title: Do the classification of areas and distance matter to the assessment results of achieving the treatment targets among type 2 diabetes patients?
abstract: BACKGROUND
  Type 2 diabetes is a major health concern all over the world. The prevention of diabetes is important but so is well-balanced diabetes care. Diabetes care can be influenced by individual and neighborhood socio-economic factors and geographical accessibility to health care services. The aim of the study is to find out whether two different area classifications of urban and rural areas give different area-level results of achieving the targets of control and treatment among type 2 diabetes patients exemplified by a Finnish region. The study exploits geo-referenced patient data from a regional primary health care patient database combined with postal code area-level socio-economic variables, digital road data and two grid based classifications of areas: an urban-rural dichotomy and a classification with seven area types.
  
  
  METHODS
  The achievement of control and treatment targets were assessed using the patient's individual laboratory data among 9606 type 2 diabetes patients. It was assessed whether hemoglobin A1c (HbA1c) was controlled and whether the recommended level of HbA1c was achieved in patients by different area classes and as a function of distance. Chi square test and logistic regression analysis were used for testing.
  
  
  RESULTS
  The study reveals that area-level inequalities exist in the care of type 2 diabetes in a detailed 7-class area classification but if the simple dichotomy of urban and rural is applied differences vanish. The patient's gender and age, area-level education and the area class they belonged to were associated with achievements of control and treatment targets. Longer distance to health care services was not a barrier to good achievements of control or treatment targets.
  
  
  CONCLUSIONS
  A more detailed grid-based area classification is better for showing spatial differences in the care of type 2 diabetes patients. Inequalities exist but it would be misleading to state that the differences are simply due to urban or rural location or due to distance. From a planning point of view findings suggest that detailed geo-coded patient information could be utilized more in resourcing and targeting the health care services to find the area-level needs of care and to improve the cost-efficient allocation of resources.
authors.affiliation: Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland. maija.toivakka@uef.fi.
authors.forename: Maija
authors.initials: M
authors.lastname: Toivakka
authors.affiliation: Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland. tiina.laatikainen@pkssk.fi.|Hospital District of North Karelia, Joensuu, Finland. tiina.laatikainen@pkssk.fi.|Department of Chronic Disease Prevention, National Institute for Health and Welfare (THL), Helsinki, Finland. tiina.laatikainen@pkssk.fi.
authors.forename: Tiina
authors.initials: T
authors.lastname: Laatikainen
authors.affiliation: Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland. timo.kumpula@uef.fi.
authors.forename: Timo
authors.initials: T
authors.lastname: Kumpula
authors.affiliation: Department of Geographical and Historical Studies, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland. markku.tykkylainen@uef.fi.
authors.forename: Markku
authors.initials: M
authors.lastname: Tykkyläinen
mesh_terms: D000328:Adult; D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology; D005260:Female; D005387:Finland / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D012424:Rural Population / Q000145:classification*; D014505:Urban Population / Q000145:classification*