Acceptability to Healthcare Professionals of Home-Based HPV Self-Sampling for Cervical Screening: A French Qualitative Study Conducted in an Area with Low Access to Health Services.

Self-sampling may improve participation in cervical cancer secondary prevention programs by women who do not respond or respond irregularly when invited to contact a health professional for the collection of a cervical specimen. It could also help resolve access problems in areas with a low physician density. The present qualitative study examined barriers to screening, effective screening strategies, and the advantages and disadvantages of sending women urine or vaginal self-sampling kits in two medically underserved administrative departments in France (Mayenne and Sarthe) showing low cervical screening coverage. As part of the CapU4 randomized trial, a team of psychologists investigated the attitudes and experiences of 59 healthcare professionals (gynecologists, general practitioners, and midwives) through semi-structured interviews. Results indicated that health professionals believe that self-sampling may address the issues of low physician density and underscreening by removing logistical, organizational, financial, and psychological obstacles. They confirmed trust in the use of vaginal self-sampling, with urine self-sampling as an alternative solution (e.g., for women with vaginismus). The health professionals also identified several limitations of the self-sampling kit that will need to be addressed in future screening campaigns (incomplete kit, complex instructions, poor anatomical knowledge, and obesity).

Physician density: will we ever close the gap?

OBJECTIVE: Physician density is a crucial element of a well-functioning health system. Previous research has investigated factors affecting country-level physician supply. To date, however, no evidence has been provided about the patterns of convergence in physician density among countries. This paper thus tested club convergence in physician density in 204 countries worldwide from 1990 to 2019. A nonlinear time-varying factor model was adopted to identify potential clubs, wherein groups of countries tend to converge towards the same level of physician density. Our primary purpose was to document the potential long-lasting disparity in future global physician distribution. RESULTS: Despite physician density increasing in all regions globally from 1990 to 2019, we found no evidence in favor of the hypothesis of global convergence. Conversely, the clustering algorithm successfully identified three main patterns (i.e., three final clubs). With few exceptions, the results indicated an uneven physician distribution between the majority of North and Sub-Saharan African countries (where physician density would remain well below the estimated threshold of at least 70% of the Universal Health Coverage Services Index) and the rest of the world. These findings support the WHO's global strategy to reverse the chronic under-investment in human resources for health.

The effect of physician density on colorectal cancer stage at diagnosis: causal inference methods for spatial data applied on regional-level data.

BACKGROUND: The early detection of colorectal cancer (CRC) through regular screening decreases its incidence and mortality rates and improves survival rates. Norway has an extremely high percentage of CRC cases diagnosed at late stages, with large variations across municipalities and hospital catchment areas. This study examined whether the availability of physicians related to CRC primary diagnosis and preoperative investigations, or physician density, contributes to the observed geographical differences in late-stage incidence rates. METHOD: Municipality-level data on CRC stage at diagnosis were obtained from the Cancer Registry of Norway for the period 2012-2020. Physician density was calculated as the number of physicians related to CRC investigations, general practitioners (GPs) and specialists per 10,000 people, using physician counts per municipality and hospital areas from Statistics Norway. The relationship was examined using a novel causal inference method for spatial data-neighbourhood adjustment method via spatial smoothing (NA approach)-which allowed for studying the region-level effect of physician supply on CRC outcome by using spatially referenced data and still providing causal relationships. RESULTS: According to the NA approach, an increase in one general practitioner per 10,000 people will result in a 3.6% (CI -0.064 to -0.008) decrease in late-stage CRC rates. For specialists, there was no evidence of a significant correlation with late-stage CRC distribution, while for both groups, GPs and specialists combined, an increase of 1 physician per 10,000 people would be equal to an average decrease in late-stage incidence rates by 2.79% (CI -0.055 to -0.001). CONCLUSION: The study confirmed previous findings that an increase in GP supply will significantly improve CRC outcomes. In contrast to previous research, this study identified the importance of accessibility to both groups of physicians-GPs and specialists. If GPs encounter insufficient workforces in hospitals and long delays in colonoscopy scheduling, they will less often recommend colonoscopy examinations to patients. This study also highlighted the efficiency of the novel methodology for spatially referenced data, which allowed us to study the effect of physician density on cancer outcomes within a causal inference framework.

Physician care access plays a significant role in extending global and regional life expectancy.

BACKGROUND: Previous cross-sectional studies generally did not fully consider the potential confounding factors associated with physician impact on overall population health. This ecological study controlled for health, demographic and socioeconomic confounders while using total physician density for predicting overall population health globally and regionally. METHODS: Ecological data were extracted from the United Nations agencies for 215 populations. Considering the competing effects of economic affluence, urban advantages and obesity, correlations between physician density and life expectancy at birth (LEB) were analysed with scatter plots, bivariate correlation, partial correlation and multiple linear regression analyses. Countries are also grouped for exploring the regional correlations between physician density and LEB. RESULTS: Physician density correlates to LEB and this relationship remains regardless of the competition of the individual confounders, economic affluence, urbanization and obesity, or their combination. Physician density has the greatest influence on LEB, while economic affluence is second. Physician density explains 64.89% of LEB in this study. Together with constant bivariate correlations in country groupings, power correlation without a plateau or U shape in the trendline of the scatterplots, suggests that a shortage of physicians is a worldwide issue. CONCLUSIONS: Physician density is a major independent contributor for LEB both globally and with special regard to the developing world. Telehealth may be an alternative to increase physicians' capacity while funding for increasing physician employment is desirable.

Socioeconomic Factors Contributing to Antibiotic Resistance in China: A Panel Data Analysis.

The relationship between socioeconomic factors and antibiotic resistance (ABR) prevalence remains a knowledge gap in China. In this study, our aim was to examine the association between ABR prevalence and socioeconomic factors across 30 provinces in mainland China. We used two measures of level of ABR: the proportion of methicillin-resistant Staphylococcus aureus (MRSA), third-generation cephalosporin-resistant Escherichia coli (3GCREC), and third-generation cephalosporin-resistant Klebsiella pneumoniae (3GCRKP), and the aggregate resistance. The data of ABR prevalence, education, gross domestic product (GDP) per capita, out-of-pocket (OOP) health expenditure, physician density, hospital bed density, and public toilet density during 2014 and 2018 in 30 provinces in mainland China were included. We examined the association between ABR prevalence and potential contributing socioeconomic factors using panel data modeling. In addition, we explored this relationship in the eastern, central, and western economic zones. Our results indicated that GDP per capita was significantly positively correlated with ABR in mainland China and the eastern economic zone; however, significantly positive associations did not exist in the central and western economic zones. Surprisingly, both higher GDP per capita and higher OOP health expenditure were associated with a higher level of MRSA, but a lower level of 3GCREC; higher physician density was associated with a lower level of MRSA, but a higher level of 3GCREC. In addition, ABR prevalence presented a decline trend during 2014 and 2018. Our study showed the potential associ-ations between resistance and GDP per capita, OOP health expenditure, physician density. It high-lights that the social and economic determinants can be of importance in tacking the development and spread of ABR in mainland China.

Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma.

BACKGROUND: Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions. METHODS: Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density. RESULTS: The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancer-specific 5-year mortality. CONCLUSIONS: Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes.

Hospitalization Trajectories in Home- and Community-Based Services Recipients: The Influence of Physician and Social Care Density.

OBJECTIVES: Repeated hospitalizations among older adults receiving Home- and Community-Based Services (HCBS) may indicate unmet medical and social needs. This study examined all-cause hospitalization trajectories and the association between area-level resource density for medical and social care and the trajectory group membership. METHODS: The study participants included 11,223 adults aged 60 years or older who were enrolled in public HCBS programs in Michigan between 2008 and 2012. Data sources included the Michigan interRAI-Home Care, Dartmouth Atlas of Health Care Data, the American Community Survey, and the County Business Patterns from the Census Bureau. The group-based trajectory modeling was used to identify trajectories of hospitalization over 15 months. Correlates of the trajectories were examined using multinomial logistic regression. RESULTS: Four distinct hospitalization trajectory groups emerged: "never" (43.1%)-individuals who were rarely hospitalized during the study period, "increasing" (19.9%)-individuals who experienced an increased risk of hospitalization, "decreasing" (21.6%)-individuals with a decreased risk, and "frequent" (15.8%)-individuals with frequent hospitalizations. Older adults living in areas with a higher number of social service organizations for older adults and persons with disability were less likely to be on the "frequent" trajectory relative to the "decreasing" trajectory. The density of primary care physicians was not associated with the trajectory group membership. DISCUSSION: Area-level social care resource density contributes to changes in 15-month hospitalization risks among older adult recipients of HCBS.

Associations between area-level deprivation, rural residence, physician density, screening policy and late-stage colorectal cancer in Canada.

BACKGROUND: Important social disparities in colorectal screening exist in Canada. Few studies have assessed disparities further along the cancer control continuum. Here we assess the associations between social and material deprivation, physician density, rural residence, and the absence of provincial mail-based screening programs and colorectal cancer (CRC) stage at diagnosis. METHODS: Colorectal cancer cases and stage data ("local or regional" if stage 0, I, or II, "late" if stage III or IV) were obtained through the Canadian Cancer Registry (2011-2015, N = 54,745). Cases were linked to 2006 Canadian Census Dissemination Area-level data on rural/urban status, exposure to a provincial mail-based screening program, and social and material deprivation (Pampalon Index quintile groups); and to Scott's Medical Database 2011 physician density data (<7 vs. ≥ 7/10,000). Age, sex, and predictor-adjusted Generalized estimating equation (GEE) Poisson models were used to determine independent associations between predictors and late-stage at diagnosis. RESULTS: Half of CRC cases are diagnosed at stage III or IV (51 %), with younger age groups experiencing higher late-stage prevalence (57 % among those aged 18-49). The covariate-adjusted late-stage prevalence was 2-percentage points higher in most materially- and socially-deprived areas (95 % CI: 1 %, 4 %, in both, respectively) and in provinces with no mail-based screening programs (95 % CI: 1 %, 2 %). No significant differences were observed according to rural residence or physician density. CONCLUSIONS: Social disparities in late-stage CRC diagnosis are modest. Continued surveillance of these disparities may be warranted as provinces continue to promote early cancer detection through screening, and stage distributions may change overtime.

Variation in the utilization of robotic surgical operations.

The appropriate use of the robot in surgery continues to evolve. Robotic operations (RO) are particularly advantageous for deep pelvic and retroperitoneal procedures, but the implementation of RO is unknown. We aimed to examine regional variation for the most commonly performed RO in general, gynecologic, and urologic surgery. A three-state inpatient database from 2008 to 2011 was used. Nine common robotic inpatient general, gynecologic and urologic surgery procedures were analyzed. States were divided into hospital service areas (HSAs). The percentage of RO was calculated for each operation. Hospital service areas that had < 50% or > 150% of the RO average were outliers. Hospital service areas were compared based on demographics, patterns of adoption, variation in usage, and association with population, physician and hospital density. Hysterectomies were the procedure that was performed most often robotically. Over 50% of radical prostatectomies were performed robotically. Procedures with the highest rate of RO performance were performed with the least variation. Characteristics that were significantly correlated with RO included provider and hospital density. Variation in the utilization of RO is common and differs by operation. Physician density impacts access to care and is associated with the variation in use of RO depending on procedure type. Further research is needed to understand the causes of variation and adoption of RO.

[Do online ratings reflect structural differences in healthcare? The example of German physician-rating websites]. / Spiegeln Onlinebewertungen Strukturunterschiede in der Versorgung wider? Eine Analyse am Beispiel von Arztbewertungsportalen.

BACKGROUND: Previous surveys have shown that patient satisfaction varies with the regional supply of physicians. Online ratings on physician-rating websites represent a relatively new instrument to display patient satisfaction results. The aim of this study was (1) to assess the current state of online ratings for two medical disciplines (dermatologists and ear, nose and throat (ENT) specialists), and (2) to analyze online derived patient satisfaction results according to the physician density in Germany. METHODS: We collected online ratings for 420 dermatologists and 450 ear, nose, and throat (ENT) specialists on twelve German physician-rating websites. We analyzed the online ratings according to the physician density (low, medium, high physician density). For this purpose, we collected secondary data from both physician-rating websites and the regional associations of statutory health insurance physicians. Data analysis was performed using Median tests and Chi-square tests. RESULTS: In total, 10,239 online ratings for dermatologists and 8,168 online ratings for ENT specialists were analyzed. Almost all dermatologists (99.3 %) and ENT specialists (98.9 %) were listed on one of the physician-rating websites. A total of 93.5 % of all listed dermatologists and 96.9 % of ENT-specialists were rated on at least one of the physician-rating websites. Significant differences were found in the distribution (i.e., percentage of listed or rated physicians) of the ratings according to the regional physician density on only one physician-rating website (p<0.001). Furthermore, online ratings were shown to be better in regions with a higher physician density on two physician-rating website. On jameda.de, for example, dermatologist ratings were better in regions with a higher physician density compared to regions with a lower number of physicians (average rating: 2.16 vs. 2.67; p<0.001). CONCLUSIONS: Online ratings of dermatologists and ENT specialists hardly differ in terms of regional physician density. Physician-rating websites thus do not appear to be appropriate to mirror differences in the health service delivery structure. Our findings thus do not confirm the results from previously published studies.

Treatment gaps in Parkinson's disease care in the Philippines.

Neurological services and resources are scarce in low-income and developing countries, such as the Philippines. We looked into the treatment gaps in Parkinson's disease (PD) care in the Philippines in the following areas: epidemiology, healthcare, financial coverage, pharmacotherapy, surgical treatment and manpower. We collected relevant data on the above-mentioned areas. There is no available Philippine data on PD prevalence. Philippine healthcare is paid through user fees at the point of service. The average consultation fee in Manila ranges from US$10.57-31.74. The average minimum daily wage is US$9.39-10.17. Philippine healthcare is devolved to the local government units. Deep brain stimulation surgery is only available in Manila. Most PD medications are available in the Philippines. There are only nine movement disorder specialists for a population of 100.98 million. Gaps and challenges in PD care in the Philippines still exist.

[Provision of outpatient specialist care for mental disorders : Minor regional differences in treatment needs, major regional differences in availability]. / Ambulante fachärztliche Versorgung psychischer Störungen : Kleine regionale Unterschiede im Bedarf, große regionale Unterschiede in der Versorgungsdichte.

BACKGROUND: Due to the high burden attributed to mental disorders, an important purpose of a general healthcare system is to provide comprehensive medical specialist care that is both locally available and in line with demand; however, the density of outpatient physicians and psychotherapists significantly varies between regions in Germany. To verify if these variations reflect regional variations of morbidity rates, routine data of statutory health insurance companies are analyzed on a regular basis. But these administrative data directly depend on the actual regional health care supply. Hence, independent epidemiological data on prevalence rates of mental disorders could be a valuable supplement. METHODS: Analyses are based on prevalence rates of the representative epidemiological German health interview and examination survey and its mental health module (DEGS1-MH) as well as supplemental data from the German national and regional associations of statutory health insurance physicians. The associations between prevalence rates and density of outpatient physicians and psychotherapists were computed for the DEGS sample points, representing 139 different German districts. Transregional care provision for neighboring regions was taken into account. RESULTS: There were neither significant associations of regional density of outpatient physicians and psychotherapists with prevalence rates of mental disorders in general nor with prevalence rates of severe mental disorders; however, taking into account transregional care provision for neighboring regions the huge variability of provider density decreases. DISCUSSION: The regional inequality of physician and psychotherapist density cannot be explained by regional differences in treatment needs. The results indicate potential improvements in healthcare provision for mental disorders in Germany through the adaptation to actual morbidity rates; however, the definition of treatment needs in mental disorders requires further evaluation.

Regional distribution of physicians: the role of comprehensive private health insurance in Germany.

OBJECTIVE: In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients. METHODS: The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010. RESULTS: Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect. CONCLUSION: From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.