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

OBJECTIVE: To measure access to primary care physicians (PCPs) using a 2-step floating catchment area and explore the associations between access to PCPs and mortality related to all-causes, cancers, and heart disease in Washington State. METHODS: An ecological study employing generalized linear regression models of access to PCPs and mortality rates in 4,761 block groups in Washington State in 2015. To measure access to PCPs, we used a 2-step floating catchment area approach, taking into account area-level population, supply of PCPs, and travel time between PCPs, as well as area-level population with a distance decay function. RESULTS: A 1-unit increase in PCP access score was associated with a reduction of 4.2 all-cause deaths per 100,000 people controlling for socioeconomic characteristics. A 1-unit increase in PCP access score was associated with a reduction of 2.7 cancer deaths and a reduction of 2.1 heart disease deaths per 100,000 people controlling for socioeconomic characteristics. CONCLUSIONS: Better access to PCPs was associated with lower mortality from all-causes, cancers, and heart disease. The 2-step floating catchment area approach can help with the identification of PCP shortage areas, the development of rural residency programs, and the expansion of the physician workforce in Washington State and other regions.

Closure of proximal colorectal fistulas using fibrin sealant.

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4-365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1-5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6-65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.