Travel time to emergency care not by geographic time, but by optimal time: A nationwide cross-sectional study for establishing optimal hospital access time to emergency medical care in South Korea.

Increase in travel time, beyond a critical point, to emergency care may lead to a residential disparity in the outcome of patients with acute conditions. However, few studies have evaluated the evidence of travel time benchmarks in view of the association between travel time and outcome. Thus, this study aimed to establish the optimal hospital access time (OHAT) for emergency care in South Korea. We used nationwide healthcare claims data collected by the National Health Insurance System database of South Korea. Claims data of 445,548 patients who had visited emergency centers between January 1, 2006 and December 31, 2014 were analyzed. Travel time, by vehicle from the residence of the patient, to the emergency center was calculated. Thirteen emergency care-sensitive conditions (ECSCs) were selected by a multidisciplinary expert panel. The 30-day mortality after discharge was set as the outcome measure of emergency care. A change-point analysis was performed to identify the threshold where the mortality of ECSCs changed significantly. The differences in risk-adjusted mortality between patients living outside of OHAT and those living inside OHAT were evaluated. Five ECSCs showed a significant threshold where the mortality changed according to their OHAT. These were intracranial injury, acute myocardial infarction, other acute ischemic heart disease, fracture of the femur, and sepsis. The calculated OHAT were 71-80 min, 31-40 min, 70-80 min, 41-50 min, and 61-70 min, respectively. Those who lived outside the OHAT had higher risks of death, even after adjustment (adjusted OR: 1.04-7.21; 95% CI: 1.03-26.34). In conclusion, the OHAT for emergency care with no significant increase in mortality is in the 31-80 min range. Optimal travel time to hospital should be established by optimal time for outcomes, and not by geographic time, to resolve the disparities in geographical accessibility to emergency care.

Significant reductions in tertiary hospital encounters and less travel for families after implementation of Paediatric Care Coordination in Australia.

BACKGROUND: Over a third of Australian children have long-term health conditions, often involving multiple organ systems and resulting in complex health care needs. Our healthcare system struggles to meet their needs because of sectoral fragmentation and episodic models of care. Children with medical complexity (CMC) currently rely on tertiary paediatric hospitals for most of their healthcare, but this is not sustainable. We evaluated the impacts of Care Coordination on tertiary hospital service use and family outcomes. METHODS: A pre- and post-implementation cohort evaluation of the Care Coordination service at a tertiary paediatric hospital network, was undertaken. From July 2015 CMC enrolled in the service had access to a Care Coordinator, shared-care plans, linkage with local general practitioners (GPs), and access to a 24-h Hotline from August 2016. CMC were those with ≥4 emergency department (ED) presentations, hospital stays of ≥14 days, or ≥ 10 outpatient appointments in 12 months. Medically fragile infants at risk of frequent future hospital utilisation, and children with medical problems complicated by difficult family psychosocial circumstances were also included. Care Coordinators collected outcomes for each enrolled child. Administrative data on hospital encounters 6 months pre- and post-enrolment were analysed for children aged > 6 months. RESULTS: An estimated 557 hospital encounters, were prevented in the 6 months after enrolment, for 534 children aged > 6 months. ED presentations decreased by 40% (Chi2 = 37.95; P < 0.0001) and day-only admissions by 42% (Chi2 = 7.54; P < 0.01). Overnight admissions decreased by 9% but this was not significant. An estimated Au$4.9 million was saved over 2 years due to prevented hospital encounters. Shared-care plans were developed for 83.5%. Of 84 children who had no regular GP, 58 (69%) were linked with one. Fifty-five (10%) of families were linked to the 24-h Hotline to enable remote access to support and advice. Over 50,000 km of family travel and 370 school absences was prevented. CONCLUSIONS: The Care Coordination service has clear benefits for the tertiary paediatric hospital network and for families. Ongoing evaluation is essential for continuous improvement and to support adjustments to the model according to the local context.

Leptospirosis among Returned Travelers: A GeoSentinel Site Survey and Multicenter Analysis-1997-2016.

Leptospirosis is a potentially fatal emerging zoonosis with worldwide distribution and a broad range of clinical presentations and exposure risks. It typically affects vulnerable populations in (sub)tropical countries but is increasingly reported in travelers as well. Diagnostic methods are cumbersome and require further improvement. Here, we describe leptospirosis among travelers presenting to the GeoSentinel Global Surveillance Network. We performed a descriptive analysis of leptospirosis cases reported in GeoSentinel from January 1997 through December 2016. We included 180 travelers with leptospirosis (mostly male; 74%; mostly tourists; 81%). The most frequent region of infection was Southeast Asia (52%); the most common source countries were Thailand (N = 52), Costa Rica (N = 13), Indonesia, and Laos (N = 11 each). Fifty-nine percent were hospitalized; one fatality was reported. We also distributed a supplemental survey to GeoSentinel sites to assess clinical and diagnostic practices. Of 56 GeoSentinel sites, three-quarters responded to the survey. Leptospirosis was reported to have been most frequently considered in febrile travelers with hepatic and renal abnormalities and a history of freshwater exposure. Serology was the most commonly used diagnostic method, although convalescent samples were reported to have been collected infrequently. Within GeoSentinel, leptospirosis was diagnosed mostly among international tourists and caused serious illness. Clinical suspicion and diagnostic workup among surveyed GeoSentinel clinicians were mainly triggered by a classical presentation and exposure history, possibly resulting in underdiagnosis. Suboptimal usage of available diagnostic methods may have resulted in additional missed, or misdiagnosed, cases.

Comparing Access to Laser Capsulotomy Performed by Optometrists and Ophthalmologists in Oklahoma by Calculated Driving Distance and Time.

PURPOSE: To quantify Medicare beneficiary proximity to his or her yttrium-aluminum-garnet (YAG) laser capsulotomy-providing ophthalmologist and optometrist in Oklahoma by calculating driving distances and times. DESIGN: Cross-sectional cohort study using 2014 Oklahoma Medicare 100% and 5% data sets and Google Maps distance and travel time application programming interfaces. PARTICIPANTS: U.S. fee-for-service Medicare beneficiaries and Oklahoma ophthalmologist and optometrist laser capsulotomy providers. METHODS: The 2014 Medicare Provider Utilization and Payment Limited 100% and 5% datasets from the Centers for Medicare and Medicaid (CMS) were obtained to identify the office street addresses of Oklahoma ophthalmologists and optometrists who submitted claims to Medicare for a YAG laser capsulotomy, and the county addresses of the corresponding Medicare beneficiaries who received the laser capsulotomy. The shortest travel distances and travel times between the beneficiary and the laser provider were calculated by using Google Maps distance and travel time application programming interfaces. MAIN OUTCOME MEASURES: Beneficiary driving distances and times to his or her YAG laser capsulotomy-providing Oklahoma ophthalmologist and optometrist. RESULTS: In 2014, 90 (57%) of 157 Oklahoma ophthalmologists and 65 (13%) of 506 Oklahoma optometrists submitted a total of 7521 and 3751 YAG laser capsulotomy claims to Medicare, respectively. By using the Medicare Limited 5% dataset, there was no difference in driving distance between beneficiaries who received a laser capsulotomy from an ophthalmologist (median, 39 miles; interquartile range [IQR], 13-113 miles) compared with an optometrist (median, 46 miles; IQR, 13-125 miles; P = 0.93) or in driving time to an ophthalmologist (median, 47 minutes; IQR, 19-110 minutes) compared with an optometrist (median, 50 minutes; IQR, 17-117 minutes; P = 0.76). CONCLUSIONS: For Medicare beneficiaries, there was no difference in geographic access to YAG laser capsulotomy whether performed by an Oklahoma ophthalmologist or optometrist as determined by calculated driving distances and times.

"I go I die, I stay I die, better to stay and die in my house": understanding the barriers to accessing health care in Timor-Leste.

BACKGROUND: Despite public health care being free at the point of delivery in Timor-Leste, wealthier patients access hospital care at nearly twice the rate of poorer patients. This study seeks to understand the barriers driving inequitable utilisation of hospital services in Timor-Leste from the perspective of community members and health care managers. METHODS: This multisite qualitative study in Timor-Leste conducted gender segregated focus groups (n = 8) in eight districts, with 59 adults in urban and rural settings, and in-depth interviews (n = 8) with the Director of community health centres. Communication was in the local language, Tetum, using a pre-tested interview schedule. Approval was obtained from community and national stakeholders, with written consent from participants. RESULTS: Lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without it, many communities resort to carrying patients by porters or on horseback, walking or paying for (unaffordable) private arrangements to reach hospital, or opt for home-based care. Other significant out-of-pocket expenses for hospital visits were blood supplies from private suppliers; accommodation and food for the patient and family members; and repatriation of the deceased. Entrenched nepotism and hospital staff denigrating patients' hygiene and personal circumstances were also widely reported. Consequently, some respondents asserted they would never return to hospital, others delayed seeking treatment or interrupted their treatment to return home. Most considered traditional medicine provided an affordable, accessible and acceptable substitute to hospital care. Obtaining a referral for higher level care was not a significant barrier to gaining access to hospital care. CONCLUSIONS: Onerous physical, financial and socio-cultural barriers are preventing or discouraging people from accessing hospital care in Timor-Leste. Improving access to quality primary health care at the frontline is a key strategy for ensuring universal access to health care, pursued alongside initiatives to overcome the multi-faceted barriers to hospital care experienced by the vulnerable. Improving the availability and functioning of patient transport services, provision of travel subsidies to patients and their families and training hospital staff in standards of professional care are some options available to government and donors seeking faster progress towards universal health coverage in Timor-Leste.

Association Between Travel Distance and Choice of Treatment for Prostate Cancer: Does Geography Reduce Patient Choice?

OBJECTIVE: To determine whether the distance between a prostate cancer patient's home and treatment facility was related to the choice of treatment received among those opting for surgery or radiation. METHODS AND MATERIALS: We identified 222,804 patients diagnosed with National Comprehensive Cancer Network low-, intermediate-, or high-risk N0M0 prostate cancer and treated with local therapy (surgery or radiation alone, with or without hormone therapy) using the National Cancer Database. We used multivariable logistic regression to determine whether the choice of radiation therapy vs radical prostatectomy varied by distance among patients living in rural and urban areas. Analyses were adjusted for geographic location within the United States, age, race, Charlson/Deyo comorbidity score, year of diagnosis, income quartile, education quartile, Gleason score, prostate-specific antigen level, and T stage. RESULTS: Patients living in urban or rural areas were less likely to receive radiation compared with surgery if they lived farther from the treatment facility. Among urban patients living ≤5 miles from the treatment facility, 53.3% received radiation, compared with 47.0%, 43.6%, and 33.8% of those living 5 to 10, 10 to 15, or >15 miles away, respectively (P<.001 in all cases). Similarly, rural patients were less likely to receive radiation the farther they lived from the treatment facility (≤25 miles: 62.3%; 25-50 miles: 55.5%; 50-75 miles: 38.4%; >75 miles: 23.8%; P<.05 in all cases). These trends were also present when each risk group was analyzed separately. CONCLUSION: Patients with prostate cancer in both urban and rural settings were less likely to receive radiation therapy rather than surgery the farther away they lived from a treatment center. These findings raise the possibility that the geographic availability of radiation treatment centers may be an important determinant of whether patients are able to choose radiation rather than surgery for localized prostate cancer.

Antenatal care and women's birthing decisions in an Indonesian setting: does location matter?

INTRODUCTION: Poor maternal health outcome, still a major health problem in developing countries, is influenced by both women's personal characteristics and the characteristics of the place where they live. Identifying the spatial distribution and clusters of poor maternal health outcomes can assist in developing geographically specific interventions. This article examines the influence of urban and rural settings on antenatal care and birthing decisions in South Sulawesi, a province in Indonesia, and investigates the existence of geographical clusters of women's decision regarding antenatal care and birth assistance. METHODS: Data were derived from a survey of 485 women who recently gave birth. Household coordinates, midwives' location and hospital location were recorded using a handheld global positioning system (GPS). Logistic regression was used to examine the influence of place of residence on antenatal care and women's birthing decisions. SaTScan software was used to identify the location of geographical clusters. ArcGIS v9.3 was used to visualize and interpret the distribution of facilities and clusters. RESULTS: Area of residence determines the likelihood of a woman presenting for antenatal care--care that pregnant women receive from skilled birth attendants. The likelihood of hospital delivery or delivery at home with the support of a skilled birth attendant (SBA), however, was not determined by residential area. Distance to nearest SBA, working as a village midwife, was associated with the likelihood to be assisted by her at home. Attendance of SBA at home, or delivery at a hospital, were clustered in urban areas at different geographical locations, but no similar clustering occurred in rural areas. In contrast, women with low numbers of antenatal care visits and a traditional birthing assistant (TBA) at home were clustered in particular rural areas, but low antenatal care visits and use of TBA were not clustered in urban areas. CONCLUSIONS: Although area of residence did not appear to influence the likelihood of women delivering at hospital or with SBA at home, clusters of women follow particular patterns of behaviour in different geographic settings. This clustering highlights the heterogeneity of both urban and rural areas.

[Characteristics of integrated care programmes and their impact on patient benefit: a discrete-choice experiment for integrated care networks]. / Eigenschaften von integrierten Versorgungs-programmen und deren Einfluss auf den Patientennutzen: Ein Discrete-Choice Experiment für Versorgungsnetzwerke.

PURPOSE: Innovative care models shall reduce the frictional losses in health-care. The successful implementation of care networks requires the acceptance by the health care providers, by the patients and citizens as well as by the payers. The consideration of preferences is an essential factor for success. The aim of this study is to analyse patient preferences. METHODS: With the help of Discrete-Choice experiment 21 patient-relevant attributes of innovative healthcare programmes were examined. On the basis of a balanced overlapping design (sawtooth) a total of 140 choice sets with the highest possible D efficiency was generated. The 21 attributes were divided into 4 thematic priorities for analysis. The cost attribute was integrated as a uniform comparator. The evaluation was done by a random effects logit estimation (STATA). RESULTS: The representative samples (N=1 322) revealed that in all 4 DCE blocks the attribute "additional costs" had the strongest influence on the patients choice (1: coeff.; 1.047; 2: coeff.: 1.105; 3.: coeff.: 0.956; 4.: coeff.: 0.954). This was followed by "medical apparatus and facilities", "waiting time for an appointment", "professional experience", "travelling time to treatment site", and "exchange of clinical information". "Transfer management" and "consideration of individual circumstances" for example, had a small influence on patient choice. CONCLUSION: In order to increase the acceptance of innovative health-care programmes preferences must be known and integrated into the design of the services. The present study has attempted to depict the patients' perspectives towards the new care systems. The individual selection decisions were not, as would be expected, influenced by the innovative approaches such as case management or shared decision making but rather by the quality of the infrastructure, the waiting times and professional experience.

Integrated health impact assessment of travel behaviour: model exploration and application to a fuel price increase.

Transportation policy measures often aim to change travel behaviour towards more efficient transport. While these policy measures do not necessarily target health, these could have an indirect health effect. We evaluate the health impact of a policy resulting in an increase of car fuel prices by 20% on active travel, outdoor air pollution and risk of road traffic injury. An integrated modelling chain is proposed to evaluate the health impact of this policy measure. An activity-based transport model estimated movements of people, providing whereabouts and travelled kilometres. An emission- and dispersion model provided air quality levels (elemental carbon) and a road safety model provided the number of fatal and non-fatal traffic victims. We used kilometres travelled while walking or cycling to estimate the time in active travel. Differences in health effects between the current and fuel price scenario were expressed in Disability Adjusted Life Years (DALY). A 20% fuel price increase leads to an overall gain of 1650 (1010-2330) DALY. Prevented deaths lead to a total of 1450 (890-2040) Years Life Gained (YLG), with better air quality accounting for 530 (180-880) YLG, fewer road traffic injuries for 750 (590-910) YLG and active travel for 170 (120-250) YLG. Concerning morbidity, mostly road safety led to 200 (120-290) fewer Years Lived with Disability (YLD), while air quality improvement only had a minor effect on cardiovascular hospital admissions. Air quality improvement and increased active travel mainly had an impact at older age, while traffic safety mainly affected younger and middle-aged people. This modelling approach illustrates the feasibility of a comprehensive health impact assessment of changes in travel behaviour. Our results suggest that more is needed than a policy rising car fuel prices by 20% to achieve substantial health gains. While the activity-based model gives an answer on what the effect of a proposed policy is, the focus on health may make policy integration more tangible. The model can therefore add to identifying win-win situations for both transport and health.

Evaluation of blood donor deferral causes in the Trinidad and Tobago National Blood Transfusion Service.

The majority of blood donations in Trinidad and Tobago are made as replacement by family members or friends. National Blood Transfusion Policy was drafted in 2007 to promote voluntary, repeated donation. The objective of this study is to assess the current rate and reasons for donor deferral, and the aim is to guide the proposed donor education and recruitment programme. A retrospective study of pre-donation deferral of prospective blood donors at the National Blood Transfusion Centre, Port of Spain, Trinidad and Tobago, was conducted. Records of all pre-donation deferrals over a 12-month period were studied. As many as 11,346 pre-donation screening interviews were conducted. There were 4043 (35.6%) deferrals. The most common reasons for donor deferral were exposure to high-risk sexual activity (27.6%), low haemoglobin 22.2% and hypertension 17.5%. Other reasons such as medication, chronic medical illness, tattoos, travel history, recent pregnancy, surgery or presentation outside the accepted age limit caused 33.8% of all deferrals and the majority (34.7%) of male deferrals. Low haemoglobin (44.5%) was the most common reason among females. The rate of deferral of voluntary donors was not significantly different from that for replacement donors (31.7 vs. 35.4%, P = 0.25). This study exposed a lack of public awareness as the principal reason for an unacceptably high rate of donor deferral. Donor education about selection criteria needs to be urgently addressed as an objective of the National Policy. Monitoring and evaluation of deferral rates and reasons could be used as one indicator of the effectiveness of the Policy.

Meningococcal carrier rate before and after hajj pilgrimage: effect of single dose ciprofloxacin on carriage.

We determined the carriage rate of Neisseria meningitidis before and after hajj pilgrimage among a group (1) of 674 randomly selected Iranian pilgrims, and the effect of 500 mg of ciprofloxacin given 24 hours before return on the reduction of meningococcal carriers among another group (2) of 123 randomly selected Iranian pilgrims. Throat specimens taken 1 hour before departure on the hajj and immediately on return were cultured. Carriage rates of N. meningitidis in group 1 were 5.2% before and 4.6% after pilgrimage (P = 0.65); 3 new serogroups (Z, Z and A) were identified on return. In group 2, the carriage rate decreased from 8.1% to zero before and after pilgrimage.

Health emigration: a challenge in paediatric oncology.

For the past 10 years European states have experienced an increasing flow of emigrating families from developing countries seeking better medical care for their sick children. For Italian paediatricians this has become a new challenge, considering the cultural differences in customs regarding the illness. The onset of a life-threatening disease has a strong impact on the family. The natural bond between the patient and the family must be preserved and strengthened; parents should be encouraged to entertain their child during hospitalization. The inclusion of art therapy may facilitate communication, especially for children of a different language and culture. This approach can help medical staff to understand better both the child's and the parents' anxieties and feelings. This article discusses facets of the now well-known phenomenon of ;health emigration', that is, when a family searches abroad in the hope of finding the most advanced medical treatment possible for their sick child.

Fisioterapia y ocio: la presencia del fisioterapeuta en el llamado turismo saludable / Physiotherapy and leisure: the presence of physiotherapists in health tourism

El problema del intrusismo en las profesiones sanitarias como es el caso de la fisioterapia es un problema frecuente que se ve agravado por la importante oferta y demanda que existe del llamado "turismo saludable" donde dentro de las ofertas de ocio se encuentran tratamientos relajantes, antiestrés o antifatiga que aplican en muchos casos técnicas de masaje, aquaterapia, fangoterapia etc, tratamientos donde en la mayoría de los casos no se dispone de los profesionales necesarios para realizarlos. Hemos analizado las ofertas de ocio en las que se incluyen técnicas encuadrables dentro de la capacitación profesional específica del fisioterapeuta presentes en la red y en cuatro oficinas de diferentes agencias de viajes para conocer en que medida estas ofertas terapéuticas están respaldadas por la actuación de un fisioterapeuta. El numero de resultados en la búsqueda en la red utilizando la entrada "Turismo y salud" es de 1.770.000 y si nos ceñimos exclusivamente a las paginas Web de España el número de resultados es de 676.000. Hemos realizado un muestreo aleatorio utilizando como número de selección el número de orden, y hemos estudiado 250 páginas Web. Sólo en el 24 % se hace referencia expresa a la existencia de la fisioterapia como una realidad sustentada por los profesionales correspondientes, mientras que en el 96 % se hace referencia al uso de técnicas como: Cinesiterapia, Masaje, Electroterapia, Magnetoterapia, Ergoterapia, Hidroterapia, Balneoterapia, Climatoterapia, Talasoterapia, Termoterapia, Crioterapia, Vibroterapia, Fototerapia o Presoterapia. Cuando hemos comprobado telefónicamente si existía un fisioterapeuta encargado de realizar estos tratamientos únicamente hemos encontrado respuestas positivas en un 45 % de los centros que los ofertaban

Review of 1 year's activity in the Grampian travel clinic: the importance of the oil industry.

BACKGROUND: A review of the activities of the Grampian travel clinic was carried out over 1 year to obtain an overall perspective of the clinic workload and to determine how much of the workload was dependent on the oil industry. METHODS: A specially designed data collection sheet was completed for each of the 669 consultations conducted at the Grampian travel clinic, Aberdeen, between February 1, 2002, and January 31, 2003. RESULTS: Patients attending the clinic came in equal numbers from the city of Aberdeen and the Grampian region. Twenty-five percent were traveling for work purposes: 87.4% of this travel was oil related, and most patients were headed to Africa. The commonest vaccines given were for yellow fever, Japanese B encephalitis, and rabies, reflecting the specialist nature of the clinic. Most travelers did leave adequate time for immunization before travel. The public is still apprehensive about using mefloquine as malarial prophylaxis. CONCLUSIONS: Most attendees were traveling on holiday, but a quarter of the consultations were for travel related to the oil industry. Almost 70% of attendees had already visited their general practitioner and were therefore attending the clinic for specialist advice and vaccines. There is a need for increased clinic capacity.

Attitudes, subjective norms and perception of behavioural control as predictors of sun-related behaviour in Swedish adults.

BACKGROUND: Exposure to ultraviolet (UV) radiation is the major preventable cause of skin cancer. The aim of this study was to investigate the explanatory value of attitudes, subjective norms and perceived behavioural control on behaviours related to UV exposure. METHOD: A random population-based sample (n = 1752, 18-37 years of age) in the Stockholm County, Sweden, answered a questionnaire with items on sun related behaviours and beliefs. The items concerned issues influenced by the Theory of Planned Behaviour, that is, attitudes, subjective norms and perceived behavioural control. Logistic regression analysis was used to examine the associations between behaviours and beliefs. RESULTS: Positive attitudes towards being tanned and being in the sun were both strongly associated with time spent in the sun, intentional tanning, sunbed use, going on vacation to a sunny resort, intention to decrease sunbathing and use of protection against the sun. Perceiving sunbathing as risky was associated with using different ways to protect and intending to reduce sun exposure. Having people around oneself who frequently sunbathe was related to intentional tanning and vacations to sunny resorts. Finally, perceived behavioural control was associated with use of sunscreen and use of other ways to protect from the sun among women. CONCLUSION: The study identified factors on which primary preventive interventions towards decreasing sun exposure should be focused.

Phantoms in the snow: Canadians' use of health care services in the United States.

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.