Geospatial variations in the quality of type 2 diabetes care – Evidence from electronic health records in North Karelia, Finland

Public examination of a doctoral dissertation in the field of Geography

Doctoral candidate: M.Sc. Maija Toivakka

Date and venue: 24.4. at 12 noon, online at

Language of the public examination: Finnish

Language of the dissertation: English

Increasing rates of obesity, lifestyle changes and longer life expectancy are the main driving forces behind the worldwide increase in the type 2 diabetes prevalence. While the prevention of type 2 diabetes is important, providing good quality care for people who have been diagnosed with the disease is at least equally important. In Finland, the care of type 2 diabetes is based on clinical treatment guidelines. However, it is poorly known how the treatment guidelines are implemented in practice and what the real outcomes of care are at the patient level and in different geographical contexts.

This dissertation explores the inequalities in the quality of type 2 diabetes care and in type 2 diabetes prevalence in the health care district of Siun sote and its subregions, located in North Karelia, Finland. The study design is multidisciplinary joining the fields of health geography and health sciences. The empirical part of the dissertation comprises four research articles that aim to investigate whether and how the inequalities in the quality of care are associated with several register- and geographic information system (GIS)- based factors. Electronic health records (EHRs) of type 2 diabetes patients are linked with the register based individual data on patient socioeconomics, the register- and GIS- based small-area factors on socioeconomics, the built environment and the accessibility in the patient’s residential neighbourhood.

This study shows that combining patient EHRs with geospatial perspectives, provides an evidence-based approach that could be utilized to support decision making in chronic disease care and in health care service planning. The use of EHRs from regional patient register is valuable and provides a good opportunity for disease management and monitoring. The results indicate that the type 2 diabetes care assessed by indicators of process of care and treatment outcomes and type 2 diabetes prevalence are not equally distributed in the study region. The results demonstrate that the place characteristics of the patients’ residential neighbourhood are related to the quality of care. Geospatial variation exists between different geospatial scales and areal classifications both in type 2 diabetes prevalence and its care. For example, patients in sparsely populated rural areas compared with patients elsewhere in the region achieve the treatment outcomes the weakest. In postal code areas where the areal educational attainment is low, the achievement of the treatment targets is also poorer.

The findings from this dissertation could be utilised to identify small-areas and settlement types where the disease burden is high and to show areas where patients are at risk of poor diabetes care outcomes. Register- and GIS- based indicators describing the quality of care or the population at various levels of geospatial detail provide tailored and useful information to be used in type 2 diabetes management and in health care service planning. Subsequently, the management of type 2 diabetes care could be more effectively tailored and improved to the small areas, sub-regions and settlement types that are most in need, as well as to the socioeconomic groups at risk.

The doctoral dissertation of MSc Maija Toivakka, entitled Geospatial variations in quality of type 2 diabetes care. Evidence from electronic health records in North Karelia, Finland, will be examined at the Faculty of Social Sciences and Business Studies. The opponent in the public examination will be Professor Markku Löytönen of the University of Helsinki, and the custos will be Professor Markku Tykkyläinen of the University of Eastern Finland.

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