Accessibility to health services, especially for persons with a disease with such an impact as dementia, is important in order to ensure guideline-orientated diagnosis and optimal therapy.
Dementia is a disease with a major impact on patients, relatives and society; and its importance will grow in the future due to demographic changes. In Germany, the population aged 65 years and older consisted of over 15 million persons in the year 2005 (19% of the total population). Based on the statistic assumptions, this number will increase to between 21 and 25 million persons (over 30% of the total population) in the year 2050 . Optimal health care at the onset of the disease is needed to ensure a higher quality of life and a longer independent living with dementia. It is also crucial for the community, since caring for patients is an important economic factor. Direct costs for dementia range between 9.000 and 16.0000 Euros in European countries per year .
Access to ambulatory health care
Access to physicians is a widely discussed topic. Important barriers to access primary care in Europe were analyzed by Schoen et al., who identified costs for medication and waiting times to see a specialists as well as the time a physician spends with a patients as major influencing factors . Also, the physical ability to access health care is important, i.e. public transportation or the availability of physicians within walking distance. There is a rather controversial discussion on the optimal number of general practitioners or specialists per inhabitants in an area. Internationally, the scientific literature on service provision in rural areas points to a lack of physicians and to possible incentives to make the work in rural areas more attractive for physicians (e.g. for America, see ; for Scotland, see ), while clear indicators to measure over- or underprovision of physicians or quality of care are lacking in Germany [6, 7]. Nevertheless, it can be assumed that access especially to specialists is more difficult in rural areas than in urban areas due to a lower physician density and less public transport.
In Germany, the physician atlas states that general practitioners are found throughout most areas. Regionally, Germany can be subcategorized in federal states (Länder), those in administrative districts (Bezirke), those into counties (Kreise) and those into municipalities (Gemeinden). Counties often include a county seat and a surrounding rural area. On a county level, the service supply is sufficiently given; only in some areas in the north-east an under-supply is noticeable on county level. However, it has to be considered that counties are rather large areas combining more urbanized and more rurally influenced regions with differences in population density and infrastructure. Therefore, it cannot be assumed that the density of general practitioners is equally distributed in a county .
The situation regarding specialist care is different. In this publication we focus on neurologists and psychiatrists. While, according o the physician atlas, in most areas there seems to be an oversupply on a county-level, there is region in the federal state Saxony-Anhalt that has an undersupply regarding neurologists and psychiatrists (NPs) . For specialists even more than for the group of GPs, regional variance within a county is probable because of different population densities within the counties. The stated oversupply on a county-level therefore needs to be addressed critically. Hence, we will differentiate on a smaller level, the municipalities.
Regional differences in utilization
Differences in service utilization for persons living in urban or rural areas have been described, even though studies concerning health care utilization by elderly patients in rural areas, especially by dementia patients, are scarce. One way to determine poor service provision or utilization is to analyze hospital admissions for ambulatory care sensitive conditions (ACSC). The hypothesis is that those admissions could be prevented in a sufficient ambulatory care system. Mobley et al. analyzed all ACSCs in the US, showing that if the degree of poverty for elderly is high in rural areas, those persons tend to have a higher admission rate for ACSCs than their urban counterparts . Laditka showed that persons in low supply areas had higher risks for ambulatory care sensitive hospitalization. Areas with adequate supply on the other hand showed a lower risk .
That service supply is not only a question of the crude distance but also a question of social space is discussed in Castleden et al. study on geographic differences in rural palliative care, identifying a complex combination of distance, location, aesthetics and sites of care in Canada. The authors conclude that the growing elderly population in rural areas leads to difficulties in formal and informal service provision at the end of live, since the modes of transportation and condition of transportation possibilities can differ widely .
There is few research published focussing especially on service utilization by patients with dementia. Morgan et al. describe a rural and remote memory clinic for Canada, after reviewing existing studies showing limited access availability for services, problems concerning transportations and distances . In another study on dementia patients in Canada, the authors conclude that while there are no differences in reported unmet health needs, rural dementia patients reported that needed care was unavailable or not accessible . In a study from Germany, Donath et al. analyzed diagnostic procedures and dementia therapy in rural and urban areas, finding only differences in the rate of imaging techniques as diagnostic instruments. Differences concerning other procedures such as referrals to specialists or physical examinations were not found .
Especially for elderly and patients with dementia, regional differences in nursing care availability are also of importance. Rothgang et al. found various differences in the supply of nursing facilities (ambulatory as well as stationary) between federal states and rural and urban areas in Germany . This closer regional differentiation will grow in importance since the demographic change occurs unbalanced between the federal states in Germany. By the year 2050, the portion of persons aged 65 years and older will range between 54% (in Bremen) and 87% (in Thüringen) [16, 17].
Defining rural and urban
When evaluating health behaviour in rural areas, one faces the problem of defining "urban" and "rural". While this is already a difficult task for one specific region or country, it is hardly possible to find a common international standard; i.e. a rural area in Germany has to be discussed differently than rural areas in larger countries like the USA, Canada or Australia.
Castleden et al. describe in their introduction the geographic point of view, identifying rurality as a socially and culturally constructed phenomenon, and list a number of studies focus on inequalities in services provision, health behaviour and rural lifestyles [11, 18].
Other than the theoretical side of "urban" and "rural", it is crucial to find an empirical definition for analysis. Various factors can be considered, such as population density, absolute number of inhabitants, distance to nearest agglomerated area, infrastructure of transportation, etc. This problem has been pointed out before .
In this paper, we use the municipality types defined by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBR) (see methods section).
German Health Insurance System
To interpret the utilization patterns of the patients, information on the German health insurance system is necessary. In Germany, next to the hospital sector there is an independent outpatient/ambulatory system. Physicians in the hospital sector are not working in ambulatory care and vice versa. The ambulatory sector consists of physicians working alone or in group offices. Usually, the primary care physician is the person first contacted by patients, but he does not have a gate-keeper function, all patients can contact physicians of any specialization at any time. A fee of 10 Euros has to be paid for each quarter for ambulatory care; to avoid paying this fee at each consultation, a referral is needed.
Aim of the study
Based on this background, this study aims to evaluate the actual ambulatory medical services utilization of dementia patients in the German Statutory Health Insurance in the year before and after the diagnosis of dementia in rural and urban areas. Since studies in this area are scarce, especially in Germany, our study tries to fill this gap. We assume that the service utilization, mainly for specialists care, is lower in rural areas. An overall analysis of the service utilization with no geographic focus has already been made with these data .