between neighborhood disadvantage and Alzheimer disease neuropathology was evaluated via logistic regression, adjusting for age, sex, and year of death., Results: The sample consisted of 447 decedents (249 men [56%]; mean [SD] age, 80.3 [9.5] years; median year of death, 2011) spanning 24 years of donation. Fewer decedents (n = 24 [5.4%]) originated from the top 20% most disadvantaged neighborhood contexts. Increasing neighborhood disadvantage was associated with an 8.1% increase in the odds of Alzheimer disease neuropathology for every decile change on the Area Deprivation Index (adjusted odds ratio, 1.08; 95% CI, 1.07-1.09). As such, living in the most disadvantaged neighborhood decile was associated with a 2.18 increased odds of Alzheimer disease neuropathology (adjusted odds ratio, 2.18; 95% CI, 1.99-2.39)., Conclusions and Relevance: The findings of this cross-sectional study suggest that social determinants of health data can be linked to preexisting autopsy samples as a means to study sociobiological mechanisms involved in neuropathology. This novel technique has the potential to be applied to any brain bank within the United States. To our knowledge, this is the first time Alzheimer disease neuropathology has been associated with neighborhood disadvantage.

Background: Rates of hospital admissions for bronchiolitis vary seasonally and geographically across England; however, seasonal differences by area remain unexplored. We sought to describe spatial variation in the seasonality of hospital admissions for bronchiolitis and its association with local demographic characteristics., Methods: Singleton children born in English National Health Service hospitals between 2011 and 2016 (n=3 727 013) were followed up for 1 year. Poisson regression models with harmonic functions to model seasonal variations were used to calculate weekly incidence rates and peak timing of bronchiolitis admissions across English regions and clinical commissioning groups (CCGs). Linear regression was used to estimate the joint association of population density and deprivation with incidence and peak timing of bronchiolitis admissions at the CCG level., Results: Bronchiolitis admission rates ranged from 30.9 per 1000 infant-years (95% CI 30.4 to 31.3) in London to 68.7 per 1000 (95% CI 67.9 to 69.5) in the North West. Across CCGs, there was a 5.3-fold variation in incidence rates and the epidemic peak ranged from week 49.3 to 52.2. Admission rates were positively associated with area-level deprivation. CCGs with earlier peak epidemics had higher population densities, and both high and low levels of deprivation were associated with earlier peak timing., Conclusions: Approximately one quarter of the variation in admission rates and two-fifths of the variation in peak timing of hospital admissions for bronchiolitis were explained by local demographic characteristics. Implementation of an early warning system could help to prepare hospitals for peak activity and to time public health messages., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Newborn mortality in Cambodia remains high, with sepsis and complications of delayed care-seeking important contributing factors. Intervention study objectives were to improve infection control behavior by staff in health centers; improve referral of sick newborns; increase recognition of danger signs, and prompt care-seeking at an appropriate health facility; and appropriate referral for sick newborns by mothers and families of newborn infants., Methods: The stepped-wedge cluster-randomized controlled trial took place in rural Cambodia from February 2015 to November 2016. Sixteen clusters consisted of public health center catchment areas serving the community. The intervention included health center staff training and home visits to mothers by community health volunteers within 24 hours of birth and on days 3 and 7 after delivery, including assessment of newborns for danger signs and counselling mothers. The trial participants included women who had recently delivered a newborn who were visited in their homes in the first week, as well as health center staff and community volunteers who were trained in newborn care. Women in their last trimester of pregnancy greater than 18 years of age were recruited and were blinded to their group assignment. Mothers and caregivers (2494) received counseling on handwashing practices, breastfeeding, newborn danger signs, and prompt, appropriate referral to facilities., Results: Health center staff in the intervention group had increased likelihood of hand washing at recommended key moments when compared with the control group, increased knowledge of danger signs, and higher recall of at least three hygiene messages. Of mother/caregiver participants at 14 days after delivery, women in the intervention group were much more likely to know at least three danger signs and to have received messages on care-seeking compared with controls., Conclusions: The intervention improved factors understood to be associated with newborn survival and health. Well-designed training, followed by regular supervision, enhanced the knowledge and self-reported behavior of health staff and health volunteers, as well as mothers' own knowledge of newborn danger signs. However, further improvement in newborn care, including care-seeking for illness and handwashing among mothers and families, will require additional involvement from broader stakeholders in the community., Competing Interests: All authors declare that there are no conflicts of interest.

Background: Administrative data were used to investigate changes in hospitalizations for atrial fibrillation (AF), AF-related stroke, and treatment patterns between 2012 and 2016., Methods: From the 'Ricerca e Salute' database, a population- and patient-based repository involving >12 million inhabitants and linking demographics, prescriptions, and hospital discharge records, all patients discharged alive with a diagnosis of AF between 2012 and 2015 were followed for 1 year., Results: A total of 194,030 AF patients were included. The number of AF cases increased ~10% over time, from 4.0 per 1,000 inhabitants in 2012 to 4.4 per 1,000 in 2015. At 1 year, hospitalizations for ischemic stroke decreased from 21.3 per 1,000 patients with AF in 2012-2013 to 14.7 per 1,000 in 2015-2016 (-31%, 95% CI -18 to -41). Over the same period, oral anticoagulant (OAC) use increased from 56.7% to 64.4% (+14%, 95% CI +8 to +26), vitamin K antagonist use decreased (from 55.9 to 36.7%; -34%, 95% CI -21 to -44), whereas direct OACs (DOACs) increased (from <1% in 2012 to 27.7% in 2015). Antiplatelet prescriptions fell from 42.6% in 2012 to 28.1% in 2015. Hospitalizations for major bleeds, mainly gastrointestinal, increased from 1.5‰ in 2012-2013 to 2.3‰ in 2015-2016, whereas hemorrhagic stroke admissions decreased from 6.5‰ to 4.1‰., Conclusions: There was a slight increase in the prevalence of AF between 2012 and 2015, whereas the overall use of antiplatelet agents decreased and that of OAC, particularly DOACs, increased. Over the same period, 1-year hospitalizations for ischemic stroke declined substantially, with a declining rate of hemorrhagic strokes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

National Cancer Institute (NCI) designated cancer centers are charged with reducing disparities, improving cancer-related health outcomes, and increasing clinical trial participation for the catchment area population. Succeeding in this endeavor requires a clear definition of each cancer center's geographic catchment area as well as the demographic characteristics of the populations residing in the catchment area. For this reason, the definition of the catchment area is now a required element of NCI grant applications. This primer provides detailed information related to the definition of cancer centers' catchment areas and provides a case example from the University of Texas MD Anderson Cancer Center to highlight best practice strategies for compiling and interpreting cancer health statistics for the catchment area., (© 2020 Elsevier Inc. All rights reserved.)

Aim: To assess the measures of disease frequency and determine the clinical features of primary biliary cholangitis (PBC) in two Croatian regions., Methods: Databases of two tertiary hospitals, one located in the continental and one in the coastal region of Croatia, were retrospectively searched for PBC patients diagnosed from 2007 to 2018. Epidemiologic data analysis was restricted to patients from each hospital's catchment area. We analyzed factors related to response to therapy and event-free survival (EFS), defined as absence of ascites, variceal bleeding, encephalopathy, hepatocellular carcinoma, liver transplantation (LT), or death. In addition, we determined clinical and demographic data of transplanted PBC patients., Results: Out of 83 PBC patients, 86.7% were female, with a median age at diagnosis of 55 years. Average PBC incidence for the 11-year period was 0.79 and 0.89 per 100000 population, whereas the point prevalence on December 31, 2017 was 11.5 and 12.5 in the continental and coastal region, respectively. Of 76 patients with complete medical records, 21% had an advanced disease stage, 31.6% had an associated autoimmune condition, and all received ursodeoxycholic acid. EFS rate at 5 years was 95.8%. In an age and sex-adjusted multivariate Cox regression model, the only factor significantly associated with inferior EFS was no response to therapy (HR=18.4; P=0.018). Of all Croatian patients who underwent LT, 3.8% had PBC, with the survival rate at 5 years after LT of 93.4%., Conclusion: This study gives pioneer insights into the epidemiological and clinical data on PBC in Croatia, thus complementing the PBC map of Southeast Europe.

Background: The International Diabetes Federation (IDF) recently reported that there are 1.8 million South Africans with diabetes, and estimates an additional undiagnosed population of 69% of the total number of diabetics. The African continent is expected to see the highest increase in diabetes globally by 2045. Healthcare measures to manage this surge in diabetes and its related complications should be tailored to Africa's unique challenges; however, the epidemiolocal data essential for policy development are lacking. Bridging the data gap will guide funding distribution and the creation of evidence-based initiatives for diabetes., Objectives: To investigate the frequency, age proportion and distribution of new patients diagnosed with diabetes in the public healthcare sector of Eastern Cape (EC) Province, South Africa (SA)., Methods: All data collected to date were obtained from the EC District Health Information System. According to the information collected from the Department of Health, diabetes-related data collection fields were implemented in 2013, which resulted in this 4-year study. Additional open-source data on population estimates, mortality and medical aid coverage were provided by Statistics SA., Results: Of the eight districts in the province, O R Tambo was recorded as having the highest average proportion of new patients diagnosed with diabetes. A positive correlation was found between the calculated incidence of disease and the diabetes mortality rate., Conclusions: The study showed an annual growth in the incidence of diabetes in the EC since 2014, and highlights the issue of an increasing burden of diabetes in the rural population. This increase is consonant with predictions by authoritative bodies on the growing burden of diabetes in Africa. The pattern of distribution highlights the deprived district of O R Tambo contradicting the well-known link between diabetes and urbanisation.

Background: The current epidemiology of inflammatory bowel disease (IBD) in the multi-ethnic United Kingdom is unknown. The last incidence study in the United Kingdom was carried out over 20 years ago., Aim: To describe the incidence and phenotype of IBD and distribution within ethnic groups., Methods: Adult patients (> 16 years) with newly diagnosed IBD (fulfilling Copenhagen diagnostic criteria) were prospectively recruited over one year in 5 urban catchment areas with high South Asian population. Patient demographics, ethnic codes, disease phenotype (Montreal classification), disease activity and treatment within 3 months of diagnosis were recorded onto the Epicom database., Results: Across a population of 2271406 adults, 339 adult patients were diagnosed with IBD over one year: 218 with ulcerative colitis (UC, 64.3%), 115 with Crohn's disease (CD, 33.9%) and 6 with IBD unclassified (1.8%). The crude incidence of IBD, UC and CD was 17.0/100000, 11.3/100000 and 5.3/100000 respectively. The age adjusted incidence of IBD and UC were significantly higher in the Indian group (25.2/100000 and 20.5/100000) compared to White European (14.9/100000, P = 0.009 and 8.2/100000, P < 0.001) and Pakistani groups (14.9/100000, P = 0.001 and 11.2/100000, P = 0.007). The Indian group were significantly more likely to have extensive disease than White Europeans (52.7% vs 41.7%, P = 0.031). There was no significant difference in time to diagnosis, disease activity and treatment., Conclusion: This is the only prospective study to report the incidence of IBD in an ethnically diverse United Kingdom population. The Indian ethnic group showed the highest age-adjusted incidence of UC (20.5/100000). Further studies on dietary, microbial and metabolic factors that might explain these findings in UC are underway., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest., (©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Discrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates., Methods: We constructed a retrospective cohort (1997-2015) of incident cases of non-affective psychosis aged 16-50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach., Results: Our case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4-35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4-20.3)., Conclusions: Case ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

Objectives: To examine trends and utilization patterns of NYC abortion services by nonresidents since growing abortion restrictions across many states could drive women to seek care in less restrictive jurisdictions including NYC., Study Design: We used data from Induced Termination of Pregnancy certificates filed with the NYC Department of Health and Mental Hygiene in 2005-2015. An autoregressive integrated moving average (ARIMA) model was fit to the monthly nonresident abortion rate time series. Pearson's χ 2 tests determined associations between women's residence and other variables., Results: During 2005-2015, 885,816 abortions were reported in NYC, with 76,990 (8.7%) among nonresidents; 50,211 (65.2%) nonresidents lived in other New York State counties. The NYC abortion rate declined from 49.4 per 1000 women 15-44 in 2005 to 32.7 in 2015, while the nonresident rate showed minimal change from 0.12 per 1000 US women 15-44 in 2005 to 0.10 in 2015. ARIMA(0,1,1)(0,0,1) [12] fit the time series indicating minimal monthly changes in nonresident rates reflecting seasonal patterns and shorter-term dependencies between successive observations. Nonresidents differed from residents in all investigated variables including terminating at 20+ weeks (9.0% vs. 2.5%, p<.001) and having procedural methods (87.2% vs. 82.2%, p<.001)., Conclusions: Nonresidents constituted few abortion patients in NYC with minimal change in nonresident rates in 2005-2015. Nonresidents more often sought later-term abortions and more complicated procedures posing greater associated costs/risks. Monitoring nonresident abortion trends and utilization patterns is valuable for planning local service delivery particularly in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions., Implications: While we found limited change in nonresident abortion rates in NYC in 2005-2015, other jurisdictions bordering more restrictive states could show different results and should consider conducting similar research. Such analyses are important in jurisdictions committed to providing comprehensive women's healthcare where nonresidents may increasingly seek abortions in the future., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Spatial accessibility to health services is a key factor in terms of public health. Even though some tools are available, establishing accessibility criteria applicable from one geographic scale to another remains difficult. Therefore, we propose a method for creating a health accessibility index applicable on a large geographic scale, based on a methodology that overcomes the limitations of political-administrative divisions and which allows a multi-scalar approach to be implemented. The index highlights, on a national scale, areas of cumulative health disadvantages. This index of accessibility to health care combines accessibility and availability and can be adapted to many geographical scales. As accessibility can be understood in various dimensions, a score could be calculated for various fields such as education and culture. The index can help policymakers to identify under-endowed areas and find optimal locations. In terms of public health, it may be used to understand the mechanisms underlying geographic health disparities., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine geographic access to community health centers (CHC accessibility) before and after Health Center Program expansion in three Southern states., Data Sources: Community health center data were from the Health Resources and Services Administration (1967-2016). Population estimates and sociodemographic characteristics were from the American Community Survey (2006-2015)., Study Design: We used the two-step floating catchment area method to calculate CHC accessibility for census tracts in 2008 and 2016. We mapped census tract-level variation and used spatial regression to assess to what extent indicators of potential CHC need were associated with change in accessibility from 2008 to 2016., Principal Findings: Community health center accessibility increased by 192 percent overall, and the proportion of tracts with no accessibility decreased by 65 percent. Indicators of potential need were not associated with greater gains in CHC accessibility from 2008 to 2016, but census tracts with less accessibility at baseline saw larger accessibility increases., Conclusions: Community health center accessibility substantially increased from 2008 to 2016, but increases did not differentially impact groups with greater potential need. This approach for measuring CHC accessibility offers significant improvement in granularity over traditional CHC accessibility measures., (© Health Research and Educational Trust.)

There are ongoing policy concerns surrounding the difficulty in obtaining timely appointments to primary healthcare services and the potential impact on, for example, attendance at accident and emergency services and potential health outcomes. Using the case study of potential access to primary healthcare services in Wales, Geographic Information System (GIS)-based tools that permit a consideration of population-to-provider ratios over space are used to examine variations in geographical accessibility to general practitioner (GP) surgeries offering appointment times outside of 'core' operating hours. Correlation analysis is used to explore the association of accessibility scores with potential demand for such services using UK Population Census data. Unlike the situation in England, there is a tendency for accessibility to those surgeries offering 'extended' hours of appointment times to be better for more deprived census areas in Wales. However, accessibility to surgeries offering appointments in the evening was associated with lower levels of working age population classed as 'economically active'; that is, those who could be targeted beneficiaries of policies geared towards 'extended' appointment hours provision. Such models have the potential to identify spatial mismatches of different facets of primary healthcare, such as 'extended' hours provision available at GP surgeries, and are worthy of further investigation, especially in relation to policies targeted at particular demographic groups., (© 2019 John Wiley & Sons Ltd.)

Understanding patients' travel behavior for seeking hospital care is fundamental for understanding healthcare market and planning for resource allocation. However, few studies examined the issue comprehensively across populations by geographical, demographic, and health insurance characteristics. Based on the 2011 State Inpatient Database in Florida, this study modeled patients' travel patterns for hospital inpatient care across geographic areas (by average affluence, urbanicity) and calendar seasons, and across subpopulations (by age, gender, race/ethnicity, and health insurance status). Overall, travel patterns for all subpopulations were best captured by the log-logistic function. Patients in more affluent areas and rural areas tended to travel longer for hospital inpatient care, so did the younger, whites, and privately insured. Longer travel distances may be a necessity for rural patients to cope with lack of accessibility for local hospital care, but for the other population groups, it may indicate rather better mobility and more healthcare choices. The results can be used in various healthcare analyses such as accessibility assessment, hospital service area delineation, and healthcare resource planning.

The number of hospital beds per capita, an important measure of equity in healthcare availability and resource allocation, was found to vary across geographic areas in many countries, including the USA. The hospital service areas (HSAs) have proven to be more meaningful spatial units for studying health-seeking behaviors and health resource allocation and service utilization. However, when evaluating the geographical balance in ratios of hospital beds to population (HBtP), no existing HSA delineation methods directly consider the underlying population distribution. Using Geographic Information Systems (GIS), this study incorporated the State Inpatient Database with census data to develop a population-based HSA delineation method. The census-derived HSAs were produced for Florida and were validated by aggregating and comparing with the traditional flow-based HSAs. The difference in current ratios of HBtP between the most over- and under-served HSAs was approximately 60 times. Significant clusters of high and low ratios were found in Miami and Jacksonville metropolitan areas, respectively. Such results may be of interest to relevant stakeholders and contribute to planning and optimization of hospital resource allocation and healthcare policy-making. Furthermore, the discovery of a strong correlation between the numbers of hospital discharges and the population at ZIP code level holds a remarkable potential for affordable population estimation, especially in non-census years.

Floating Catchment Area (FCA) methods are a popular tool to investigate accessibility to public facilities, in particular health care services. FCA approaches are attractive because, unlike other accessibility measures, they take into account the potential for congestion of facilities. This is done by 1) considering the population within the catchment area of a facility to calculate a variable that measures level of service, and then 2) aggregating the level of service by population centers subject to catchment area constraints. In this paper we discuss an effect of FCA approaches, an artifact that we term demand and level of service inflation. These artifacts are present in previous implementations of FCA methods. We argue that inflation makes interpretation of estimates of accessibility difficult, which has possible deleterious consequences for decision making. Next, we propose a simple and intuitive approach to proportionally allocate demandand and level of service in FCA calculations. The approach is based on a standardization of the impedance matrix, similar to approaches popular in the spatial statistics and econometrics literature. The result is a more intiuitive measure of accessibility that 1) provides a local version of the provider-to-population ratio; and 2) preserves the level of demand and the level of supply in a system. We illustrate the relevant issues with some examples, and then empirically by means of a case study of accessibility to family physicians in the Hamilton Census Metropolitan Area (CMA), in Ontario, Canada. Results indicate that demand and supply inflation/deflation affect the interpretation of accessibility analysis using existing FCA methods, and that the proposed adjustment can lead to more intuitive results., Competing Interests: The authors have declared that no competing interests exist.

Background: This scoping survey is a preliminary part of the Scottish Care of Older People (SCoOP) audit programme, which aims to assess specialist service provision for older people with frailty in Scotland, and provide benchmarking data for improving services., Methods: The survey was distributed to nominated consultant geriatricians based in 12 of the 14 Scottish health boards who completed data to the 'best of their knowledge'. Data collected were: consultant and specialty doctor level workforce; days of frailty unit operation; multidisciplinary team discussion frequency; and, physiotherapy and occupational therapy availability. Consultant cover was correlated with population data, and scores for service components used to derive separate acute and community service provision scores., Results: Consultant geriatrician availability varies widely across Scottish health boards with a median of 1.45 [range: 0.54-2.40; interquartile range (IQR): 0.71-2.28] full-time equivalent consultant geriatricians per 10,000 people ≥65 years. Variation was also present in the service provision scores [score range 0 (none) to 1.0 (very good)]: for acute services, the median national service provision score was 0.81 (range: 0.50-0.89; IQR: 0.75-0.85) and for community services 0.60 (range: 0.48-0.82; IQR: 0.52-0.65)., Conclusions: This report clearly demonstrates mismatch between workforce and services in both acute and community settings in the context of the population size. Future surveys will build on this preliminary information to audit service provision for older people at an individual hospital level., Competing Interests: No conflict of interests declared

Background and Aims: The number of inflammatory bowel disease [IBD]-related visits to the emergency department [ED] is increasing in North America. This study evaluates the relationship between access to specialists and utilization of ED services., Methods: We conducted a population-based study of all IBD patients in Ontario in 2014-2015 to measure utilization of non-emergency IBD care by specialists [NICS] and ED visits. After characterizing regional variation in access to gastroenterologists and region-wide implementation of NICS, we constructed regression models to determine whether they were predictors of individual utilization of NICS and ED services., Results: The number of gastroenterologists per 1000 IBD patients varied geographically, ranging from 1.13 to 10.65, as did the region-wide proportion of patients who received NICS, ranging from 21% to 52%. Compared with those with low access to gastroenterologists, those living in areas with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI]: 2.27-2.47) and high [OR, 1.83; 95% CI: 1.71-1.95] access were more likely to receive NICS. The risk of visits to the ED was lower among those residing in regions with moderate [OR, 0.78; 95% CI: 0.75-0.82] and high access [OR, 0.74; 95% CI: 0.69-0.80] to gastroenterologists and in regions where implementation of NICS was not low [OR, 0.78; 95% CI: 0.75-0.81]., Conclusions: Poor access to outpatient IBD specialist care contributes to IBD-related ED visits. Strategies to increase specialist access may reduce the utilization of emergency services., (Copyright © 2018 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The Population Health Assessment initiative by NCI sought to enhance cancer centers' capacity to acquire, aggregate, and integrate data from multiple sources, as well as to plan, coordinate, and enhance catchment area analysis activities., Methods: Key objectives of this initiative are pooling data and comparing local data with national data. A novel aspect of analyzing data from this initiative is the methodology used to weight datasets from sites that collected both probability and nonprobability samples. This article describes the methods developed to weight data, which cancer centers collected with combinations of probability, and nonprobability sampling designs., Results: We compare alternative weighting methods in particular for the hybrid probability and nonprobability sampling designs employed by different cancer centers. We also include comparisons of local center data with national survey data from large probability samples., Conclusions: This hybrid approach to calculating statistical weights can be implemented both within cancer centers that collect both probability and nonprobability samples with common measures. Aggregation can also apply to cancer centers that share common data elements, and target similar populations, but differ in survey sampling designs., Impact: Researchers interested in local versus national comparisons for cancer surveillance and control outcomes should consider various weighting approaches, including hybrid approaches, when analyzing their data., (©2019 American Association for Cancer Research.)

In May 2016, the NCI announced supplemental funding for NCI-Designated Cancer Centers to conduct research to better characterize populations within cancer center catchment areas. The initiative was intended to support primary data collection efforts to better define and describe cancer center catchment areas using a multilevel population health framework. The long-term goal was to facilitate collaborations in which researchers, providers, public health practitioners, and nonprofit organizations could utilize the data to develop or expand applied cancer control research, planning, and implementation, with an emphasis on local health disparities and communication inequalities. This CEBP Focus issue on "Population Health Assessment in Cancer Center Catchment Areas" highlights the results from those catchment area data collection efforts. Articles highlight research from surveys conducted to define and describe cancer center catchment areas using both probability and nonprobability designs and a variety of sampling techniques, survey modes, and data linkages. Some articles report pooled analyses of data collected by multiple cancer centers to highlight local versus national comparisons based on standardized behavioral and demographic measures. Others examine rural-urban differences in measures relevant to cancer prevention and control. The studies published in this Focus will provide the field with a myriad of methodologic approaches for defining and describing cancer center catchment areas., (©2019 American Association for Cancer Research.)

Background: NCI-Designated Cancer Centers provide key cancer research, prevention, and treatment services to members of their catchment area. Characterization of these areas may be complex given the diverse needs of the populations within, particularly those from low socioeconomic position (SEP). The purpose of this paper is to describe the characterization of the Dana-Farber/Harvard Cancer Center (DF/HCC) catchment area through using a two-pronged approach., Methods: Participants ( n = 1,511) were recruited through (i) an online, probability-based survey ( n = 1,013) and (ii) a supplementary, in-person survey from priority groups (African Americans, Latinos, blue-collar workers, low SEP, homeless; n = 498) within Massachusetts. Study staff worked closely with community partners across the state to reach individuals who may not usually be included in online surveys., Results: There were several differences across samples, with the community-based sample having a higher percentage of low SEP, low education, African Americans, and Latinos compared with the online sample. Differences were also noted in the cancer-related behaviors of the samples, with the community-based sample having higher rates of smoking, particularly within those who were homeless or make less than $20,000 per year. Fewer community-based subgroups were current with cancer screenings, and more showed more indication of potential communication inequalities compared with statewide estimates., Conclusions: The sampling strategy used to characterization of the DF/HCC catchment area provided broad, statewide estimates and additional focus on vulnerable populations, highlighting several potential areas for intervention., Impact: This study provides data to highlight the value of using multiple sampling strategies when characterizing cancer center catchment areas., (©2018 American Association for Cancer Research.)

A spatially adaptive floating catchment is a circular area that expands outward from a provider location until the estimated demand for services in the nearest population locations exceeds the observed number of health care services performed at the provider location. This new way of creating floating catchments was developed to address the change of spatial support problem (COSP) by upscaling the availability of the service observed at a provider location to the county-level so that its geographic association with utilization could be measured using the same spatial support. Medicare Fee-for-Service claims data were used to identify beneficiaries aged ≥ 65 years who received outpatient pulmonary rehabilitation (PR) in the Southeastern United States in 2014 (n = 8798), the number of PR treatments these beneficiaries received (n = 132,508), and the PR providers they chose (n = 426). The positive correlation between PR availability and utilization was relatively low, but statistically significant (r = 0.619, p < 0.001) indicating that most people use the nearest available PR services, but some travel long distances. SAFCs can be created using data from health care systems that collect claim-level utilization data that identifies the locations of providers chosen by beneficiaries of a specific health care procedure., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Late life depression is associated with a significant burden of disease. Estimating depression in older adults can be difficult and requires different methodological approaches from those fitting younger adults. As community prevalence data is scarce in Portugal, we estimated the prevalence of depression in a sample of older Portuguese adults. Moreover, we investigated the association between depression and disability., Methods: A cross-sectional comprehensive one-phase survey was conducted of all residents aged 65 and over of one urban and one rural catchment area in Southern Portugal. Standardized 10/66 assessments include a comprehensive cognitive module and the Geriatric Mental State (GMS)-AGECAT. Information on demographics, non-communicable disease risk factors and disability/functioning (WHODAS 2.0) was also recorded. Depression was assessed using both ICD-10 and EURO-D criteria., Results: We interviewed 1405 older people (mean age 74.9, SD = 6.7 years; 55.5% women) after 313 (18.2%) refusals to participate. The prevalence rate for ICD-10 depression was 4.4 (95% CI 3.5-5.6) and 18.0 (95% CI 16.0-20.1) using the EURO-D case definition. As compared with having no depression, ICD-10 depression was associated with a higher level of disability, even after adjusting for confounders (4.8, 95% CI 2.8-8.1). The same happened with subsyndromal depression ('EURO-D only') cases (2.2, 95% CI 1.4-3.5)., Limitations: Non-generalisability of findings outside of catchment areas., Conclusions: In this sample of older Portuguese people, the prevalence of depression was high and so were the associated levels of disability. EURO-D diagnoses may provide a better picture of clinically significant old age depression as a basis for health and social service planning., (Copyright © 2018. Published by Elsevier B.V.)

The spatial equity of the healthcare system is an important factor in assessing how the different medical service demands of residents are met by different levels of medical institutions. However, previous studies have not paid sufficient attention to multilevel healthcare accessibility based on both the divergence of hierarchical healthcare supplies and variations in residents' behavioral preferences for different types of healthcare. This study aims to propose a demand-driven "2R grid-to-level" (2R-GTL) method of analyzing the spatial equity in access to a multilevel healthcare system in Chengdu. Gridded populations, real-time travel distances and residents' spatial behavioral preferences were used to generate a dynamic and accurate healthcare accessibility assessment. The results indicate that significant differences exist in the spatial accessibility to different levels of healthcare. Approximately 90% of the total population living in 57% of the total area in the city can access all three levels of healthcare within an acceptable travel distance, whereas multilevel healthcare shortage zones cover 42% of the total area and 12% of the population. A lack of primary healthcare is the most serious problem in these healthcare shortage zones. These results support the systematic monitoring of multilevel healthcare accessibility by decision-makers. The method proposed in this research could be improved by introducing nonspatial factors, private healthcare providers and other cultural contexts and time periods.

Many Canadians experience unequal access to primary care services, despite living in a country with a universal health care system. Health inequalities affect all Canadians but have a much stronger impact on the health of vulnerable populations. Health inequalities are preventable differences in the health status or distribution of health resources as experienced by vulnerable populations. A geospatial approach was applied to examine how closely the distribution of primary care providers (PCPs) in London, Ontario meet the needs of vulnerable populations, including people with low income status, seniors, lone parents, and linguistic minorities. Using enhanced two step floating catchment area (E2SFCA) method, an index of geographic access scores for all PCPs and PCPs speaking French, Arabic, and Spanish were separately developed at the dissemination area (DA) level. To analyze how PCPs are distributed, comparative analyses were performed in association with specific vulnerable groups. Geographical accessibility to all PCPs, and PCPs who speak specific minority languages vary considerably across the city of London. Access scores for French- and Arabic-speaking PCPs are found comparatively high (mean = 2.85 and 1.01 respectively) as compared to Spanish-speaking PCPs (mean = 0.47). Additionally, many areas with high proportions of vulnerable populations experience low accessibility. Despite its exploratory nature, this study offers insight into intra-urban distributions of geographical accessibility to primary care resources for vulnerable groups. These findings can facilitate health researchers and policymakers in the development of recommendations to increase levels of accessibility of specific population groups in underserved areas., Competing Interests: The authors have declared that no competing interests exist.

Due to restrictions on personnel availability, the service capacity at a health facility may vary day to day based on an established schedule. This temporal variability influences a user's choice set, modifying their possible choices. As a result, the spatial accessibility of public health care may be constantly reshaped rather than being a relatively static experience as commonly represented in place-based spatial accessibility literature. Building on the latest advances in the two-step floating catchment method, this study presents further advancements through the inclusion of health facility schedules to better represent health care availability in the assessment of accessibility. The results show that the proposed method reveals communities with relatively poor accessibility that are hidden with many existing methods. By exposing the available care within time windows, a more accurate picture of the services available to be accessed is revealed. The findings suggest that improvement in the number of doctor hours at health facilities may reduce the disparities found in accessibility scores for communities. Further, in public health care systems similarly structured, the spatial configuration of facilities with doctors can be considered at the administrative level to ensure adequate levels of access across the jurisdiction., (© 2018 John Wiley & Sons, Ltd.)

This study quantifies the spatiotemporal risk of child abuse and neglect in Los Angeles at the census tract level over a recent 4-year period, identifies areas of increased risk, and evaluates the role of structural disadvantage in substantiated child maltreatment referrals. Child maltreatment data on 83,379 child maltreatment cases in 1,678 census tracts spanning 2006-2009 were obtained from the Los Angeles County Department of Children and Family Services. Substantiated referral counts were analyzed across census tracts with Bayesian hierarchical spatial models using integrated nested Laplace approximations. Results showed that the unadjusted yearly rate of child abuse and neglect held fairly steady over the study period decreasing by only 2.57%. However, the temporal term in the spatiotemporal model reflected a downward trend beginning in 2007. High rates of abuse and neglect were predicted by several neighborhood-level measures of structural burden. Every 1-unit decrease in the social vulnerability index reduced the risk of child abuse and neglect by 98.3% (95% CrI = 1.869-2.1042) while every 1-unit increase in the Black-White dissimilarity index decreased child abuse and neglect risk by 70.6%. The interaction of these variables demonstrated the protective effect of racial heterogeneity in socially vulnerable neighborhoods. No such effect was found in neighborhoods characterized by low levels of vulnerability. Population-based child abuse and neglect prevention and intervention efforts should be aided by the characteristics of neighborhoods that demonstrate strong spatial patterns even after accounting for the role of race and place.

Background: Studying and measuring accessibility to care services has become a major concern for health care management, particularly since the global financial collapse. This study focuses on Tuscany, an Italian region, which is re-organizing its inpatient and outpatient systems in line with new government regulations. The principal aim of the paper is to illustrate the application of GIS methods with real-world scenarios to provide support to evidence-based planning and resource allocation in healthcare., Methods: Spatial statistics and geographical analyses were used to provide health care policy makers with a real scenario of accessibility to outpatient clinics. Measures for a geographical potential spatial accessibility index using the two-step floating catchment area method for outpatient services in 2015 were calculated and used to simulate the rationalization and reorganization of outpatient services. Parameters including the distance to outpatient clinics and volumes of activity were taken into account., Results: The spatial accessibility index and the simulation of reorganization in outpatient care delivery are presented through three cases, which highlight three different managerial strategies. The results revealed the municipalities where health policy makers could consider a new spatial location, a shutdown or combining selected outpatient clinics while ensuring equitable access to services., Conclusions: A GIS-based approach was designed to provide support to healthcare management and policy makers in defining evidence-based actions to guide the reorganization of a regional health care delivery system. The analysis provides an example of how GIS methods can be applied to an integrated framework of administrative health care and geographical data as a valuable instrument to improve the efficiency of healthcare service delivery, in relation to the population's needs.

Healthcare accessibility has become an issue of social equity. An accurate estimation of existing healthcare accessibility is vital to plan and allocate health resources. Healthcare capacity, population demand, and geographic impedance are three essential factors to measure spatial accessibility. Additionally, geographic impedance is usually represented with a function of travel time. In this paper, the three-step floating catchment area (3SFCA) method is improved from the perspectives of the temporal dimension and population demand. Specifically, the travel time from the population location to the service site is precisely calculated by introducing real-time traffic conditions instead of utilizing empirical speed in previous studies. Additionally, with the utilization of real-time traffic, a dynamic result of healthcare accessibility is derived during different time periods. In addition, since the medical needs of the elderly are higher than that of the young, a demand weight index of demand is introduced to adjust the population demand. A case study of healthcare accessibility in Wuhan shows that the proposed method is effective to measure healthcare accessibility during different time periods. The spatial accessibility disparities of communities and crowdedness of hospitals are identified as an important reference for the balance between the supply and demand of medical resources.

Accessible primary healthcare is important to national healthcare in general and for older persons in particular, in societies where the population is ageing rapidly, as in Singapore. However, although much policy and research efforts have been put into this area, we hardly find any spatial perspective to assess the accessibility of these primary healthcare services. This paper analyzes the geographical accessibility of one major healthcare service in Singapore, namely, General Practitioners (GPs) services under the Community Health Assist Scheme (CHAS) for older persons. A Python script was developed to filter the website data of the Housing Development Board (HDB) of Singapore. The data derived was comprehensively analyzed by an Enhanced 2-Step Floating Catchment Area (E2SFCA) method based on a Gaussian distance-decay function and the GIS technique. This enabled the identification of areas with relatively weak geographical accessibility of CHAS-GPs. The findings are discussed along with suggestions for health practitioners, service planners and policy makers. Despite its initial nature, this study has demonstrated the value of innovative approaches in data collection and processing for the elderly-related studies, and contributed to the field of healthcare services optimization and possibly to other human services.

Importance: Little is known about the types of primary care practices that have chosen to participate in the Comprehensive Primary Care Plus (CPC+) program or about how participation could affect disparities., Objective: To describe practices that joined the CPC+ model and compare hospital service areas with and without CPC+ practices., Design, Setting, and Participants: This comparative cross-sectional study identified 2647 CPC+ practices in round 1 (from January 1, 2017; round 1 is ongoing through 2021). Using IMS Health Care Organization Services data, ownership and characteristics of health systems and practices were extracted. Practices participating in the CPC+ program were compared with practices with similar proportions of primary care physicians (>85%) within the 14 regions designated as eligible to participate by the Centers for Medicare & Medicaid Services. Within eligible regions, hospital service areas with (n = 434) and without (n = 322) 1 or more CPC+ practice were compared. Characteristics compared included area-level population demographics (from the US Census Bureau), health system characteristics (from the IMS Health Care Organization Services), and use of health services by Medicare fee-for-service enrollees (Dartmouth Atlas)., Main Outcomes and Measures: Area-level characteristics of all eligible CPC+ regions, areas without a CPC+ practice, and areas with 1 or more CPC+ practices., Results: Of 756 eligible service areas, 322 had no CPC+ practices and 434 had at least 1 CPC+ practice. Of 2647 CPC+ practices, 579 (21.9%) had 1 physician and 1791 (67.7%) had 2 to 10 physicians. In areas without CPC+ practices, the population had a lower median income ($43 197 [interquartile range, $42 170-$44 224] vs $57 206 [interquartile range, $55 470-$58 941]), higher mean share of households living in poverty (17.8% [95% CI, 17.2%-18.4%] vs 14.4% [95% CI, 13.9%-15.0%]), higher mean educational attainment of high school or less (52.7% [95% CI, 51.7%-53.6%] vs 43.1% [95% CI, 42.1%-44.2%]), higher mean proportion of disabled residents (17.7% [95% CI, 17.3%-18.2%] vs 14.2% [13.8%-14.6%]), higher mean participation in Medicare (21.9% [95% CI, 21.3%-22.4%] vs 18.8% [95% CI, 18.3%-19.1%]) and Medicaid (22.2% [95% CI, 21.5%-22.9%]) vs 18.5% [95% CI, 17.8%-19.2%]), and higher mean proportion of uninsured residents (12.4% [95% CI, 11.9%-12.9%] vs 10.3% [95% CI, 9.9%-10.7%]) (P < .001 for all) compared with areas that had a CPC+ practice., Conclusions and Relevance: According to this study, although a diverse set of practices joined the CPC+ program, practices in areas characterized by patient populations with greater advantage were more likely to join, which may affect access to advanced primary care medical home models such as CPC+, by vulnerable populations.

Background: Human animal-bite injuries are a serious public health problem due to associated risk for rabies virus exposure. Animal-bite injuries especially dog bites are useful indicators for assessing the risk of rabies virus transmission and need for rabies post exposure prophylaxis (PEP). Understanding the epidemiology and surveillance of animal bites and rabies post-exposure prophylaxis is critical in implementing Kenya's national rabies elimination strategy. We aimed to describe the incidence of human animal-bite injuries, patient/biting animal characteristics, uptake of rabies PEP and factors associated with animal bite incidents., Methods: We reviewed animal bite records from outpatient and anti-rabies vaccine (ARV) registers of 17 health facilities from five counties. An animal bite was defined as an entry of an animal bite of the class mammal including humans in registers in a person of any age from January 2011 to December 2016. We collected demographic and information on PEP uptake. We calculated descriptive statistics, odds ratios (OR) and 95% confidence interval (CI) to examine factors associated with being an animal bite case-patient. We also calculated incidence of animal bites using health facility catchment population for year 2016 as the denominator., Results: We analyzed 7307 records. The median age was 22 years (IQR = 31 years); there were 4019 (55%) male and age < 15 years were 2607 (37%). Dogs accounted for 6720 (93%) of bites of which 78% were owned free-roaming dogs. Of the 5674 (88%) cases that received rabies PEP, 2247 (40%) got at least three-doses. The median time from bite to seeking medical care was 2 days (IQR = 4 days). Being bitten on the head/face (OR = 5.8; CI: 3.3-10.2); being bitten by owned free-roaming dog (OR = 1.7; CI: 1.5-1.9) and being male (OR = 1.4; CI: 1.3-1.5) were significantly associated with being an animal-bite case-patient. Being male, being bitten on head/face and being bitten by owned free-roaming dog remained independently associated with being an animal bite case-patient at multivariable logistic regression. Bite-incidence was 289 bites /100,000 persons among all counties., Conclusion: Preventing dog bites would most effectively reduce bite injuries by improving public health education among children below 15 years, encouraging early PEP initiation and completion, development and implementation of responsible dog ownership and animal behaviour educational programmes as well as improving human and veterinary health linkages.

Objective: To demonstrate the use of multiple-membership multilevel models, which analytically structure patients in a weighted network of hospitals, for exploring between-hospital variation in preventable hospitalizations., Data Sources: Cohort of 267,014 people aged over 45 in NSW, Australia., Study Design: Patterns of patient flow were used to create weighted hospital service area networks (weighted-HSANs) to 79 large public hospitals of admission. Multiple-membership multilevel models on rates of preventable hospitalization, modeling participants structured within weighted-HSANs, were contrasted with models clustering on 72 hospital service areas (HSAs) that assigned participants to a discrete geographic region., Data Collection/extraction Methods: Linked survey and hospital admission data., Principal Findings: Between-hospital variation in rates of preventable hospitalization was more than two times greater when modeled using weighted-HSANs rather than HSAs. Use of weighted-HSANs permitted identification of small hospitals with particularly high rates of admission and influenced performance ranking of hospitals, particularly those with a broadly distributed patient base. There was no significant association with hospital bed occupancy., Conclusion: Multiple-membership multilevel models can analytically capture information lost on patient attribution when creating discrete health care catchments. Weighted-HSANs have broad potential application in health services research and can be used across methods for creating patient catchments., (© 2017 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Objective: To investigate the association between older adults' potentially avoidable hospitalization rates and both a geographic measure of primary care physician (PCP) access and a standard bounded-area measure of PCP access., Data Sources: State physician licensure data from the Virginia Board of Medicine. Patient-level hospital discharge data from Virginia Health Information. Area-level data from the American Community Survey and the Area Health Resources Files. Virginia Information Technologies Agency road network data. US Census Bureau TIGER/Line boundary files., Study Design: We use enhanced two-step floating catchment area methods to calculate geographic PCP accessibility for each ZIP Code Tabulation Area in Virginia. We use spatial regression techniques to model potentially avoidable hospitalization rates., Data Collection/extraction: Geographic accessibility was calculated using ArcGIS. Physician locations were geocoded using TAMU GeoServices and ArcGIS., Principal Findings: Increased geographic access to PCPs is associated with lower rates of potentially avoidable hospitalization among older adults. This association is robust, allowing for spatial spillovers in spatial lag models., Conclusions: Compared to bounded-area density measures, unbounded geographic accessibility measures provide more robust evidence that avoidable hospitalization rates are lower in areas with more PCPs per person. Results from our spatial lag models reveal the presence of positive spatial spillovers., (© Health Research and Educational Trust.)