title: The effect of concentrating obstetrics services in fewer hospitals on patient access: a simulation.
abstract: BACKGROUND
  In Japan, the number of obstetrics facilities has steadily decreased and the selection and concentration of obstetrics facilities is progressing rapidly. Obstetrics services should be concentrated in fewer hospitals to improve quality of care and reduce the workload of obstetricians. However, the impact of this intensification of services on access to obstetrics hospitals is not known. We undertook a simulation to examine how the intensification of obstetrics services would affect access to hospitals based on a variety of scenarios, and the implications for health policy.
  
  
  METHODS
  The female population aged between 15 and 49 living within a 30-min drive of an obstetrics hospital was calculated using a Geographic Information System for three possible intensification scenarios: Scenario 1 retained facilities with a higher volume of deliveries without considering the geographic boundaries of Medical Service Areas (MSAs, zones of healthcare administration and management); Scenario 2 prioritized retaining at least one hospital in each MSA and then retained higher delivery volume institutions, while Scenario 3 retained facilities to maximize population coverage using location-allocation modeling. We also assessed the impact of concentrating services in academic hospitals and specialist perinatal medical centers (PMCs) alone.
  
  
  RESULTS
  In 2011, 95.0% of women aged 15-49 years lived within a 30-min drive of one of 1075 obstetrics hospitals. This would fall to 82.7% if obstetrics services were intensified into academic hospitals and general and regional PMCs. If 55.0% of institutions provided obstetrics services, the coverage would be 87.6% in Scenario 1, whereas intensification based on access would achieve over 90.5% coverage in Scenario 2 and 93.9% in Scenario 3.
  
  
  CONCLUSIONS
  Intensification of obstetrics facilities impairs access, but a greater caseload and better staffing have the potential advantages of better clinical outcomes and reduced costs. It is essential to consult residents of hospital catchment areas when reorganizing clinical services; a simulation is a useful means of informing these important discussions.
authors.affiliation: Division of Health Policy and Management, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan. koikes@jichi.ac.jp.|Department of Health Management and Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. koikes@jichi.ac.jp.
authors.forename: Soichi
authors.initials: S
authors.lastname: Koike
authors.affiliation: Department of Community-Based Medical System, Faculty of Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. matmo10@jb3.so-net.ne.jp.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Matsumoto
authors.affiliation: Department of Medical Community Network and Discharge, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan. ide@chiba-u.jp.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Ide
authors.affiliation: Department of Public Health and Health Policy, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. white-eye@hiroshima-u.ac.jp.
authors.forename: Saori
authors.initials: S
authors.lastname: Kashima
authors.affiliation: Department of Planning, Information and Management, The University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. atarashih@adm.h.u-tokyo.ac.jp.
authors.forename: Hidenao
authors.initials: H
authors.lastname: Atarashi
authors.affiliation: Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. yasunagah-tky@umin.ac.jp.
authors.forename: Hideo
authors.initials: H
authors.lastname: Yasunaga
mesh_terms: D000328:Adult; D003695:Delivery of Health Care / Q000706:statistics & numerical data / Q000639:trends*; D036861:Delivery, Obstetric / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D040362:Geographic Information Systems / Q000706:statistics & numerical data / Q000639:trends*; D006297:Health Services Accessibility / Q000706:statistics & numerical data / Q000639:trends*; D006761:Hospitals / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D007564:Japan / Q000453:epidemiology; D008875:Middle Aged; D009774:Obstetrics / Q000706:statistics & numerical data / Q000639:trends*; D011247:Pregnancy; D055815:Young Adult