The equity of access to orthodontic dental care for children in the North East of England

OBJECTIVES: To assess the equity of access to primary care orthodontic treatment in relation to deprivation in the County Durham and Tees Valley Strategic Health Authority area. STUDY DESIGN: An observational study based on Dental Practice Board data for the County Durham and Tees Valley Strategic Health Authority area with a population of 1.13 million. METHODS: The postcode of all orthodontic claims made by National Health Service dentists across the area in the financial years 2002/2003 and 2003/2004 were obtained and the claim rate per 1000 at risk population calculated for each ward. These ward rates were then compared to both the level of deprivation measured by the Index of Multiple Deprivation 2000 and the children's dental registration rate of the area. RESULTS: Inequity in access to orthodontic care was observed. There was a moderate negative correlation r = -0.40 suggesting wards with the lowest claim rates had the greatest deprivation. In addition, the wards with the lowest child dental registration rates also had the lowest claim rates for orthodontic treatment. CONCLUSIONS: Currently, there is inequity of access to orthodontic treatment for children in County Durham and Tees Valley. The move towards local commissioning for dental services within the NHS will provide an opportunity to reduce inequalities in access.     

Equity in access to care in the era of health system reforms in Turkey

ObjectiveTo evaluate access to healthcare from an equity perspective on the way toward Universal Health Coverage in Turkey.MethodsThe country representative data from 2006 to 2013 Turkey Income and Living Conditions Surveys were analyzed. Private household residents aged fifteen and older were asked for self-reported unmet need for medical care in the past twelve months. The dependent variable had three categories: no unmet need, unmet need due to cost, and unmet need due to availability (waiting list and distance problems). Predictors of unmet need were assessed by a multinomial logistic regression analysis.FindingsThe prevalence of unmet need declined between 2006 and 2013. While educational inequalities in declared unmet need also decreased, the income gradient becomes more important. In 2013, controlling for other factors, the propensity to report unmet need was 10 times higher for those in the poorest-income quintile compared to the richest (versus 7 times in 2006).ConclusionOverall access to healthcare has gradually improved in Turkey in the health reform process, but 9% of people still declared unmet need due to cost in 2013, after the implementation of Universal Health Insurance. This was nearly four times the EU average. Unfavourable economic and labour market conditions can be challenges for effective universal health coverage.     

Constructing access in predictive medicine. Comparing classification for hereditary breast cancer risks in England, Germany and the Netherlands

In the first decade of the twenty-first century, predictive forms of medicine, largely associated with genetics, have become increasingly prominent. This has given rise to questions about the social consequences of this development, for example with regard to the distribution of health care access. Drawing on qualitative interviews with clinic staff and public officials and on document analyses, we analyse how access to risk assessment and monitoring for hereditary breast cancer predispositions in Germany, the Netherlands and England is produced through the interaction of risk classification and health care organisation. For each of the three countries, we show how particular combinations of genetic testing and family history data, classification of risks and allocation of monitoring services in practice contribute to specific forms of inclusion and exclusion. Thus, we show how risk assessment and monitoring in Germany attributes a large role to genetic testing; how family history information plays a large role in the Netherlands; and how regional differences in health care have a significant influence in England. On the basis of our case study, we argue that health care organisation is an important facet of the allocation of health care access, as it plays an important role in mediating the influence of risk assessment technologies and risk categories in health care access. We conclude that the allocation of risk assessment and monitoring in predictive medicine deserve more extensive political attention.     

Dental health and access to dental care for ethnic minorities in Sweden

Objective. To describe access to dental care in a population-based sample of foreignborn Swedish residents in relation to dental health. Design. The study was based on data from the Immigrant Survey of Living Conditions in four minority study groups consisting of a total of 1,898 Swedish residents born in Poland, Chile, Turkey and Iran aged 2760. An age-matched study group of 2,477 Swedish-born residents from the Survey of Living Conditions of 1996 was added as a comparison group. The study also included 2,228 children aged 315 years in the minority households and 2,892 children in the households of the Swedish-born study group. Results. The risk of poor dental health was higher in all four minority study groups than for the Swedish-born study group after adjusting for socio-economic variables. In the adult minority study groups the adjusted odds ratios (ORs) for having prostheses and problems with chewing was 6.3 (4.39.1) and 2.7 (1.84.3), respectively, for the Polish-born, 4.8 (3.37.1) and 3.2 (2.14.9) for the Chilean-born, 4.6 (3.16.9) and 4.8 (3.67.2) for the Turkish-born, and 2.7 (1.54.8) and 6.5 (4.110.3) for the Iranian-born compared with the Swedish-born. In the child study group all four minority groups had an increased risk of caries ranging from OR 1.6 (1.32.1) in the Chilean group to 2.5 (2.03.0) in the Turkish group compared with the children with Swedish-born parents. The adults in all four minority study groups more often lacked regular treatment by a dentist than Swedish-born residents. The OR for not having been treated by a dentist during the 2 years preceding the interview ranged from 1.9 (1.42.6) in the Polish-born study group to 3.0 (2.34.0) in the Chilean-born study group after adjustment for socio-economic factors and general health. Conclusion. This study demonstrates that adults in minority populations in Sweden use less dental care despite having greater needs of dental treatment than the majority population. This inequity calls for action in health policy and preventive dental health programmes.     

Disparities in access to health care in three French regions

Objectives

This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d’Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

Methods

To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization – bypass surgery and angioplasty – among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.

Results

In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

Conclusions

Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.     

Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey

A prior national survey of one in eight randomly selected general practices in England estimated that 39% of general practices [95% confidence interval (CI) 35-43%] provided some access to complementary or alternative medicine (CAM) therapies in 1995. A repeat survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs (95% CI 46-52%). The change was due to increased provision in-house; the proportion of practices making NHS referrals remained unchanged. The proportion of services supported by patient payments rose from 26 to 42%.     

Payment systems and incentives in primary care: implications of recent reforms in Estonia and Romania

Since the early 1990s, major reform in healthcare has been adopted in former communist countries in Central and Eastern Europe. More than 20 years after, reform in healthcare still draws much interest from policy makers and academics alike. One of the dynamic components of reform has been the reform of payment systems in primary care. This article looks at recent developments in payment systems and financial incentives in Estonia and Romania. We conclude that finding the appropriate mix in paying and incentivizing primary care providers in a transitional context is no easy solution for healthcare policy makers who need to carefully weigh in the advantages and inherent problems of various payment arrangements. In a transitional, rapidly changing healthcare system and society, and a context of financial stringency, the theoretical effects of payment mechanisms may be more difficult to predict and manage than it is expected. Copyright © 2013 John Wiley & Sons, Ltd.     

A new index of access to primary care services in rural areas

Objective: To outline a new index of access to primary care services in rural areas that has been specifically designed to overcome weaknesses of using existing geographical classifications.
Methods: Access was measured by four key dimensions of availability, proximity, health needs and mobility. Population data were obtained through the national census and primary care service data were obtained through the Medical Directory of Australia. All data were calculated at the smallest feasible geographical unit (collection districts). The index of access was measured using a modified two-step floating catchment area (2SFCA) method, which incorporates two necessary additional spatial functions (distance-decay and capping) and two additional non-spatial dimensions (health needs and mobility).
Results: An improved index of access, specifically designed to better capture access to primary care in rural areas, is achieved. These improvements come from: 1) incorporation of actual health service data in the index; 2) methodological improvements to existing access measures, which enable both proximity to be differentiated within catchments and the use of varying catchment sizes; and 3) improved sensitivity to small-area variations.
Conclusion: Despite their recognised weaknesses, the Australian government uses broad geographical classifications as proxy measures of access to underpin significant rural health funding programs. This new index of access could provide a more equitable means for resource allocation.
Implications: Significant government funding, aimed at improving health service access inequities in rural areas, could be better targeted by underpinning programs with our improved access measure.     

Accounting for uncertainty in policy decision making: Improving access to pediatric dental care

ObjectiveTo introduce a statistical inference framework for policy decision making on access to pediatric dental care.Data SourcesSecondary data were collected for the state of Colorado for year 2019.Study DesignThe access model was an optimization model, matching the demand (patients) and supply (providers) of dental care. Sampling distributions of model inputs were specified using hierarchical Bayesian models, with hyperparameters informed by prior information derived from multiple data sources. Simultaneous inference was applied to identify areas for access improvement. The model was applied to make inference on the pediatric dental care in Colorado, accounting for financial access, differentiated into public (Medicaid and CHIP), private (commercial and out‐of‐pocket), and without financial access.Data Collection/Extraction MethodsMultiple data sources informed the access measurement approach including: 2017 American Community Survey, 2019 Colorado Dental Board, and 2019 National Provider Plan and Enumeration System, 2019 InsureKidsNow.gov among others.Principal FindingsThe median access measure (travel distance) was greater than the Colorado access standards in 16.9% and 65.1% of census tracts for children with private financial access and publicly insured, respectively. Accounting for uncertainty (confidence level 99%), these percentages decreased to 14.6% and 25.6%, respectively, with mostly suburban and rural tracts failing to meet the standards. The median disparity for Medicaid and CHIP versus private financial access was greater than 5 miles in 84.5% and 81.6% of census tracts, respectively. Accounting for uncertainty (confidence level 99%), these percentages declined to 19.5% and 10.5%, respectively, with significant disparities around the metropolitan areas.ConclusionsWhile many communities failed to meet access standards, when accounting for uncertainty, most urban ones did not fail. Disparities in spatial access between publicly and privately insured were most acute in urban communities. Medicaid insured experienced higher disparities than CHIP insured; those differences were not identified when not accounting for uncertainty.     

U.S. medical students' attitudes about patients' access to care

OBJECTIVE: Accessing adequate medical services remains a major struggle for many Americans, but U.S. medical students' beliefs regarding access to care have not been thoroughly examined. METHODS: All medical students in the Class of 2003 at 16 U.S. schools were eligible to complete three questionnaires during their medical training: during freshman orientation, orientation to wards, and their senior year (n=2316, response rate=80.3%). Students responded to three questions about health care provision. RESULTS: Overall, 35% of students strongly agreed that "physicians have a responsibility to take care of patients regardless of their ability to pay;" only 5% disagreed. Only 8% disagreed that "access to basic health care is a fundamental human right." We found the same significant associations with opinions on access as we did with "responsibility to treat," although the associations tended to be stronger for access. Only 10% of students agreed that "Managed care, as it is now delivered, is a good way to deliver health care to the U.S. population." CONCLUSION: Most U.S. medical students support universal access to medical care, though variations in this support, its decline with additional years of medical education, and concerns about managed care are noteworthy, and have policy implications for America's health and health care workforce.     

The importance of knowledge transfer between specialist and generic services in improving health care: a cross-national study of dementia care in England and The Netherlands

Knowledge transfer (KT) between specialist and generic services is widely seen as an important strategy for improving the quality of integrated dementia care. This article elaborates on intra- and inter-organizational features associated with successful KT. A provisional conceptual framework is suggested, based on literature about inter-organizational networks and knowledge management. Professional and organizational cultures, domain perceptions, perceived dependency and the availability of resources are suggested as significant influences upon the motivation and perceived capacity to engage in KT. Personal and organizational continuity is identified as an important process quality. Data from four local case studies in England and The Netherlands are used to develop and specify the provisional framework. A conceptual model is built to explain the relative success or failure of KT.     

The 3 A's of the access process to long-term care for elderly: Providers experiences in a multiple case study in the Netherlands

The access process is an important step in the care provision to independently living elderly. Still, little attention has been given to the process of access to long-term care for older clients. Access can be described by three dimensions: availability, affordability and acceptability (three A's).In this paper we address the following question: How do care providers take the three dimensions of access into account for the access process to their care and related service provision to independently living elderly?To answer this question we performed a qualitative study. We used data gathered in a multiple case study in the Netherlands.This study provides insight in the way long-term care organizations organize their access process. Not all dimensions were equally present or acknowledged by the case organizations. The dimension acceptability seems an important dimension in the access process, as shown by the efforts done in building a relationship with their clients, mainly through a strong personal relationship between client and care advisor. In that respect it is remarkable that the case organizations do not structurally evaluate their access process. Availability is compromised by practical issues and organizational choices. Affordability hardly seems an issue. Further research can reveal the underlying factors that influence the three A dimensions.     

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.     

Racial and ethnic residential segregation and access to health care in rural areas

This study examined the relationship between racial/ethnic residential segregation and access to health care in rural areas. Data from the Medical Expenditure Panel Survey were merged with the American Community Survey and the Area Health Resources Files. Segregation was operationalized using the isolation index separately for African Americans and Hispanics. Multi-level logistic regression with random intercepts estimated four outcomes. In rural areas, segregation contributed to worse access to a usual source of health care but higher reports of health care needs being met among African Americans (Adjusted Odds Ratio [AOR]: 1.42, CI: 0.96-2.10) and Hispanics (AOR: 1.25, CI: 1.05-1.49). By broadening the spatial scale of segregation beyond urban areas, findings showed the complex interaction between social and spatial factors in rural areas.     

Choices and utilization in dental care

We examine the determinants of the utilization of dentists services among adults entitled to age-based subsidized dental care, using data from the Finnish Health Care Survey of 1996. We apply a three-part model to investigate the care-seeking decision, the choice of a private/public dentist, and the number of visits to each chosen dentist. Seeking care is found to be determined mainly by dentists recall and mostly deterred by the expense of private care. Insufficient public availability and recall positively affect the choice of a private dentist, whereas income and dentist density increase the number of private visits. Need and socioeconomic variables are controlled for and are also important determinants. The findings suggest that lowering copayments and user fees and increasing the public supply of dental care, accompanied by an efficient recall system, might improve access to dental care and better steer the choice between sectors.     

Changes in health insurance coverage and health care access as teens with disabilities transition to adulthood

BackgroundPre-ACA, less than 6% of children with disabilities were uninsured, compared with more than 42% of young adults with disabilities ages 19–25. Individuals with disabilities face greater barriers to health care access upon transition into adulthood.ObjectivesWe examined whether the ACA dependent coverage provision and Medicaid expansion improved the transition from pediatric to adult healthcare systems by reducing the gap in insurance coverage and access to care between teens and young adults with disabilities.MethodsUsing cross-sectional data from the 2006–2009 and 2011–2015 National Health Interview Survey (n = 10,136), we estimate the change in insurance coverage and access to care from pre-to post-ACA time periods for teens (ages 13–18) and young adults (ages 19–25) with disabilities in a difference-in-differences model. We completed the same analyses for these groups in Medicaid expansion and non-expansion states.ResultsBoth teens and young adults with disabilities made significant gains in insurance coverage (4.55 and 8.96% point gains respectively, p < .001) and access to care (4.01 and 3.14% points decline in delayed care due to cost, p < .05) under the dependent coverage provision and Medicaid expansion.ConclusionsMedicaid expansion had a greater impact on both insurance coverage and on access to care than did the dependent coverage provision. The benefits of these changes flowed primarily to young adults with disabilities, reducing the gaps in insurance coverage between teens and young adults, and expanding access to care for both groups, providing a more seamless transition from pediatric to adult health care systems, post-ACA.     

"I spent nine years looking for a doctor": exploring access to health care among immigrants in Mississauga, Ontario, Canada

There is a growing body of research in Canada and from other countries acknowledging that immigrants face barriers in accessing health care services. As immigrants make up an increasing percentage of the population in many developed nations, a better understanding and eliminating these barriers is a major priority. This research contributes to current understandings of access among immigrant populations in Canada by exploring perceptions of access to care through focus groups with a diverse group of immigrants living in a Mississauga, Ontario neighbourhood. The results of eight focus groups reveal that immigrants face geographic, socio-cultural and economic barriers when attempting to access health care services in their community. This paper provides policy recommendations relevant to the federal, provincial and local levels for eliminating these barriers.