Disease-wide accessibility of the elderly in primary care setting: The relationship between geographic accessibility and utilization of outpatient services in Tokushima prefecture, Japan

Yoshimi Tsuji, Tomohiro Hirao, Ai Fujikawa, Yoichi Hoshikawa, Akira Yoshioka, Takeshi Yoda, Takeshi Suzue

4Kagawa Prefectural Government, Kagawa, Japan.
Department of Nursing, Kagawa Prefecture College of Health Sciences, Kagawa, Japan.
Department of Public Health, Faculty of Medicine, Kagawa University, Kagawa, Japan.
Takamatsu City Public Health Center, Kagawa, Japan.

DOI: 10.4236/health.2012.46053                

Abstract

In Japan, a rapid pace of aging coupled with the lower birth rates causes the decrease of the population especially in rural area, which leads to the problems with the delivery of healthcare services. We investigated the relationship between the geographical accessibility (time and distance) and the utilization rate of outpatient services in the elderly by major disease groups in Tokushima prefecture, Japan. Distances and driving times to the nearest facilities from residential sites in major disease categories were measured by using geographic information system. Utilization data was obtained from the claim data. In diseases of the musculoskeletal system and connective tissue (M00-M99), diseases of the digestive system (K00-K93), endocrine, nutritional and metabolic diseases (E00-E90), diseases of the eye and adnexa (H00-H59) and diseases of the respiratory system (J00-J99), there were moderate negative correlations (around –0.4 to –0.6) both in distance and time. Distance and time to the nearest facilities were important factors for the utilization of outpatient services of major disease categories in Japanese elderly. Comprehensive approach which include socio- economic factors is needed to mitigate access problems in aging Japanese society.

Keywords

Geographic Accessibility; Aging;Primary Care; Healthcare Utilization

1. INTRODUCTION

Aging is an issue that all developed countries are facing. In Japan, a rapid pace of aging coupled with the lower birth rates causes the decrease of the population especially in rural area, which leads to the problems with the delivery of social services [1-3]. Healthcare is one of the important social services which influence on the well-being of the people. In Japan universal access is guaranteed to all residents, so anyone can take healthcare services with no significant financial or geographical problems [4]. However, in rural areas the elderly may experience the difficulties in seeking healthcare services because the facilities are scarcer than in urban areas. Moving long distance to the medical facilities may lead to an inability to receive necessary treatments at right time and worsen the illnesses.

Several studies on geographic accessibility in health care have been published. Most of them investigated the accessibility of specific services, such as vaccination, pediatric care and emergency care [5-11], or some of them showed the effect on health outcome [12-15], however, disease-wide accessibility of the elderly in primary care setting was not well-investigated. To evaluate the healthcare accessibility of the elderly as a public health issue, appropriate area setting such as prefecture and considering major diseases which are popular among the elderly are required.

In this study we investigated the relationship between the geographical accessibility (time and distance) and the utilization rate of outpatient services in the elderly by major disease groups in Tokushima prefecture, Japan. We used publicly opened data from several government organiza-tions. Geographical accessibility and healthcare utilization were estimated by using geographical information system and claim data of health insurance respectively. Relationships between them were analyzed by measuring coefficients of correlation.

2. METHODS

2.1. Study Area

Tokushima prefecture is located on Shikoku Island in the southwestern part of Japan. Three fourth of the land is covered by mountains and the other is narrow plain and coast areas. Its population was 810 thousand in 2005 and the population density was 195 per square kilometer. 24.4% of the population (197 thousand) was the aged 65 or more. The prefecture consisted of 50 municipalities in 2005. Most of them are located in mountainous area and have the issues of aging and a population decline. Tokushima prefecture was considered one of the typical local areas of Japan (Figure 1).

2.2. Data Source

In this study we defined the elderly as aged 65 years or more. We obtained 2005 population data of Tokushima prefecture in 500 m² block level from the 2005 Population Census of Japan, reported by the Statistical Survey Department, Statistics Bureau, Japanese Ministry of Internal Affairs and Communications [16]. A list of clinics and hospitals which included address and specialties were publicly released by Tokushima prefectural government [17]. As for utilization of medical facilities, we employed the statistics of Tokushima National Health Insurance 2003 and 2004 [18,19], which included the aggregated data on age, sex and disease (major category of ICD10) specific utilization of outpatient services in May for 50 municipalities in Tokushima Prefecture. Because 88.5% of the aged 65 or more who lived in Tokushima prefecture enrolled in Tokushima National Health Insurance Organization in 2003, the data was considered the representation of the elderly in Tokushima Prefecture. We used the average of 2003 and 2004 for the analysis. The road network data for Tokushima Prefecture was derived from the National Land Numerical Information released by the National and Regional Policy Bureau, Japanese Ministry of Land Infrastructure, Transport and Tourism [20].

Figure 1. Distribution of the population aged 65 years or more in Tokushima prefecture.

2.3. Measuring Geographic Access

Distances and driving times via normal roads between residential sites and medical facilities were measured by using geographic information system. As for residential sites we assumed all residents within 500 m² block located at the center of the block. As for medical facilities the locations of the facilities were geocoded by using the CSV Address Matching Service supplied by the Center for Spatial Information Science at the University of Tokyo [21]. In October 2006, there were 3394 blocks and 831 medical facilities (in specialties there were 654 Internal Medicine, 202 Orthopedic Surgery, 80 Ophthalmology and 62 Psychiatry access points because several facilities had more than 2 specialties) in Tokushima Prefecture (Figure 2).

To estimate travel distance and time, we constructed digital transportation network by using digital data of road and average travel speed at the time of rush hours [22]. We specified the nearest points on the road network from center of block and the location of medical facilities; then measured the shortest routes between two points. We employed the distance and time to the nearest facility as variables of geographic accessibility. To estimate the average distance and travel time in each municipality, block level data were aggregated weighted by the population of block.

2.4. Estimating the Utilization in the Elderly

Data on utilization of medical facilities was provided as total sum of the days of visit in May. To estimate the age, sex, and disease specific utilization rate of outpatient services in each municipality, we employed the following equation.

Utilization rate of outpatient services per 1000 Population = Total sum of the days of visit/(Number of insured × 20 days) × 1000,

where 20 days means the working days of May in Japan.

Table 1 showed the utilization rate of outpatient services in major disease groups. Because 7 disease group, diseases of the circulatory system (I00-I99), diseases of the musculoskeletal system and connective tissue (M00- M99), diseases of the digestive system (K00-K93), endocrine, nutritional and metabolic diseases (E00-E90), diseases of the eye and adnexa (H00-H59), diseases of the respiratory system (J00-J99) and mental and behavioral disorders (F00-F99), contributed more than 80% of total utilization, we analyzed the accessibility of these 7 disease categories.

Conflicts of Interest

The authors declare no conflicts of interest.

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