The Role of Location for Equitability and Improved Quality of Care
Denese M. Neu, Ph.D.
HHS Planning & Consulting, Inc.
773‐944‐5122
The Conversation
This presentation revisits research conducted in 2002. Although spatial methods and mapping software has advanced tremendously, the findings remain significant. This presentation aims to improve the cross‐dialogue between public health, planning, and private sector health care delivery. It links policy/funding to people and place.
Catalytic Quotes
• “What is Healthy People 2010?”
• “Why would should doctors care about urban issues?”
• “We don’t address quality standards until we have to.”
• “We want more people on dialysis – not less. That’s how we make our money.”
• “We built that new clinic. Get some patients in there.”
Background
The idea for this research emerged while working as an area dialysis administrator in the New Orleans area. This position was with an international provider. The quotes in the previous slide came from my superiors.
Advocacy for the patient suggests a lack of awareness and/or disregard for the barrier of distance for medical treatment compliance.
The Following Maps
The first map helps orient the viewer to the spatial distribution of race in Orleans Parish (same geography as the City of New Orleans).
The second map orients the viewer to the spatial distribution of poverty in Orleans Parish.
Each of these maps demonstrate the value of mapping at a smaller geographic scale to visualize data patterns that would not be evident at the zip code level.
A Few Points About Dialysis Patients and Funding Policy
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Approximately 300,000 patients in the U.S.
Entitlement Program (Medicare = approximately 75% of the revenue source for a $16 Billion/year industry).
A stereotypical patient is a white male, over 44 years of age with diabetes or hypertension.
Disparity: 1 of every 3 patients is African American.
The Louisiana patient profile is a black male, over 44, with a household income below $15,000.
A 2005 study suggests that 33% of patients are walking disabled.
LOCATION MATTERS
• Walking disability is relevant. This increases the burden of distance because the patient cannot easily traverse smaller distances between home, bus stop, clinic.
• Other factors that increase the burden of distance are: transportation networks, safety/comfort, cultural competency, lack of community diversity, and waiting times.
The CMS Dialysis Facility Search Tool
By Name
By Proximity
Within a certain distance of:
City
ZIP Code
By Geography
State
County
Discussion Points
The tool links basic clinical quality indicators to geographic location. It is only a snapshot that fails to tell the full story (e.g., demographics, co‐morbidity, accessibility, cultural competency capabilities).
The tool does not scale down beyond zip code, a geography developed for nothing other than managing postal delivery. The search cannot be conducted at a shorter distance of within 5
miles. This scale does not address the burden of distance and nuances of geography which make it harder for the chronically ill to be fully engaged in their treatment.
A Spatial Map of Dialysis Clinics and Patients
The next map illustrates the spatial mismatch between supply (clinics) and demand (patients). Clinics were mapped by address; patients were mapped by zip code. In this case, zip code was the only geographic scale because of the need to protect patient confidentiality and it was the only scale in which the database was available.
The clinic distribution pattern through the center of the city appears to “stock” inner city areas. The suburban locations and patient geo‐data suggest that these clinics are sited more for the convenience of staff than for patients. However, these clinics are more likely to serve white, middle and upper class patients with access to private transportation.
The Relevancy of Distance Decay Theory
The basic principle of distance decay theory is that the farther one is from what s/he needs, the less likely s/he will be able to access it.
This theory becomes significant in the conversation about access because it addresses the burden of place and spatial mismatch. Simple availability of a clinic may not be enough to deliver treatment with good quality outcomes. A patient who is burdened by time and distance will be less capable of fully participating in the treatment plan, exercising, and engaging in meaningful life activities. It also suggests that some patients may not receive treatment delivered in a psychologically safe area and in a culturally competent manner.
This theory was anecdotally tested when an inner city clinic became a Center of Excellence after hiring from the neighborhood and developing patient education programs to improve health literacy. This clinic was classified as being incapable of good quality indicators. Prior to its forced closing as a result of Hurricane Katrina, it continued to outperform the flagship suburban clinic. Cumulative Needs Map
This next map is the visualization of the geographically linked data that was selected for the study. This would be done differently today, but the findings remain relevant for the discussion. Distance is an increased burden when evaluated with other compounding factors. Other points about the burden of distance that requires local knowledge are other spatial barriers. For example: this region lacks a regional public transit system which makes it extremely hard for bus riders to cross from one parish to another for services. Also, the Mississippi River and other geological features serve as barriers and require additional distance burden analysis.
Solutions
Reverse place‐based burden!
• Conduct quality of care research at a smaller geographic scale. • Evaluate how to “sell” profit‐driven providers on the benefits of patient accessibility.
• Develop better accountability within the private‐public partnership without harming patients. ESRD reports a high level of patient‐provider conflict. Likewise, some patients may be rejected or discharged if quality and reimbursement are linked.
• Include spatial aspects in the health care definition of access. ESRD Data
For additional information about ESRD and the dialysis industry…..
www.usrds.org
www.esrdnetworks.org
www.cms.hhs.gov/center/esrd.asp