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ObjectivesTo compare the proportions of emergency department (ED) attendances following self-harm that result in admission between hospitals, examine whether differences are explained by severity of harm and examine the impact on spatial variation in self-harm rates of using ED attendance data versus admissions data.SettingA dataset of ED attendances and admissions with self-harm to four hospitals in South East London, 2009–2016 was created using linked electronic patient record data and administrative Hospital Episode Statistics.DesignProportions admitted following ED attendance and length of stay were compared. Variation and spatial patterning of age and sex standardised, spatially smoothed, self-harm rates by small area using attendance and admission data were compared and the association with distance travelled to hospital tested.ResultsThere were 20 750 ED attendances with self-harm, 7614 (37%) resulted in admission. Proportion admitted varied substantially between hospitals with a risk ratio of 2.45 (95% CI 2.30 to 2.61) comparing most and least likely to admit. This was not altered by adjustment for patient demographics, deprivation and type of self-harm. Hospitals which admitted more had a higher proportion of admissions lasting less than 24 hours (54% of all admissions at highest admitting hospital vs 35% at lowest). A previously demonstrated pattern of lower rates of self-harm admission closer to the city centre was reduced when ED attendance rates were used to represent self-harm. This was not altered when distance travelled to hospital was adjusted for.ConclusionsHospitals vary substantially in likelihood of admission after ED presentation with self-harm and this is likely due to the differences in hospital practices rather than in the patient population or severity of self-harm seen. Public health policy that directs resources based on self-harm admissions data could exacerbate existing health inequalities in inner-city areas where these data may underestimate rates relative to other areas.

Introduction Emergency Departments experience a significant census burst after disasters. The aim of this study is to describe patient presentations at Emergency Departments in Contra Costa County, California following chemical release incidents at an oil refinery in 2007 and 2012. Specific areas of focus include hospital and community burden with an emphasis on disease classes. Methods Searching 4 weeks before through 4 weeks after each event, Emergency Department abstracts identified patients living in Contra Costa County and seeking care there or in neighboring Alameda County. City and ZIP-code of residence established proximity to the refinery. This provided the following contrast groups: Event (2007, 2012), time (before, after), location (bayside, rest of county), and within bayside, warned or not warned to shelter in place. Using the Multi-Level Clinical Classification Software, we classified primary health groups recorded 4 weeks before and after the events, then summarized the data, calculated rates, and made tables, graphs, and maps to highlight findings. Results Number of visits meeting selection criteria totalled 105020 records. Visits increased modestly but statistically significantly after the 2007 incident. After the 2012 incident, two Emergency Departments took the brunt of the surge. Censuses increased from less than 600 a week each to respectively 5719 and 3072 the first week, with the greatest number 2 days post-event. It took 4 weeks for censuses to return to normal. The most common diagnosis groups that spiked were nervous/sensory, respiratory, circulatory, and injury. Bayside communities had statistically significant increases in residents seeking care. Specifically, visits of residents in warned communities nearest the refinery increased by a factor of 3.7 while visits of residents in other nearby un-warned communities increased by a factor of 1.5. Conclusions The 2012 Emergency Department census peaked in the first week and did not return to normal for 4 weeks. Diagnoses changed to reflect conditions associated with reactions to chemical exposures. Surrounding communities and nearby hospitals experienced significant emergent burdens. In addition to changes from such events in patient diagnoses and community burden, the discussion highlights the long-term implications of failures to require adequate monitoring and warning systems and failures of health planning. Electronic supplementary material The online version of this article (10.1186/s12940-019-0484-4) contains supplementary material, which is available to authorized users.

RESUMEN Las encuestas de salud son una herramienta clave para la toma de decisiones en políticas de salud y para la planificación de los servicios de salud. El uso de métodos estadísticos para áreas pequeñas que utilizan información de diferentes ámbitos geográficos puede resultar útil para estimar indicadores de salud a una escala geográfica menor que la originalmente considerada en el diseño de una encuesta. ABSTRACT Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design.

ObjectivesTo explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons.Data sources/study settingCounty-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used.Study designA retrospective cross-sectional study using in- and outpatient secondary data was performed.Data collectionHospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care.Principal findingsCrude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r=0.65-0.70) in ACSH rates for all conditions except asthma (r=0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment.ConclusionsUnadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.

Background Life expectancy at birth (LE) has been calculated for states and counties. LE estimates at these levels mask health disparities in local communities. There are no nationwide estimates at the sub-county level. We present a stepwise approach for calculating LE using census tracts in New York state to identify health disparities. Methods Our study included 2751 census tracts in New York state, but excluded New York City. We used population data from the 2010 United States Census and 2008–2010 mortality data from the state health department. Tracts were assigned to 99.97% of the deaths. We removed tracts which had a majority of people living in group quarters. Deaths in these tracts are often recorded elsewhere. Of the remaining 2679 tracts, 6.6% of the tracts had standard errors ≥ 2 years. A geographic aggregation tool was used to aggregate tracts with fewer than 60 deaths, and then aggregate areas that had standard errors of ≥ 2 years. Results Aggregation resulted in a 9.9% reduction in the number of areas. Tracts with

Fundamento. Describir las desigualdades en mortalidad en Logroño y Pamplona, ciudades del norte de España, utilizando un indicador de privación socioeconómica por secciones censales. Métodos. Para geocodificar la residencia de los fallecidos en base a las unidades censales se utilizó la dirección postal del Boletín Estadístico de Defunción y en su defecto la del Padrón Municipal o Tarjeta Sanitaria. Las variables socioeconómicas que componen el índice de privación se obtuvieron del Censo de Población y Vivienda de 2001. Se agruparon las secciones censales por quintiles de menor a mayor privación socioeconómica y se calcularon tasas ajustadas para la mortalidad total y para una lista de causas por sexo, grupo de edad (0-64, ≥ 65) y quintil del índice de privación socioeconómico. Resultados. La comparación de la mortalidad de las zonas con menor privación socioeconómica respecto a zonas geográficas con mayor privación mostró en ambas ciudades una mayor mortalidad principalmente entre los hombres menores de 65 años. En este subgrupo se observó un gradiente positivo entre la mortalidad y el índice de privación. Las zonas situadas en el quintil de mayor privación alcanzaron un riesgo relativo (RR) de 1,61 (IC 95%, 1,33-1,92) en Pamplona y de 1,77 (IC 95%, 1,55-2,01) en Logroño. Las mujeres menores de 65 años mostraron un RR de 1,44 (IC 95%, 1,18-1,74) y de 1,48 (IC 95%, 1,10-1,95) en las zonas situadas en el quintil de mayor privación de Pamplona y Logroño, respectivamente. Conclusiones. El estudio evidenció desigualdades en mortalidad asociadas a la privación socioeconómica en las ciudades de Logroño y Pamplona. También mostró la utilidad de los indicadores socioeconómicos y de mortalidad a nivel de área pequeña para identificar desigualdades en salud Background. The objective of this study was to describe inequalities in mortality in the cities of Logroño and Pamplona, using a socioeconomic privation index by census tract. Methods. Deaths were geocoded using the mailing address of the Death Statistics Bulletin and, in its absence, that of the Spanish Municipal Register or the Spanish Health Card. The socioeconomic variables used to construct the deprivation index were obtained from the Spanish Population and Housing Census of 2001. Census tracts were grouped by socioeconomic deprivation quintiles. In each quintile, age-adjusted mortality rates were computed by sex and age group (0-64, ≥ 65). Results. In both cities, higher mortality rates were observed in the geographical areas with higher socio-economic deprivation. This was particularly evident among men under 65 for whom a positive gradient between mortality and the deprivation index was observed. The areas with higher deprivation reached a relative risk (RR) of 1.61 (CI 95%, 1, 33-1, 92) and 1.77 (CI 95%, 1, 55-2 01) in Pamplona and Logroño respectively. Among women under 65, a RR of 1.44 (CI 95%, 1, 18-1, 74) and 1.48 (CI 95%, 1, 10-1, 95) were shown for the most depressed areas of Pamplona and Logroño respectively. Conclusions. The study highlighted inequalities in mortality associated with socioeconomic deprivation in the cities of Logroño and Pamplona. Also showed was the utility of analysing socio-economic indicators and mortality by small areas in order to identify inequality in health

Background Medical practice variation refers to differences in health service utilization among regions in the same country. It is used as a tool for studying health inequities. In 2011, the OECD launched a Medical Practice Variation Project which examines regional differences within countries and explores the sources of the inter-regional differences. The aim of this study is to examine the patterns and trends in geographic variation for selected health services in Israel. Methods The analysis is based on data from the National Hospital Discharges Database (NHDD) of the Israeli Ministry of Health. The eight procedures and services studied were: medical admissions (i.e. admissions without surgical procedures); hip fractures; caesarian sections; diagnostic cardiac catheterization; cardiac angioplasty (PTCA); cardiac bypass surgery (CABG); hysterectomy; and knee replacement surgery. The data are presented for the 7 districts in Israel, determined by address of residence. Results The procedures and services with the lowest variation across the seven districts were medical admissions (RR between regions-maximum/minimum 1.3) and hip fractures (RR 1.44), while the one with the highest variation was CABG (RR 1.98). The Israeli periphery, and the northern district in particular, had higher rates of medical admissions, knee replacement and cardiac procedures. When studying the trend over time, we found a decrease in use rates for most procedures, such as coronary bypass (R. 04) and CABG (R 0.8). Medical admissions decreased by 8%, with the highest decline (16%) observed in the central districts. Conclusions This study provides Israeli policy makers with information which is vital for the strategic planning of service development, such as strengthening preventive medical services in the community, reducing cardiovascular risk factors in the periphery and expanding the national publication of clinical quality scores. Electronic supplementary material The online version of this article (doi:10.1186/s13584-016-0127-y) contains supplementary material, which is available to authorized users.

Background This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS). Methods Data for fiscal years 2007 – 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF. Results Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas. Conclusions In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare.

Objective The appropriate role for chiropractic in US health care has not been established, but third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the services that chiropractors provide. Appropriateness studies for chiropractic may inform those decisions. The purpose of this article is to discuss the implications and limitations of appropriateness studies for chiropractic. Discussion We reviewed the general context for assessment of the appropriateness and the application of appropriateness studies to chiropractic in particular. We evaluated the implications and limitations for chiropractic of methods of small area analysis and the RAND-UCLA Appropriateness Method. The RAND-UCLA Appropriateness Method has been applied to the evaluation of spinal manipulation. Regional variations in chiropractic utilization have yet to be described through small area analysis, but these methods appear to hold some potential for assessing the appropriateness of chiropractic care. Both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness. Conclusion Future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment of chiropractic appropriateness will require new evidence and perhaps new research methodologies.

Background Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007. Methods We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. Results Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. Conclusions Preventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process This work was partly supported by the FIS-FEDER projects PI080330, PI081713, PI081978, PI0463/2010, PI081017, PI081785, PI081058, PI080142, and the FUNDACIÓN CAJAMURCIA project FFIS/CM10/27

ResumenAntecedentesLas variaciones geográficas en la práctica médica se han analizado ampliamente; cuando la evidencia sobre la efectividad de las tecnologías sanitarias es fuerte, las variaciones son pequeñas y probablemente, reflejan diferencias en la necesidad; sin embargo, cuando dominan la incertidumbre o la ignorancia, la decisión médica es particularmente sensible a la oferta. En este artículo se argumenta acerca de los factores (incentivos) que influyen en la utilización hospitalaria en el Sistema Nacional de Salud (SNS) español.Material y métodoSe compararon las tasas de utilización del SNS y de Medicare (Sistema de Salud federal estadounidense para personas mayores y discapacitados).Resultados1) Las tasas de utilización españolas fueron menores para la mayor parte procedimientos a estudio, aunque en artroplastia de rodilla, de cadera y colecistectomía fueron similares; 2) a diferencia de lo que sucede en Medicare, la oferta de camas totales mostró poca correlación con las tasas de utilización; sin embargo, las poblaciones con más intervenciones, eran más intensivas para todos los procedimientos; 3) los hospitales de «alta tecnología» realizaron menos intervenciones «comunes»; por otra parte, la «cirugía innovadora » obtuvo tasas cercanas a las de Medicare.ConclusionesLas diferentes «variaciones» en ambos sistemas sanitarios sugieren una diferente estructura en los incentivos. En España la «fascinación tecnológica» es una explicación alternativa al volumen de la oferta e implicaría un SNS más focalizado en la tecnología que en las necesidades de los pacientes.AbstractBackgroundGeographic variations in medical practice have been widely described and different underlying causes have been proposed. Basically, when evidence about effectiveness is strong variations are lower and, probably, it reflects patient needs differences; nevertheless, when either uncertainty or ignorance about effectiveness dominates, medical decision making is particularly sensitive to supply. In this paper we argue about the factors (incentives) influencing hospital utilization in the Spanish National Health Service (sNHS).Matherial and methodWe have compared both sNHS utilization rates and those in MEDICARE (US Federal Health System for elderly and handicapped population).Results1) Utilization rates in Spain were lower than in MEDICARE for most of the conditions and procedures under study. However, knee or hip replacement and cholecystectomy rates were similar; 2) unlike what happened in MEDICARE, supply, as total beds per 1,000 inhabitants, showed either negative or no correlation with utilization rates; however, those populations which get more interventions get more of whatever the surgery performed; 3) High tech hospitals, in terms of tertiary and teaching hospitals, perform less «common» interventions; on the other hand, «innovative surgery» utilization rates were closed to those in MEDICARE.ConclusionsDifferences between both Health Care Systems suggest a different structure of incentives working under variations. Here in Spain, instead of supply, «high tech fascination » is becoming the alternative explanation. If true, «technology fascination» hypothesis entails a model of National Health Service focused on technology instead of patient needs.

Background: Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996-2001 and 2002-2007. Methods: We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. Results: Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996-2001 and 10.9 in 2002-2007), though not so clearly among women (3.3% in 1996-2001 and 2.9% in 2002-2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. Conclusions: Preventable mortality decreased between the 1996-2001 and 2002-2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process. © 2015 Nolasco et al.; licensee BioMed Central.

Background: While research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996–99, 2000–2003 and 2004–2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia). Methods: All deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson’s Regression models, adjusted for age and study period, and distinguishing between genders. Results: Amenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time. Conclusions: Although amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth. This work was partly supported by the FIS-FEDER projects PI040170 and PI080330.

To map out area effects on health research, this study had the following aims: (1) to inventory multilevel investigations of area effects on self rated health, cardiovascular diseases and risk factors, and mortality among adults; (2) to describe and critically discuss methodological approaches employed and results observed; and (3) to formulate selected recommendations for advancing the study of area effects on health. Overall, 86 studies were inventoried. Although several innovative methodological approaches and analytical designs were found, small areas are most often operationalised using administrative and statistical spatial units. Most studies used indicators of area socioeconomic status derived from censuses, and few provided information on the validity and reliability of measures of exposures. A consistent finding was that a significant portion of the variation in health is associated with area context independently of individual characteristics. Area effects on health, although significant in most studies, often depend on the health outcome studied, the measure of area exposure used, and the spatial scale at which associations are examined.

Fundamentos: El cáncer de mama es el más frecuente en las mujeres. El objetivo del presente estudio fue analizar la incidencia y distribución geográfica del cáncer de mama invasivo en el área de salud de León (ASL). Métodos: Estudio observacional descriptivo en el que se incluyeron mujeres con diagnóstico de neoplasia maligna de mama (CIE-9:174, CIE-10: C50) del Registro Hospitalario de Tumores del Centro Asistencial Universitario de León, entre 1/1/1996 y 31/12/2010 y con residencia en el ASL. Para el análisis de la distribución espacial se estimaron los riesgos relativos (RR) municipales suavizados mediante el ajuste del modelo de Besag, York y Mollié y sus probabilidades posteriores de que los RR fuesen > 1 (PP), utilizando métodos bayesianos. Resultados: Se incluyó un total de 2.379 casos. El número de casos nuevos y las tasas de incidencia brutas en cada trienio fueron de 72,7 (1996-1998) a 101,5 (2008-2010) por 100.000 mujeres. Las tasas a población europea por 100.000 mujeres ascendieron de 58,0 en el primer trienio y a 69,4 en el último. Se observó un incremento anual promedio del 1,3%. Varios municipios del ASL presentaron riesgos superiores al 10 %. Las PP solo fueron superiores a 0,9 en el municipio de León. Conclusiones: Las tasas observadas son de las más bajas de España. Sin embargo, el número de casos y las tasas de incidencia se incrementaron de manera mantenida en el periodo estudiado. Background: Breast cancer is the most common amongst women. The aim of this study was to analyze the incidence and geographical distribution of breast cancer in the health area of León. Methods: We designed an observational descriptive study that included women enrolled in the Hospital Tumor Registry of the Centro Asistencial Universitario in León with a diagnosis of breast malignant neoplasm (ICD-9: 174, ICD-10: 50) between 01/01/1996 and 31/12/2010 and resident in the health area of León. To study the spatial distribution, we estimated municipal relative risks (RR) smoothed by fitting the Besag, York and Mollié model and the posterior probability (PP) of RR > 1 using Bayesian methods. Results: A total of 2379 cases were included. The number of new cases and the crude incidence rate have both increased in every triennium, from 72,7 (1996-1998) to 101,5 (2008-2010) per 100,000 women. The age adjusted rates per 100,000 women (European standard population) increased from 58,0 during the first triennium to 69,4 during the last one. An average annual increase of 1,3% was observed. Several municipalities from the health area of León showed risks higher than a 10%. The PP were higher than 0.9 only in the municipality of León. Conclusions: The observed rates are among the lowest in our country. Nevertheless, the number of cases and the incidence rates have increased progressively.