Abstract


Objective:	The aim of this study was to determine whether social inequalities exist in access to outpatient care in the city of Stuttgart by use of socioeconomic and demographic analysis of the practice environments of physicians and psychotherapists. The main focus of the analysis was on differences between medical specialties. Furthermore gender distribution and foreign language skills of physicians and psychotherapists as well as handicap accessibility of their practices were correlated to several social indicators.
Methods:	After adjustment for practices with multiple locations data of 1662 physicians and psychotherapists and 142 pharmacies were included in this study. Using the street address each practice was assigned the selected socioeconomic and demographic indicators of the according city district. Practices were assigned a medical specialty using the classification of the Association of Statutory Health Insurance Physicians of Baden-Württemberg (“Kassenärztliche Vereinigung Baden-Württemberg”). Statistical analysis of social indicator values and foreign language skills of physicians and psychotherapists used the Kruskal-Wallis test with Dunn’s posttest. Statistical analysis of gender distribution the physicians and psychotherapists and office accessibility was conducted by unpaired t-test, or Mann-Whitney U test when normal distribution did not apply. Finally, linear regression analysis was conducted to determine whether distance to the city center and a city district’s population size were possible confounding factors. 
Results:	The percentage of children in the practice environments of child and youth psychotherapists is significantly higher than for other physicians and psychotherapists. The percentage of children in the practice environments of pediatricians does not deviate significantly from the overall group. However, the percentage of children in these practice environments remains below the mean percentage of children city wide. In contrast, the percentage of seniors is higher than the average in the practice environments of physicians and psychotherapists overall. All specialty practice environments with a high demographic factor show high percentages of seniors except for internal medicine. The unemployment rate in the practice environments of child and youth psychotherapists is significantly lower than in the overall group. The unemployment rate in their practice environments as well as the unemployment rate in the practice environments of pediatricians remains below the citywide unemployment rate. Due to geographical overlaps, the analysis of the percentage of immigrants in practice environments reveals a similar pattern. In addition to a lower percentage of immigrants in child and youth psychotherapists practice environments, the practice environments of medical and psychological psychotherapists overall show significantly lower percentages of immigrants. There was no significant difference between the percentage of immigrants in the practice environments of physicians and psychotherapists with Turkish or Russian language skills and the overall group. While general practitioners and pharmacies are spread wider across the city area, medical specialists more often practice in urban districts close to the city center. Most of the handicap accessible practices are located in the city center and the northern districts. The analysis shows significantly fewer handicap accessible practices in more rural districts with higher percentages of seniors.
Conclusions: 	Most general and specialty physicians are distributed well to serve increased demand for medical care in city districts with high percentages of seniors. In contrast, children in districts with high percentages of children may be disadvantaged as to access to outpatient care. There is a marked segregation within the city regarding the unemployment rate and the percentage of immigrants. The disadvantage in access to psychotherapists in districts with high unemployment rate and a large immigrant population is particularly serious. More rural districts are disadvantaged in access to several medical specialties and handicap accessible medical practices. The results indicate that the requirement planning by the Association of Statutory Health Insurance Physicians of Baden-Württemberg has not been sufficient to prevent social inequalities in outpatient care. Possible approaches to improve outpatient medical care could be a further subdivision of current planning districts or standardized inclusion of regional socioeconomic characteristics into the requirement planning of the Association of Statutory Health Insurance Physicians.