Rural and remote dental services shortages: filling the gaps through geo-spatial analysis evidence-based targeting

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1 Rural and remote dental services shortages: filling the gaps through geo-spatial analysis evidence-based targeting Yulia Shiikha, Estie Kruger and Marc Tennant Abstract Background: Australia has a significant mal-distribution of its limited dental workforce. Outside the major capital cities, the distribution of accessible dental care is at best patchy. Objective: This study applied geo-spatial analysis technology to locate gaps in dental service accessibility for rural and remote dwelling Australians, in order to test the hypothesis that there are a few key location points in Australia where further dental services could make a significant contribution to ameliorating the immediate shortage crisis. Method: A total of 2,086 dental practices were located in country areas, covering a combined catchment area of 1.84million square kilometers, based on 50 km catchment zones around each clinic. Geo-spatial analysis technology was used to identify gaps in the accessibility of dental services for rural and remote dwelling Australians. An extraction of data was obtained to analyse the integrated geographically-aligned database. Results: Resolution of the lack of dental practices for 74 townships (of greater than 500 residents) across Australia could potentially address access for 104,000 people. An examination of the socio-economic mix found that the majority of the dental practices (84%) are located in areas classified as less disadvantaged. Output from the study provided a cohesive national map that has identified locations that could have health improvement via the targeting of dental services to that location. Conclusion: The study identified potential location sites for dental clinics, to address the current inequity in accessing dental services in rural and remote Australia. Keywords (MeSH: Dental Health Services; Health Services Accessibility; Health Services Geographic Accessibility; Distribution; Rural Health Services; Rural Population; Spatial Analysis; Australia Introduction According to Australian Bureau of Statistics (ABS) (2006) data, Australia has a significant mal-distribution of its limited dental workforce (Australian Bureau of Statistics 2006). Geographically, Australia covers a very large landmass, measuring more than 20 million square kilometers. As a result, accessibility to services, including dental care, is extremely unequally distributed in areas outside of major capital cities (Kruger, Tennant & Shiyha 2013). Higher burdens of dental disease are experienced by communities that suffer greater poverty and higher marginalisation (Kruger, Jacobs & Tennant 2010). It is often these population sub-groups that are more highly represented in rural and remote Australia (Kruger, Jacobs & Tennant 2010). In a fair and equitable system, the provision of healthcare services would need to focus on those that need it most, and therefore the accessibility to care in regional Australia needs to be addressed. Efforts are being made to develop strategies and employ approaches to address the issue. Some of the current policy initiatives enacted to address these issues include the development of rural-based dental schools, the placement of university dental school clinics in rural areas and the development of optional post-graduation internships (Kruger & Tennant 2010). Additional actions such as subsidies for practitioners moving to a rural location are being tested (Kruger & Tennant 2010). However, the targeting of initiatives at strategic shortage locations has not been a part of the planning discussion to date. A wide ranging approach to addressing mal-distribution is needed (McGuire, Kruger & Tennant 2011), but at the same time critical location points of shortage should be identified expeditiously. Similarly, if the extent of the potential demand (i.e. number of people) for services in areas of accessibility shortfall was enunciated, then clear mechanisms to address these issues could be formulated. As in many other countries, Australian dental services lean heavily on private practice (fee-forservice) care models, to the extent that 85% of services are funded in this way (Willie-Stephens, Kruger & Tennant 2014). Therefore, an understanding of the shortage relative to the opportunity for fee-for-service dentistry needs to be understood in order to provide HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE) 39

2 the correct policy levers in each area. For example, areas of high wealth, with a good supply of patients, may be treated with some sort of private practice subsidy scheme to address the need, whereas the safety-net state government services may need to play a more significant role in poorer areas with a paucity of patients. In this study we, for the first time, locate gaps in dental service access for rural and remote dwelling Australians in a comprehensive national analysis that provides policy makers with a guide to address issues of access, based on evidence. Geo-spatial analysis technology was used to locate gaps in dental service accessibility for rural and remote dwelling Australians (Almado, Kruger & Tennant 2013), the hypothesis being that there are a few key locations in Australia where further dental services would make a significant contribution to ameliorating the immediate shortage. Methods and materials All data for this study were obtained from open sources and as such there was no requirement for ethics approval. Study frame Only data for rural and remote Australia were used in this study. All data in a 50 km circle around the General Post Office of each state capital were removed from the sample. Previously published data have shown that metropolitan cities are well covered with adequate accessibility to dental clinics (Rural Dental Action Group 2006). Population data were obtained from the most recently available Australian Census of Population and Housing (2006) and divided by Collection Districts (CD). These data are freely available through the Internet and are released by the Australian Bureau of Statistics (ABS) (Australian Bureau of Statistics 2014). A CD is the smallest unit for collection of the data. Also collected from the ABS website were socioeconomic indexes for areas (SEIFA) data for each census district and population level data. The ABS has combined a set of indicators (SEIFA) that provide a summary measure of socioeconomic status for people living in specific geographic regions in Australia. Each geographic area is given a score and then ranked against all other areas in Australia. The rankings are grouped into 10 equal size bands (deciles). Decile 1 contains the 10% most disadvantaged areas, and decile 10 contains the 10% least disadvantaged areas (Australian Bureau of Statistics 2014). The 2006 census data were used, as economic indicators for the most recent census are not yet released. Practice locations The physical addresses for each government and private general dental practice (specialist and prosthetist practices were removed) in all states and territories of Australia were collated from a number of open sources, including the Government Gazette and the Registration Board websites throughout 2012 (Tennant & Kruger 2013a). Data analysis Data analysis was completed using Excel (Version: 2003, Microsoft, USA) and MySQL data management software (MySQL Community Edition, Version 5.6, USA). Geographic boundary data for each CD were integrated into the population, socioeconomics, and dental practice data using QGIS (Quantum GIS Version Lisboa 1.8). All data for analysis were then extracted from the integrated geographically aligned database. Results A total of 2,086 practices were within the study frameset. Around each of these practices a catchment zone of 50 km was applied (see Figures 1 and 2). This resulted in coverage of 1.84 million square kilometers of rural and remote Australia with accessibility to dental clinics; slightly under a quarter of the area of the continent. Census districts that were less than square degrees were extracted from the total cover of CDs and are called small CDs (n=541). This arbitrarily chosen size resulted in the selection of census districts that formed towns or townships only (total residential population of 162,000 people). This process selected small census districts where the population density is high. Small CDs were used to locate areas with high population densities as quasi towns. This was necessary as no formal definitions of town sites for Australia is available. A CD is, by definition, an area that a single census officer can collect the data from in the given period of the census. Therefore, the area of a CD is a quasi-measure of density of residencies, and simultaneously provides population focal points over Australia. In keeping with the aim of the study, this approach was used to highlight key locations where dental service supply was absent, but the population density would support practice placement. A total of 226 small CDs were found outside the existing service catchment zone (of existing private and state clinics). All townships with at least one small CD with a population of 500 or more total residents and outside the existing clinics catchment zone were highlighted as potential sites where a dental service shortage existed (and a place where clinics may be potentially viable in some form with or without subsidy) (see Figure 40 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE)

3 Figure 1: A national map of rural and remote dental practices with 50 km catchment zones (diagonal hatch). Townships outside these catchment zones (light gray) are highlighted and those with at least one census district of greater than 500 residence have been indicated with dark gray 50 km catchment zones Table 1: The number and proportion of people living within a 50 km radius of a potential site for a dental service in townships that are more than 50 km from an existing dental service SEIFA UKN TOTAL NSW VIC QLD TAS WA SA NT Total PROPORTION BY STATE NSW 31.2% 27.8% 20.2% 8.2% 6.0% 6.6% VIC 41.0% 25.2% 31.5% 2.4% QLD 34.8% 11.7% 15.6% 13.1% 3.4% 5.2% 2.2% 9.0% 5.0% TAS 34.3% 31.1% 26.1% 8.4% WA 11.2% 24.4% 18.6% 16.3% 5.8% 3.4% 9.6% 10.5% 0.2% SA 62.5% 24.6% 12.9% NT 64.5% 3.5% 3.3% 2.8% 2.8% 5.0% 5.2% 12.8% HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE) 41

4 Figure 2: A high magnification view of a part of rural and remote Australia: a. Dental practices (black crosses) surrounded by 50 km catchment zones (diagonal hatch zones). Census districts are depicted in pale grey lines. b. 50 km zones (light grey) added around every township outside the existing practice catchment zones. c. 50 km catchment zones (dark grey) added around each township that has more than 500 residents (i.e. is a larger town that could provide an environment conducive to a dental practice). a. b. c. 2). These potential sites were surrounded by 50 km catchment zones and the total population of small CDs within the potential site zone accumulated and reported (see Table 1). A total of 104,000 people live in the potential site zones that could be covered by clinics in 74 sites. In summary, the resolution of the 74 sites of shortage within the discontinuous potential site zones would address the dental needs of some 104,000 township (of any size) dwelling people (resident within 50 km of the potential site). This would provide access to care for 64% of all people resident in small CDs across Australia currently more than 50 km from a clinic. The model of providing services to these sites would have to be tailored to the true local conditions of each town. Socioeconomic drivers of clinic sustainability Some of these primary target sites appear to have population sizes able to potentially sustain viable private practices (based on number of people alone). However, examination of the mix of socioeconomics finds that the vast majority (84%) are in the lower five of SEIFA deciles, with 71% being in the lower three SEIFA deciles (see Table 1). In short, it underlines the need for these sites to be investigated individually to tailor the type of support needed to provide potentially viable services. Discussion This study used geo-spatial analysis, which is a term for collections of datasets so large and complex that it becomes difficult to process without the addition of mapping systems, to locate potentially viable locations for dental practices, based on the potential number of patients. The national culmination of a number of databases into a unified geographic-based data system allowed distilling of sites where maximum benefit could be obtained in terms of total population coverage. Clearly, multiple operator sites would influence the viability of practices. However, this study was targeted at minimum cover for rural Australia and did not intend to examine (nor report on) the viability of practices in each existing site. The 74 sites that were deemed to be primary sites each had population catchment bases of above 500 people (ranging to about 5,000) within 50 km of the townships; although all did have a socioeconomic mix of residents at the less affluent end of the spectrum. This large-scale analysis leads to the requirement to look at each of the potential sites individually and to determine the type of incentives or systems needed that could be used to provide care from these sites. However, spatial accessibility is but one barrier to 42 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE)

5 obtaining care, and issues such as affordability, acceptability and accommodation need to be addressed at each site, based on the characteristics of the local population (Kruger, Perera & Tennant 2010). This study has highlighted the capacity for further enhancement of health service access for rural and remote people through large-scale geographic research. Clearly, a range of possible policy positions is available for each site, from simple advertising for a private practice, through private practice incentivisation schemes, to full government services. Each would also need analysis as to the type of practice that may be relevant. New models of visiting services may well be logical approaches at some sites. Limitations A limitation of this study was that we did not know the number of practitioners in each location, only that a dental practice existed there. The study also excluded specialist dental clinics as these clinics operate by referral from a general practice and are not primary health sites. Access to these practices is not on the basis of urgent care needs (nor basic dental care), but are referral based. Therefore, there may be demand beyond capacity in some locations but this is a task for further studies. Conclusion The process of geo-spatial analysis collation of databases provides an opportunity for translation of such analysis to other care models; for example, general medical practice, pharmacy or other essential services. The generation of more targeted policy initiatives to address workforce shortages in rural Australia (and overall mal-distribution) is essential in disciplines where financial constraints are high. Dental healthcare is one of those disciplines. A significant proportion of the overall national service is reliant on fee-for-service small business models to be effective (Tennant & Kruger 2013b). Thus, practitioners are constantly aware of the economical viability of their practice location. At the other end of the scale, states have limited resources (including human resources) and these resources should be used in the most effective manner. Any increases in funding should always be directed to areas of need and, in particular, to areas of high dental disease burden and low ability to access services. Geo-spatial information models allow dynamic analysis of requirements and rapid shortlisting of potential sites for improvement, which provides a method for evidence-based policy making. Continued use of both geo-spatial analysis and geographic systems focused on strategic and financial analysis, coupled with further modelling, can assist in determining the resource implications of future changes in access, while producing an acceptable framework for health service organisation in general, and in a global context. The hypothesis underpinning this study was that there were a few key townships in Australia where additional dental services would make a significant contribution to ameliorating the immediate services shortage experienced by a significant proportion of the population. The study identified about 75 townships where new dental services could bring access to within 50 km for over 100,000 Australians. Acknowledgment: The authors would like to thank the Brocher Foundation for the opportunity provided to the author (MT) to be a residential Fellow during the study development. References Almado, H. Kruger, E. and Tennant, M. (2013). The application of spatial analysis technology to planning access oral health care for at risk populations in Australian capital cities. Australian Journal Primary Health (10): 1071/PY Australian Bureau of Statistics (2006). Australia s health work force: selected health occupations. Canberra, ACT, ABS. Available at: nsf/mf/ (accessed 17 June 2015). Australian Bureau of Statistics (2014). Socio-Economic Indexes for Areas In: Census for a brighter future ABS. Canberra, ACT. Available at: abs.gov.au/ausstats/abs@.nsf/mf/ /2013 Kruger, E. Jacobs, A. and Tennant, M. (2010). Sustaining oral health services in remote and indigenous communities: a review of 10 years experience in Western Australia. International Dental Journal (60): Kruger, E. Perera, I. and Tennant, M. (2010). Aboriginal Medical Services based dental clinics and a rural community dental clinic: a comparative analysis. Australian Journal Primary Health (16): Kruger, E. Tennant, M. and Shiyha, J. (2013). Dentistto-population and practice-to-population ratios: in a shortage environment with gross mal-distribution what should rural and remote communities focus their attention on? Rural Remote Health (3): Kruger, E. and Tennant, M. (2010). Short-stay rural and remote placements in dental education, an effective model for rural exposure: a review of eight years experience in Western Australia. Australian Journal of Rural Health (18): HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE) 43

6 McGuire, S. Kruger, E. and Tennant, M. (2011). Travel patterns for government emergency dental care in Australia: a new approach using GIS tools. Australian Dental Journal (56): Rural Dental Action Group (2006). Dental Health Survey Available at: bookshelf/health/submissions/rdag%20summary% pdf (accessed 17 June 2015). Tennant, M. and Kruger, E. (2013a). A national audit of Australian dental practice distribution: do all Australians get a fair deal? International Dental Journal 63: Tennant, M. and Kruger, E. (2013b). Turning Australia into a flat-land : scenarios in addressing the disparity in ruralcity dental practice distribution. International Dental Journal 64: Willie-Stephens, J., Kruger, E. and Tennant, M. (2014). Public and private dental services in NSW: a high resolution geographic information system analysis of access to care for 7 million Australians. NSW Public Health Bulletin 24(4): doi: /NB Yulia Shiikha, PhD Honorary Research Fellow International Research Collaborative - Oral Health and Equity The University of Western Australia Nedlands WA 6009 AUSTRALIA Corresponding author: Estie Kruger, BChD, MChD Associate Professor International Research Collaborative - Oral Health and Equity The University of Western Australia Nedlands WA 6009 AUSTRALIA estie.kruger@ uwa.edu.au Marc Tennant, BDSc, PhD Winthrop Professor International Research Collaborative - Oral Health and Equity The University of Western Australia Nedlands WA 6009 AUSTRALIA 44 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 44 No ISSN (PRINT) ISSN (ONLINE)