Division of General Surgery, University of Utah, Salt Lake City.
Department of Geography, University of Utah, Salt Lake City.
JAMA Health Forum. 2022 Oct 7;3(10):e223633. doi: 10.1001/jamahealthforum.2022.3633.
Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics.
To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022.
Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3).
In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities.
In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.
拥有急诊外科服务的医院为广泛的时间敏感疾病提供了基本的护理。通常使用的空间可达性衡量指标，如距离或旅行时间，已被证明比更全面的指标低估了差异。
使用增强型两步浮动捕获法（E2SFCA）评估美国范围内具有急诊外科能力的医院的人口水平空间可达性差异。
设计、设置和参与者：这是一项使用 2015 年美国社区调查数据的横断面研究。国家普查街区组（CBG）的社区特征数据与具有急诊部门和住院手术服务的医院的地理坐标相匹配，并确定了具有先进临床资源的医院。空间可达性通过空间可达性比（SPAR）进行测量，这是一种 E2SFCA 方法，可捕捉到到医院的距离、人口需求和医院容量。进行了小区域分析，以评估护理机会不足的人群和与空间可达性低相关的社区特征。数据分析于 2021 年 2 月至 2022 年 7 月进行。
低空间可达性定义为 SPAR 比全国平均值低 1.0 个标准差以上（SPAR <0.3）。
在 217663 个 CBG 中（CBG 的中位数[IQR]年龄，39.7[33.7-46.3]岁），有 3853 家具有急诊外科能力的医院和 1066 家（27.7%）具有先进临床资源的医院。在 3.2 亿居民中，有 3080 万人（9.6%）的人在任何具有急诊外科服务的医院的护理机会较低，有 8260 万人（25.8%）的人在具有先进资源的中心的护理机会较低。在所有情况下，保险状况都与护理机会不足有关（公共保险：调整后的比率比[aRR]，1.21；95%CI，1.12-1.25；无保险 aRR，1.58；95%CI，1.52-1.64）。在大都市和农村地区，高份额（>第 75 个百分位）的西班牙裔和其他（亚洲人；美洲印第安人、阿拉斯加原住民或太平洋岛民；以及 2 个或更多种族和族裔少数群体）社区也与低可达性有关。在获得先进资源医院的机会方面也出现了类似的模式，但存在更明显的种族和族裔差异。
在这项关于外科护理可达性的横断面研究中，近 1/10 的美国居民的任何具有急诊外科服务的医院的空间可达性较低，1/4 的人到具有先进临床资源的医院的空间可达性较低。在大都市和农村地区，保险覆盖率高或无保险的居民和种族和族裔少数群体比例较高的社区面临着有限的急诊外科护理机会的最大风险。这些发现支持使用 E2SFCA 模型来确定外科护理可达性较低的地区，并指导卫生系统的发展。
