Analyzing Cost-Effectiveness of Allocating Neurointerventionist for Drive and Retrieve System for Patients with Acute Ischemic Stroke.

OBJECTIVES: There are regional disparities in implementation rates of endovascular thrombectomy due to time and resource constraints such as endovascular thrombectomy specialists. In Hokkaido, Japan, Drive and Retrieve System (DRS), where endovascular thrombectomy specialists perform early endovascular thrombectomies by traveling from the facilities where they normally work to facilities closer to the patient. This study analyzed the cost-effectiveness of allocating a endovascular thrombectomy specialist for DRS to treat stroke patients. MATERIALS AND METHODS: he number of ischemic stroke patients expected to receive endovascular thrombectomy in Hokkaido in 2015 was estimated. It was assumed that an additional neutointerventionist was allocated for DRS. The analysis was performed from the government's perspective, which includes medical and nursing-care costs, and the personnel cost for endovascular thrombectomy specialist. The analysis was conducted comparing the current scenario, where patients received endovascular thrombectomy in facilities where endovascular thrombectomy specialists normally work, with the scenario with DRS within 60 min drive distance. Patient transport time was analyzed using geographic information system, and patient severity was estimated from the transport time. The primary outcome was incremental cost-effectiveness ratio (ICER) in each medical area which was calculated from the incremental costs and the incremental quality-adjusted life years (QALYs), estimated from patient severity using published literature. The entire process was repeated 100 times. RESULTS: DRS was most cost-effective in Kamikawachubu area, where the ICER was $14,173±16,802/QALY, significantly lower than the threshold that the Japanese guideline suggested. CONCLUSIONS: Since DRS was cost-effective in Kamikawachubu area, the area should be prioritized when a endovascular thrombectomy specialist for DRS is allocated as a policy.

Market Consolidation and Mortality in Patients Initiating Hemodialysis.

BACKGROUND: It is uncertain whether consolidation in health care markets affects the quality of care provided and health outcomes. OBJECTIVES: To examine whether changes in market competition resulting from acquisitions by two large national for-profit dialysis chains were associated with patient mortality. METHODS: We identified patients initiating in-center hemodialysis between 2001 and 2009 from a registry of patients with end-stage renal disease in the United States. We considered two scenarios when evaluating consolidation from dialysis facility acquisitions: one in which we considered only those patients receiving dialysis in markets that became substantially more concentrated to have been affected by consolidation, and the other in which all patients living in hospital service areas where a facility was acquired were potentially affected. We used a difference-in-differences study design to examine the associations between market consolidation and changes in mortality rates. RESULTS: When we considered the 12,065 patients living in areas that became substantially more consolidated to have been affected by consolidation, we found a nominally significant (8%; 95% confidence interval 0%-17%) increase in likelihood of death after consolidation. Nevertheless, when we considered all 186,158 patients living in areas where an acquisition occurred to have been affected by consolidation, there was no observable effect of market consolidation on mortality. CONCLUSIONS: Decreased market competition may have led to increased mortality among a relatively small subset of patients initiating in-center hemodialysis in areas that became substantially more concentrated after two large dialysis acquisitions, but not for most of the patients living in affected areas.

Geographic Variation in Breast Reconstruction Modality Use Among Women Undergoing Mastectomy.

PURPOSE: Despite changes in legislation and an increase in public awareness, many women may not have access to the various types of breast reconstruction. The purpose of this study was to evaluate variation in reconstructive modality at the health service area (HSA) level and its relationship to the plastic surgeon workforce in the same area. METHODS: Using the Arkansas, California, Florida, Nebraska, and New York state inpatient databases, we conducted a cross-sectional study of adult women undergoing mastectomy for cancer from 2009 to 2012. The primary outcomes were receipt of reconstruction and the reconstructive modality (autologous tissue versus implant) used. All data were aggregated to the HSA level and augmented with plastic surgeon workforce data. Correlation coefficients were calculated for the relationship between the outcomes and workforce. RESULTS: The final sample included 67,984 women treated across 103 HSAs. The average patient was 58.5 years, had private insurance (53.5%), and underwent unilateral mastectomy for invasive cancer. At the HSA level, the median immediate breast reconstruction rate was 25.0% and varied widely (interquartile range, 43.2%). In areas where reconstruction was performed, the median autologous (10.2%) and free tissue (0.4%) reconstruction rates were low, with more than 30% of HSAs never using autologous tissue. There was a direct correlation between an HSA's plastic surgeon density and autologous reconstruction rate (r = 0.81, P < 0.001). CONCLUSIONS: Despite efforts to remove financial barriers and improve patients' awareness, accessibility to various modalities of reconstruction is inadequate for many women. Efforts are needed to improve the availability of more comprehensive breast reconstruction care.

Cross-border spatial accessibility of health care in the North-East Department of Haiti.

BACKGROUND: The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border. METHODS: To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios. RESULTS: The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans. CONCLUSION: The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

Medicare Facility Diagnosis-Related Groups Have Outpaced Individual Physician Payment.

BACKGROUND: We set out to compare the rates of Medicare reimbursement to physicians versus hospitals for several major vascular procedures over a period of 5 years. METHODS: We queried the Wolters Kluwer MediRegs database to collect Medicare reimbursement data from fiscal years 2011 to 2015. We surveyed reimbursements for carotid endarterectomy, carotid angioplasty and stenting, femoropopliteal bypass, and lower extremity fem-pop revascularization with stenting. Based on data availability, we surveyed physician reimbursement data on the national level and in both medically overserved and underserved areas. Hospital reimbursement rates were examined on a national level and by hospitals' teaching and wage index statuses. RESULTS: We found that for all 4 vascular procedures, Medicare reimbursements to hospitals increased by a greater percentage than to physicians. By region, underserved areas had lower physician reimbursements than the national average, while the opposite was true for overserved areas. Additionally, for hospital Medicare reimbursements, location in a high wage index accounted for a significant increase in reimbursement over the national average, with teaching status contributing to this increase in a smaller extent. CONCLUSIONS: These data on Medicare reimbursements indicate that payments to hospitals are increasing more significantly than to physicians. This disparity in pay changes affects both independent and academic vascular surgeons. Medicare should consider pay increases to independent providers in accordance to the hospital pay increase.

The Struggle for Equity: An Examination of Surgical Services at Two NGO Hospitals in Rural Haiti.

BACKGROUND: Health systems must deliver care equitably in order to serve the poor. Both L'Hôpital Albert Schweitzer (HAS) and L'Hôpital Bon Sauveur (HBS) have longstanding commitments to provide equitable surgical care in rural Haiti. HAS charges fees that demonstrate a preference for the rural population near the hospital, with free care available for the poorest. HBS does not charge fees. The two hospitals are otherwise similar in surgical capacity and rural location. METHODS: We retrospectively reviewed operative case-logs at both hospitals from June 1 to Aug 31, 2012. The records were compared by total number of operations, geographic distribution of patients and number of elective operations. Using geography as a proxy for poverty, we analyzed the equity achieved under the financial systems at both hospitals. RESULTS: Patients from the rural service area received 86% of operations at HAS compared to 38% at HBS (p < 0.001). Only 5% of all operations at HAS were performed on patients from outside the service area for elective conditions compared to 47% at HBS (p < 0.001). Within its rural service area, HAS performed fewer operations on patients from the most destitute areas compared to other locations (40.3 vs. 101.3 operations/100,000 population, p < 0.001). CONCLUSIONS: Using fees as part of an equity strategy will likely disadvantage the poorest patients, while providing care without fees may encourage patients to travel from urban areas that contain other hospitals. Health systems striving to serve the poor should continually evaluate and seek to improve equity, even within systems that provide free care.

[Morbidity observed in a health area: Impact on professionals and funding]. / Morbilidad observada en un área sanitaria: variabilidad e impacto en profesionales y en financiación.

OBJECTIVE: To analyze morbidity, in the context of a health area, and broken down by health centre, of patients who made contact with healthcare services, in order to propose an adjustment to finance the payment per capita. DESIGN: A descriptive study of morbidity observed in citizens assigned a health area during year 2010. SITE: Health Area 9. Autonomous Community of Madrid. Formed by the municipalities of Fuenlabrada, Humanes, and Moraleja de Enmedio. All levels of health care included. PARTICIPANTS: All citizens with health card assigned to a health center in the area who has maintained contact with the public health service's own area. MEASUREMENTS: Coded contact of patients are grouped using the Population Grouping Clinical Risk 3M TM Software (CRG). Each patient is included in a homogeneous and exclusive group with a numerical morbidity and clinical sense. Through the health card is known primary care centre, physician, age and sex. RESULTS: The distribution of morbidity is obtained by primary care centre, primary care physician, age and sex analyzing differences and combinations. CONCLUSIONS: It was found that the average values of the population morbidity are different in each primary care centre. In order to maintain the principle of equity in health care, it is suggested that an adjustment is made to the per capita payment based on the morbidity rate of the population.

Association of U.S. Dialysis facility neighborhood characteristics with facility-level kidney transplantation.

BACKGROUND: Improving access to optimal healthcare may depend on the attributes of neighborhoods where patients receive healthcare services. We investigated whether the characteristics of dialysis facility neighborhoods--where most patients with end-stage renal disease are treated--were associated with facility-level kidney transplantation. METHODS: We examined the association between census tract (neighborhood)-level sociodemographic factors and facility-level kidney transplantation rate in 3,983 U.S. dialysis facilities where kidney transplantation rates were high. Number of kidney transplants and total person-years contributed at the facility level in 2007-2010 were obtained from the Dialysis Facility Report and linked to the census tract data on sociodemographic characteristics from the American Community Survey 2006-2010 by dialysis facility location. We used multivariable Poisson models with generalized estimating equations to estimate the link between the neighborhood characteristics and transplant incidence. RESULTS: Dialysis facilities in the United States were located in neighborhoods with substantially greater proportions of black and poor residents, relative to the national average. Most facility neighborhood characteristics were associated with transplant, with incidence rate ratios (95% CI) for standardized increments (in percentage) of neighborhood exposures of: living in poverty, 0.88 (0.84-0.92), black race, 0.83 (0.78-0.89); high school graduates, 1.22 (1.17-1.26); and unemployed, 0.90 (0.85-0.95). CONCLUSION: Dialysis facility neighborhood characteristics may be modestly associated with facility rates of kidney transplantation. The success of dialysis facility interventions to improve access to kidney transplantation may partially depend on reducing neighborhood-level barriers.

[Decentralized outpatient teams in community-based psychiatric care: comparison of two Bavarian rural catchment areas]. / Dezentrale ambulante Teams in der gemeindenahen psychiatrischen Versorgung : Zwei bayerische ländliche Regionen im Vergleich.

BACKGROUND: Psychiatric outpatient clinics (PIAs) are an indispensable care service for crisis intervention and multidisciplinary treatment of people suffering from severe and persistent mental disorders. The decentralization of outpatient clinics can be understood as a further step in the deinstitutionalization process. METHODS: This cross-sectional study (n=1,663) compared the central outpatient clinic with the decentralized teams for the year 2010 by means of analyses of variance, χ(2)-tests and robust multivariate regression models. The longitudinal assessment (descriptively and by means of Prais-Winsten regression models for time series) was based on all hospitalizations for the two decentralized teams (n = 6,693) according to partial catchment areas for the time period 2002-2010 in order to examine trends after their installation in the year 2007. RESULTS: Decentralized teams were found to be similar with respect to the care profile but cared for relatively more patients suffering from dementia, addictive and mood disorders but not for those suffering from schizophrenia and personality disorders. Decentralized teams showed less outpatient care costs as well as psychopharmacological expenses but a lower contact frequency than the central outpatient clinic. Total expenses for psychiatric care were not significantly different and assessed hospitalization variables (e.g. total number of annual admissions, cumulative length of inpatient-stay and annual hospitalizations per patient) changed slightly 3 years after installation of the decentralized teams. The number of admissions of people suffering from schizophrenia decreased whereas those for mood and stress disorders increased. DISCUSSION: Decentralized outpatient teams seemed to reach patients in rural regions who previously were not reached by the central outpatient clinic. Economic figures indicate advantages for the installation of such teams because care expenses are not higher than for patients treated in centralized outpatient clinics and because hospitalization figures for the whole catchment area did not increase.

The financial impact of hospitals on the local economy--2 new factors.

This research effort presents a descriptive analysis of the financial impact that several hospitals have on their local economy. An earlier study published by the authors included 3 distinct, yet overlapping components of financial impact: (1) the hospital system as a major health care provider, (2) the hospital system as a large employer, and (3) the hospital system as an entity whose employees contribute greatly to their local community. This new study added additional financial impact factors: (4) the hospital system as an organization committed to major construction projects in pursuit of its health services mission, and (5) the hospital system as an entity that pays taxes to government agencies. The inextricable relationship of these 5 categories both increases and enhances the impact of the hospital system on the local region. The results of this updated and expanded analysis suggest strongly that the hospital system represents 1 of the primary contributors to the economy of the region. The hospital system adds $3 billion to the $28 billion local economy, which means that the hospital system and its employees are responsible for 10.7% of the total economic prowess of the region.

The influence of drug use in university hospitals on the pharmaceutical consumption in their surrounding communities.

AIM: To investigate the influence of hospital drug choices on pharmaceutical consumption for nine competitive classes in the surrounding community. METHODS: Ecological study. Data from the national survey on drugs in hospitals were used to extract quantities purchased by 25 French university hospitals for three 'hospital classes' (EPOs, LMWHs and setrons) and six 'ambulatory classes' (PPIs, ACEIs and ARBs, statins, α-adrenoreceptor antagonists (AAAs) and selective serotonin re-uptake inhibitors SSRIs). Re-imbursed quantities for patients living in the hospital's catchment area were extracted from the national health insurance database. The relationship between the use of a brand in hospitals and their catchment areas was assessed using multivariate linear regressions with instrumental variables. RESULTS: An increase of 1 day of treatment with one brand in the hospital was associated with a significant increase of 2.8 days of treatment with the same brand in the catchment area. However, results strongly varied according to classes. An increase of 1 day of treatment in the hospital was significantly associated with an increase of 0.21 day for 'hospital classes' and 21.8 days for 'ambulatory classes' in the catchment area. Strong variations were seen across 'ambulatory classes'. The effect was maximal for cardiovascular classes and not significant for AAAs and SSRIs. The size of the effect also varied with hospital characteristics: small and proximity university hospitals exerted the greatest influence. CONCLUSIONS: Hospital consumption influences the use of drugs in the community. A significant effect was found, especially for competitive classes used on a long-term basis. The economic consequences of these findings need to be addressed.

The effect of activity-based financing on hospital length of stay for elderly patients suffering from heart diseases in Norway.

BACKGROUND: Whether activity-based financing of hospitals creates incentives to treat more patients and to reduce the length of each hospital stay is an empirical question that needs investigation. This paper examines how the level of the activity-based component in the financing system of Norwegian hospitals influences the average length of hospital stays for elderly patients suffering from ischemic heart diseases. During the study period, the activity-based component changed several times due to political decisions at the national level. METHODS: The repeated cross-section data were extracted from the Norwegian Patient Register in the period from 2000 to 2007, and included patients with angina pectoris, congestive heart failure, and myocardial infarction. Data were analysed with a log-linear regression model at the individual level. RESULTS: The results show a significant, negative association between the level of activity-based financing and length of hospital stays for elderly patients who were suffering from ischemic heart diseases. The effect is small, but an increase of 10 percentage points in the activity-based component reduced the average length of each hospital stay by 1.28%. CONCLUSIONS: In a combined financing system such as the one prevailing in Norway, hospitals appear to respond to economic incentives, but the effect of their responses on inpatient cost is relatively meagre. Our results indicate that hospitals still need to discuss guidelines for reducing hospitalisation costs and for increasing hospital activity in terms of number of patients and efficiency.

Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas.

BACKGROUND: In many countries, financial assistance is awarded to physicians who settle in an area that is designated as a shortage area to prevent unequal accessibility to primary health care. Today, however, policy makers use fairly simple methods to define health care accessibility, with physician-to-population ratios (PPRs) within predefined administrative boundaries being overwhelmingly favoured. Our purpose is to verify whether these simple methods are accurate enough for adequately designating medical shortage areas and explore how these perform relative to more advanced GIS-based methods. METHODS: Using a geographical information system (GIS), we conduct a nation-wide study of accessibility to primary care physicians in Belgium using four different methods: PPR, distance to closest physician, cumulative opportunity, and floating catchment area (FCA) methods. RESULTS: The official method used by policy makers in Belgium (calculating PPR per physician zone) offers only a crude representation of health care accessibility, especially because large contiguous areas (physician zones) are considered. We found substantial differences in the number and spatial distribution of medical shortage areas when applying different methods. CONCLUSIONS: The assessment of spatial health care accessibility and concomitant policy initiatives are affected by and dependent on the methodology used. The major disadvantage of PPR methods is its aggregated approach, masking subtle local variations. Some simple GIS methods overcome this issue, but have limitations in terms of conceptualisation of physician interaction and distance decay. Conceptually, the enhanced 2-step floating catchment area (E2SFCA) method, an advanced FCA method, was found to be most appropriate for supporting areal health care policies, since this method is able to calculate accessibility at a small scale (e.g., census tracts), takes interaction between physicians into account, and considers distance decay. While at present in health care research methodological differences and modifiable areal unit problems have remained largely overlooked, this manuscript shows that these aspects have a significant influence on the insights obtained. Hence, it is important for policy makers to ascertain to what extent their policy evaluations hold under different scales of analysis and when different methods are used.

Addressing poverty through disease control programmes: examples from Tuberculosis control in India.

INTRODUCTION: Tuberculosis remains a major public health problem in India with the country accounting for one-fifth or 21% of all tuberculosis cases reported globally. The purpose of the study was to obtain an understanding on pro-poor initiatives within the framework of tuberculosis control programme in India and to identify mechanisms to improve the uptake and access to TB services among the poor. METHODOLOGY: A national level workshop was held with participation from all relevant stakeholder groups. This study conducted during the stakeholder workshop adopted participatory research methods. The data was elicited through consultative and collegiate processes. The research study also factored information from primary and secondary sources that included literature review examining poverty headcount ratios and below poverty line population in the country; and quasi-profiling assessments to identify poor, backward and tribal districts as defined by the TB programme in India. RESULTS: Results revealed that current pro-poor initiatives in TB control included collaboration with private providers and engaging community to improve access among the poor to TB diagnostic and treatment services. The participants identified gaps in existing pro-poor strategies that related to implementation of advocacy, communication and social mobilisation; decentralisation of DOT; and incentives for the poor through the available schemes for public-private partnerships and provided key recommendations for action. Synergies between TB control programme and centrally sponsored social welfare schemes and state specific social welfare programmes aimed at benefitting the poor were unclear. CONCLUSION: Further in-depth analysis and systems/policy/operations research exploring pro-poor initiatives, in particular examining service delivery synergies between existing poverty alleviation schemes and TB control programme is essential. The understanding, reflection and knowledge of the key stakeholders during this participatory workshop provides recommendations for action, further planning and research on pro-poor TB centric interventions in the country.

Explaining regional variations in health care utilization between Swiss cantons using panel econometric models.

BACKGROUND: In spite of a detailed and nation-wide legislation frame, there exist large cantonal disparities in consumed quantities of health care services in Switzerland. In this study, the most important factors of influence causing these regional disparities are determined. The findings can also be productive for discussing the containment of health care consumption in other countries. METHODS: Based on the literature, relevant factors that cause geographic disparities of quantities and costs in western health care systems are identified. Using a selected set of these factors, individual panel econometric models are calculated to explain the variation of the utilization in each of the six largest health care service groups (general practitioners, specialist doctors, hospital inpatient, hospital outpatient, medication, and nursing homes) in Swiss mandatory health insurance (MHI). The main data source is 'Datenpool santésuisse', a database of Swiss health insurers. RESULTS: For all six health care service groups, significant factors influencing the utilization frequency over time and across cantons are found. A greater supply of service providers tends to have strong interrelations with per capita consumption of MHI services. On the demand side, older populations and higher population densities represent the clearest driving factors. CONCLUSIONS: Strategies to contain consumption and costs in health care should include several elements. In the federalist Swiss system, the structure of regional health care supply seems to generate significant effects. However, the extent of driving factors on the demand side (e.g., social deprivation) or financing instruments (e.g., high deductibles) should also be considered.

The impact of comorbidities, regional trends, and hospital factors on discharge dispositions and hospital costs after acoustic neuroma microsurgery: a United States nationwide inpatient data sample study (2005-2009).

OBJECT: Hospitalization cost and patient outcome after acoustic neuroma surgery depend on several factors. There is a paucity of data regarding the relationship between demographic features such as age, sex, race, insurance status, and patient outcome. Apart from demographic factors, there are several hospital-related factors and regional issues that can affect outcomes and hospital costs. To the authors' knowledge, no study has investigated the issue of regional disparity across the country in terms of cost of hospitalization and discharge disposition. METHODS: The authors analyzed the Nationwide Inpatient Sample (NIS) database over the years 2005-2009. Several variables were analyzed from the database, including patient demographics, comorbidities, and surgical complications. Hospital variables, such as bedsize, rural/urban location, teaching status, federal or private ownership, and the region, were also examined. Patient outcome and increased hospitalization costs were the dependent variables studied. RESULTS: A total of 2589 admissions from 242 hospitals were analyzed from the NIS data over the years 2005-2009. The mean age was 48.99 ± 13.861 years (± SD), and 304 (11.7%) of the patients were older than 65 years. The cumulative cost incurred by the hospitals from 2005 to 2009 was $948.77 million. The mean expenditure per admission was $76,365.09 ± $58,039.93. The mean total charges per admission rose from $59,633.00 in 2005 to $97,370.00 in 2009. The factors that predicted most significantly with other than routine (OTR) disposition outcome were age older than 65 years (OR 2.22, 95% CI 1.411-3.518; p < 0.001), aspiration pneumonia (OR 16.085, 95% CI 4.974-52.016; p < 0.001), and meningitis (OR 11.299, 95% CI 3.126-40.840; p < 0.001). When compared with patients with Medicare and Medicaid, patients with private insurance had a protective effect against OTR disposition outcome. Higher comorbidities predicted independently for OTR disposition outcome (OR 1.409, 95% CI 1.072-1.852; p = 0.014). The West region predicted negatively for OTR disposition outcome. Large hospitals were independently associated with higher hospital charges (OR 4.269, 95% CI 3.106-5.867; p < 0.001). The West region had significantly higher (p < 0.001) mean hospital charges than the other regions. Patient factors such as meningitis and aspiration pneumonia were strong independent predictors of increased hospital charges (p < 0.001). Higher comorbidities (OR 1.297, 95% CI 1.036-1.624; p = 0.023) and presence of neurofibromatosis Type 2 (OR 2.341, 95% CI 1.479-3.707; p < 0.001) were associated with higher hospital charges. CONCLUSIONS: The authors' study shows that several factors can affect patient outcome and hospital charges for patients who have undergone acoustic neuroma surgery. Factors such as younger age, higher ZIP code income, less comorbidity, private insurance, elective surgery, and the West region predicted for better disposition outcome. However, the West region, higher comorbidities, and weekend admissions were associated with higher hospitalization costs.

From causes to solutions--insights from lay knowledge about health inequalities.

BACKGROUND: This paper reports on a qualitative study of lay knowledge about health inequalities and solutions to address them. Social determinants of health are responsible for a large proportion of health inequalities (unequal levels of health status) and inequities (unfair access to health services and resources) within and between countries. Despite an expanding evidence base supporting action on social determinants, understanding of the impact of these determinants is not widespread and political will appears to be lacking. A small but growing body of research has explored how ordinary people theorise health inequalities and the implications for taking action. The findings are variable, however, in terms of an emphasis on structure versus individual agency and the relationship between being 'at risk' and acceptance of social/structural explanations. METHODS: This paper draws on findings from a qualitative study conducted in Adelaide, South Australia, to examine these questions. The study was an integral part of mixed-methods research on the links between urban location, social capital and health. It comprised 80 in-depth interviews with residents in four locations with contrasting socio-economic status. The respondents were asked about the cause of inequalities and actions that could be taken by governments to address them. RESULTS: Although generally willing to discuss health inequalities, many study participants tended to explain the latter in terms of individual behaviours and attitudes rather than social/structural conditions. Moreover, those who identified social/structural causes tended to emphasise individualized factors when describing typical pathways to health outcomes. This pattern appeared largely independent of participants' own experience of advantage or disadvantage, and was reinforced in discussion of strategies to address health inequalities. CONCLUSIONS: Despite the explicit emphasis on social/structural issues expressed in the study focus and framing of the research questions, participants did not display a high level of knowledge about the nature and causes of place-based health inequalities. By extending the scope of lay theorizing to include a focus on solutions, this study offers additional insights for public health. Specifically it suggests that a popular constituency for action on the social determinants of health is unlikely to eventuate from the current popular understandings of possible policy levers.

How are caseload and service utilisation of psychiatric services influenced by distance? A geographical approach to the study of community-based mental health services.

INTRODUCTION: The aim of this study was to assess how the caseload and the utilisation of community-based mental health services is influenced by distance and to socioeconomic characteristics. METHODS: Spatial and statistical analyses were conducted with a sample of 12,347 patients, with ICD-10 psychiatric diagnosis, who had at least one contact with psychiatric services in Verona, Italy, between 2000 and 2006. Three types of mental health facility were considered: acute inpatient wards, outpatient clinics, and community mental health centres (CMHC). To measure distance and accessibility, the locations of static mental health facilities and patients' homes were geocoded. Data were organised in a spatial database, which included census blocks, catchment areas locations, road network graphs, patients' and facilities' locations. In order to calculate travel distances, patients' and facilities' locations were connected to the road network. Accessibility was modelled by using the Network Analyst Service Area Function and 13 Service Areas were created around all facility locations, by measuring distances along the street network. For the epidemiological analyses, patients and census block centroids were linked to the service areas by using spatial join techniques. Epidemiological and utilisation analyses were performed for each type of setting. RESULTS: The facilities were not equally located in the catchment areas. Of particular significance, rural areas appear to be poorly served by mental health services. The distance decay effect exists, with different trends for the three types of facility. The caseload (number of patients using services) decreased with increasing distance; at a distance of 10 km, there was a decrease of 80, 60 and 85%, respectively, for CMHCs, inpatients wards and outpatients clinics. From the Poisson regression models, distance was significantly correlated (p value < 0.0001) with service use. Also univariate analyses showed a statistically significant association between distance and caseload for each type of setting (p value < 0.05), with a decrease in service use for each service area increase in distance (1.5% for acute inpatient wards, 2.0% for CMHC, and 2.1% outpatient clinics). By adding other predictors in the Poisson regression models, these percentages increased. CONCLUSIONS: Further studies are needed to evaluate the influence of other factors, such as environmental variables, that may influence the use of mental health services.

Regional differences in mortality in Greece (1984-2004): the case of Thrace.

BACKGROUND: Mortality differences at national level can generate hypothesis on possible causal association that could be further investigated. The aim of the present study was to identify regions with high mortality rates in Greece. METHODS: Age adjusted specific mortality rates by gender were calculated in each of the 10 regions of Greece during the period 1984-2004. Moreover standardized mortality rates (SMR) were also calculated by using population census data of years 1981, 1991, 2001. The mortality rates were examined in relation to GDP per capita, the ratio of hospital beds, and doctors per population for each region. RESULTS: During the study period, the region of Thrace recorded the highest mortality rate at almost all age groups in both sexes among the ten Greek regions. Thrace had one of the lowest GDP per capita (11,123 Euro) and recorded low ratios of Physicians (284) per 100,000 inhabitants in comparison to the national ratios. Moreover the ratio of hospital beds per population was in Thrace very low (268/100,000) in comparison to the national ratio (470/100,000). Thrace is the Greek region with the highest percentage of Muslim population (33%). Multivariate analysis revealed that GDP and doctors/100000 inhabitants were associated with increased mortality in Thrace. CONCLUSION: Thrace is the region with the highest mortality rate in Greece. Further research is needed to assess the contribution of each possible risk factor to the increased mortality rate of Thrace which could have important public health implications.