Physician accessibility: an urban case study of pediatric providers
Introduction
Distance to provider has been recognized as a significant barrier to healthcare access in the US since the 19th century (Hunter et al., 1986; Jarvis, 1851–1852). From that time until the middle 1970s many attempts have been made to measure spatial accessibility to health service locations, identify areas of provider shortage, and reveal social disparities in spatial accessibility in both urban and rural areas (Elesh and Schollaert, 1972; Morrill et al., 1970; Shannon and Alan Dever, 1974; US Public Health Service and Antonio Ciocco, 1954; Wennberg and Gittelsohn, 1973). The issue has been on the national policy agenda since the 1967 Report of the National Advisory Commission on Health Manpower attributed maldistribution of healthcare professionals to their preference for affluent neighborhoods (US National Advisory Commission on Health Manpower, 1967).
From that time work has continued for rural and mixed urban–rural areas, despite a lack of consensus on how to best measure spatial accessibility (Connor et al., 1995; Fortney et al., 2000; Fryer et al., 1999; Goodman et al., 1997; Joseph and Bantock, 1982; Luo and Wang, 2003; Shi et al., 1999). This primarily rural focus was fueled by the recognition that distance is an obvious impediment in sparsely populated areas, and by the well-documented trend of reduced provider-to-population ratios in rural America (Salsberg and Forte, 2002).
Concern about spatial access to healthcare providers in urban areas has not abated (Council on Graduate Medical Education, 1998; Heinrich, 2001; Smedley et al., 2002). However, with few exceptions (Gesler and Meade, 1988; McGuirk and Porell, 1984), US cities have not been studied since the middle 1970s. There are probably two reasons for this. First, attention was increasingly focused on the dramatic rise in the cost of care, and the attendant upheaval in healthcare financing and organization. Second, the intuitive spatial indicators used for large rural geographies, described below, are less relevant in congested urban areas.
Ironically, the waning of research on urban spatial accessibility of healthcare providers corresponded with the increasing accessibility of powerful software and hardware necessary for more valid and sophisticated urban studies. This study revisits the subject for a typical major US city by applying commonly available software and data. We discuss and critique some of the concepts and measurement issues, build on a promising conceptual and methodological approach not used since 1975, and report social disparities in spatial access within the case city. Our demonstration concerns primary care providers for children, although the methods are easily adapted for other age groups and healthcare services. The paper's primary contribution is that it proposes a method for measuring and analyzing spatial accessibility to physicians that is easily understood by health policy makers and is particularly useful for congested urban areas.
Section snippets
Terminology and concepts
A diverse and inconsistent terminology is used to describe aspects of healthcare access and barriers. We favor the conceptualization offered by Penchansky and Thomas (1981), who describe and measure access along five dimensions: accessibility, availability, affordability, acceptability and accommodation. The first two relate to location. Accessibility is travel impedance between client and service points, and is usually measured in units of distance or travel time. Availability refers to the
Overview
Using ArcView 8.3 software, we first created a continuous map layer representing the density of primary care providers for children (PCPCs). Density layers are made of small cells (e.g. one tenth mile square) covering the entire field of interest. The PCPC density value associated with each cell is an estimate of spatial accessibility from the cell's center.
Departing from Guptill, we also created a population density layer from census block group points. This layer had the same cell size and
Maps
The density maps in Fig. 1, Fig. 2, Fig. 3 show 5617 cells of one-tenth square mile size, which comprise 55.86 miles2 and 178 census tracts. This excludes the aforementioned low population areas. However, physicians and children located in masked areas and adjacent jurisdictions do contribute to the density calculations and maps in the manner described in the methods section.
Fig. 1 is the density of primary care physicians for children (PCPCs) per square mile. The dense central area represents
Findings
The most effective and efficient PCPC-to-child population ratio is debatable. The American Academy of Pediatrics (2000) reviewed the only two available recommendations, 41.2 (Marder and Gaumer, 1991) and 49.2 (US Department of Health and Human Services, 1980) pediatricians per 100,000 children, and reported the actual nationwide ratio for 1998 as 57.5 pediatricians per 100,000 children. Our Washington, DC ratio of 95.0 PCPCs per 100,000 children is not directly comparable to these benchmarks
Summary
This paper demonstrates a method for measuring and analyzing spatial accessibility for primary care physicians for children (PCPCs) in an urban area—a common and persistent problem for minority neighborhoods. A surface of PCPC-to-population ratios is created from a density layer of PCPCs and a density layer of child population. Working with such a ratio layer has several advantages over other measures of spatially accessibility. It avoids the patient border-crossing conundrum, it provides good
Acknowledgements
The contributions of Guagliardo, Ronzio and Joseph were supported by grant number 1P20MD000165-01 from the National Center on Minority Health and Health Disparities, NIH (PI Jill Joseph). Guagliardo also received funding from a Health and Human Services Grant from ESRI, Inc., and a grant from the Child Health Center Board of Children's National Medical Center. James Cawley, MD, of the Department of Prevention and Community Health, The George Washington School of Public Health, provided valuable
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