Telemedicine: a new health care delivery system.

The resurgence of telemedicine can be attributed to its potential for addressing intransigent problems in health care, including limited accessibility, cost inflation, and uneven quality. After discussing definitions and the genesis of telemedicine, this review focuses on conceptual issues and an assessment of past research. The scope and methodological rigor necessary for sustained development and policy making have been limited in this area of research, owing to the nature of extant telemedicine projects and the lack of a comprehensive research strategy that specifies the objectives of telemedicine research regarding accessibility, cost, and quality. Research strategies and a framework for analysis are discussed. Without a commitment to the types of research objectives, framework, and strategy presented here, the considerable promise of telemedicine, as an innovative system of care, may not be fully realized.

The Atlantic Rim Telemedicine Summit. Boston, Massachusetts, USA, May 1997.

The Transatlantic Telemedicine Summit was convened to facilitate the international exchange of ideas and experiences regarding anticipated obstacles to the deployment of telemedicine in and among Atlantic Rim countries. Presented here is a review and summary of the Summit, as well as the principal recommendations derived from the proceedings. These recommendations provide a basis for the further development of cooperative efforts in international telemedicine.

General practitioner distribution and population dynamics: Munich, 1950-1990.

The problem of variable geographic distribution of physicians appears to be universal and intransigent. There is growing evidence from several developed countries of primary physicians avoiding areas in large cities increasingly populated by poor and ethnic minorities. This paper extends the research to Germany. Here, the changing population structure of Munich from 1950 through 1990, characterized by a large influx of foreign guestworkers, is illustrated. Selected changes in the medical care system and the role of the general practitioner pertinent to the question of supply and distribution are also discussed. Within this context, the geographic distribution of general practitioners' offices is examined for possible response to the concentration of foreigners in Districts within the City. In the aggregate, the distribution of general practitioners follows the geographic trends of the general population during the study period. However, geographic distribution of general practitioners varies widely on a District by District assessment. Though the exception, in several Districts there are indications that general practitioners may be avoiding locating offices in areas characterized by high density of foreign populations. This paper also draws attention to the importance of investigative scale to conclusions relating general practitioner distribution to spatial-temporal population trends.

Locating ambulatory medical care facilities for the elderly.

The importance of effective planning strategies for the location of primary medical services for the independently living elderly increases as their absolute number and proportion in the general population increases. Current spatial planning strategies focus on providing services in centralized locations or decentralized at the level of the somewhat problematic residential "neighborhood" or catchment area. An alternative or supplemental strategy based on the actual use of community space by the elderly is presented in this article. Aggregate activity spaces are identified and illustrated using activity location data obtained for a sample of elderly urban residents. Subsequently, the aggregate spaces are used as a basis for suggesting the location of ambulatory care facilities. It is believed that the aggregate activity space represents a dynamic and more functional approach to spatial planning strategies than current approaches and, therefore, that it can be used more effectively to locate services for the elderly.

Rings of madness: service areas of 19th century asylums in North America.

The mid-19th century saw the emergence of a major medical innovation, namely, the rise of the state lunatic asylum. Beginning in the northeast, the phenomenon spread rapidly westwards. By 1875 no fewer than 71 mental hospitals were opened in 32 existing states. Although premised upon belief in the efficacy of 'moral and humane' treatment, the asylums soon became custodial rather than therapeutic institutions. Average size continually increased; some accommodated well over 2000 patients. The provision of more asylums, and broadened definitions of insanity, generated increasing patient numbers which, in turn, caused public consternation and fear of increasing 'madness' in the population. Geographic analysis of admissions in 18 U.S. states and two Canadian provinces reveals the universality of distance decay around the asylums, and demonstrates that hospital service-area cones were predominantly local in effect. Thus the 'state' asylum was in reality a local institution. The deinstitutionalization movement of recent decades is apparently bringing to a closure a 100-year cycle of incarceration-decarceration of the mentally ill. Nevertheless, whether patients are geographically concentrated or dispersed, the influence of distance decay remains a relevant consideration.

Distance and the use of mental health services.

The inverse relationship between distance from mental health services and their use has been noted over many decades and on several continents. Although many factors--diagnostic, socioeconomic, and nosocomial--may modify this correlation, its persistence is remarkable. As other barriers to use are diminished, distance remains a mutable variable for planning more effective use of many health care services.

The journey to birth: medical and geographical patterns of births to women of a rural Kentucky county, 1911-1980.

A relative lack of medical services is common in rural areas, and it has been suggested that the number of births in the mother's county of residence reflects both the availability of obstetric services as well as attitudes toward local and nonlocal medical care. In order to better understand these relationships, we analyzed the evolution of medical and geographical patterns of births to women of a rural Kentucky county in the context of both a changing philosophy and a changing availability of medical care. Specifically, using archival data, we assessed the locus (i.e., home versus hospital) and location (i.e., county) of births to Robertson County women from 1911 to 1980. Without a hospital for the entire period and with the number of physicians declining, the percentage of in-county home births increased steadily, reaching virtually 100 percent by 1950. During this same period, the number of physicians practicing there decreased from 22 to 2. Subsequent delivery patterns reflect the acceptance by the physicians and women of the "principle" of hospital delivery formally enounced in 1945. By 1965, home births had been eliminated, and Robertson County women were, of necessity, traveling the 25-30 miles to the several hospitals in contiguous counties. In the past 15 years, a substantial proportion (almost 20 percent) have elected to travel to hospitals even farther (55-60 miles) from Robertson County. Generally, the Robertson County experience reflects the "lag" observed in the rural-urban, home versus hospital birth experience. Nevertheless, since 1966, all recorded births to Robertson County women have occurred in hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacy patronage among the elderly: selected racial and geographical patterns.

In the United States the number of elderly and their percentage of the total population continues to increase. The large majority will never require care in an institution, yet they are faced with increasing health problems and decreased mobility, and almost half require prescription drugs to pursue activities of daily living. In this paper selected patterns of pharmacy patronage among a sample of elderly are presented. Overall, the percentage of elderly requiring prescriptions reflects national estimates and no significant difference is found in the expressed need for prescriptions between black and respondents. 'Neighborhood' pharmacies are perceived as being very important, but relatively few use the most geographically convenient. Nevertheless, the large majority of elderly are satisfied with distances they presently have to travel to purchase prescriptions. The observed travel patterns for prescription purchases suggest that conventional wisdom pertaining to the nature of the pharmacy journey, the notion of convenience and the traditional concept of neighborhood among the elderly should be reexamined.

The establishment of health maintenance organizations: a geographical analysis.

Seven characteristics of 243 Standard Metropolitan Statistical Areas (SMSAs) were subjected to discriminant analysis to determine whether they distinguish SMSAs where at least one health maintenance organization (HMO) was organized between 1972 and 1980 from SMSAs where no HMO developed. The discriminant function correctly classifies 77 per cent of the metropolitan areas considered. Presence of a medical school, regional location, and SMSA population were positively related to HMO establishment. Number of Medicare recipients per 1,000 SMSA residents was not associated with HMO development. (Am J Public Health 1983; 73:184-187.)

Accessibility to medical care among urban American Indians in a large metropolitan area.

Federal health and medical care programs recently mandated for American Indians living in cities are predicated upon information pertaining to their unmet health needs and assessments of their accessibility to medical care. Based upon a household survey conducted among a representative Indian population living in a large metropolitan area, an evaluation is made of the accessibility experience of this population as it pertains to primary medical care. Using measures of accessibility including travel time, appointment delay time, and waiting room time, the experiences of Indian residents of major residential sections of the area are illustrated. Comparative assessments are made on the basis of the individual convenience factors as well as on the basis of an aggregate index of accessibility that has been proposed for health planning and evaluation. Significant differences in accessibility to primary care between residents in certain residential areas are demonstrated and suggestions for revision of the accessibility standards are offered.

The search for medical care: an exploration of urban black behavior.

Results are presented of a study of the medical care-seeking behavior of black adult residents of lower and middle socioeconomic status in two predominantly black, yet geographically and socioeconomically distinct communities within the District of Columbia. Against a varied distribution of primary medical care opportunities within the District, substantial differences are demonstrated in their use by lower- and middle-status residents of a lower-class community. These differences are not, however, manifested among lower- and middle-status residents of an essentially middle-class neighborhood. The patterns of medical care-seeking behavior are observed within a framework of an almost total avoidance of the available medical care personnel and facilities in the proximate suburbs.