Approaches to quantifying spatial accessibility using the example of inpatient hospices in Germany

Approaches to quantifying spatial accessibility using the example of inpatient hospices in Germany | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Approaches to quantifying spatial accessibility using the example of inpatient hospices in Germany Theresa Petzold, Friedemann Nauck, Christian Banse, Jobst Augustin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8958592/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background. Spatial access is an important indicator to assess the quality of healthcare services and the healthcare situation. Accessibility and availability are central components of this indicator. Using inpatient hospices as an example of specialist palliative care in Germany, this study will present various indicators for operationalizing spatial access, identify regional differences, and discuss possible differences in the results caused by methodological characteristics. Methods. Locations of inpatient hospices were identified using a freely accessible web-based self-disclosure database, supplemented by lists from regional associations and own research. Spatial access was examined using provider-to-population ratios based on district level and network-based travel time Further, two variants of the floating catchment area methods (FCA), the Two-Step Floating Catchment Area (2SFCA) and Enhanced Two-Step Floating Catchment Area (E2SFCA) were applied. The analyses used geocoded locations, hospice bed capacities, population data, and road network data. Results. 295 inpatient hospices were identified. 211 of the 401 districts have at least one hospice, resulting in an availability of 36.4 beds per 1 million inhabitants for all of Germany. 90.3% of the population can reach a hospice within 30 minutes by motorized private transport. The results of the FCA methods show a heterogeneous pattern in the spatial accessibility index (SPAI i ), with the application of the slow and sharp distance decay function having different effects. Using the 2SFCA method results in uniform accessibility within the catchment areas of the hospices. While the E2SFCA method with a slow distance decay function generates smoother transition zones within the catchment areas, the sharp distance decay function induces higher spatial differentiation, particularly in rural areas, where accessibility declines sharply with distance. Conclusions. The results indicate that inpatient hospices in Germany are very accessible. However, the chosen method significantly influences the results. Indicators such as provider-to-population ratios and network-based travel time can provide a basic analysis of the care situation due to their ease of interpretation. FCA methods are more complex but also more meaningful due to their joint consideration of availability and accessibility. Health services accessibility palliative care inpatient hospices health geography floating catchment area methods E2SFCA 2SFCA GIS network analysis Figures Figure 1 Figure 2 Figure 3 Background Access in a medical context is complex and understood as a multidimensional concept. In addition to the distinction between potential and realized access [ 1 ], the dimensions of availability, accessibility, accommodation, affordability and acceptability are most frequently mentioned in this context [ 2 ]. Recent concepts add further dimensions such as approachability, appropriateness or awareness [ 3 , 4 ]. The dimensions of availability and accessibility include among others spatial aspects of potential access and can be summarized under the term ‘spatial accessibility’. This is considered to be an important indicator of the quality of healthcare services and the assessment of needs [ 1 , 2 , 5 , 6 ]. There is a wide variety of indicators for operationalizing spatial accessibility, which consider either availability or accessibility alone, or both indicators together. The best-known indicators are the provider-to-population ratio, network-based travel time, and the floating catchment area method family. The provider-to-population ratio is the simplest and best-known way of representing the availability of healthcare services. It does not include any spatial references such as geographical distances or travel times and describes the ratio between supply and potential demand. The supply is represented by the bed capacity of the healthcare facilities examined. Potential demand is represented by the population or potential patients. The ratio is calculated based on administrative regions (districts, municipalities, etc.) [ 1 , 7 ]. One possibility for examining accessibility is to perform a network analysis based on travel time. After setting a threshold value, zones of equal accessibility are calculated based on a service location (service areas or polygons) along a road network. Either distance or travel time is taken into account, whereas travel time has a greater influence on patients' mobility decisions [ 8 , 9 ]. The service areas are linked to aggregated population data located within the polygons. The potential minimum travel times between the population's places of residence and the nearest service provider are mapped [ 10 , 11 , 12 ]. For a more realistic assessment of the healthcare situation, more complex methods are needed to equally consider both dimensions of spatial accessibility. Floating catchment area methods have been established in this context for about 20 years. The basic model is the two-step floating catchment area method (2SFCA) [ 13 ]. This method uses population figures and the locations of healthcare facilities, including their capacities (usually expressed as the number of beds), to calculate the relationship between supply and demand. Contrary to other methods using fixed administrative boundaries, in 2SFCA catchment areas are flexible (floating catchments), and a maximum travel time is set as a threshold value. Many modifications have been developed based on the 2SFCA method. The most widely used is the Enhanced Two Step Floating Catchment Area Method (E2SFCA) by Luo and Qi [ 14 , 15 ]. Other variations are, for example, the Three-Step Floating Catchment Area Method (3SFCA), the integrated floating catchment method (iFCA) or the Modified Huff Model Three-Step Floating Catchment Area Method (MH3SFCA) [ 16 , 17 , 18 ]. Palliative care is explicitly recognized under the human right to health [ 19 , 20 , 21 ], and should therefore be available regardless of place of residence, financial means, or social circumstances. There are massive differences in provision of palliative and hospice care services worldwide, with Germany being among the countries with a high standard of care provision [ 22 , 23 ]. The demand for palliative and hospice care in Germany is expected to increase [ 24 , 25 ]. Due to ongoing medical advances and the wider range of medical treatment options available, people are dying at an older age and symptom patterns increase in complexity due to multimorbidity [ 26 , 27 ]. Furthermore, the incidence of both oncological and non-oncological incurable diseases is rising. In Germany, there are numerous outpatient and inpatient, non-specialist as well as specialist palliative care services. Non-specialist palliative care services include basic care provided through general practitioners, ambulant nursing services, nursing homes, and general hospital units, with the involvement of volunteer hospice services in less complex cases. In cases where the patient's situation is highly complex, treatment is provided by specialist palliative care services through inpatient palliative care units (PCU), hospital palliative care support teams, home palliative care teams (PCT), day hospices and inpatient hospices. In Germany, hospices are inpatient facilities that provide support for the seriously ill with a life expectancy of days, weeks, or a few months if treatment in a hospital is not necessary and care at home or in a nursing facility is not possible or desired. Care is provided by multi-professional teams of nurses, psychosocial and spiritual professionals and volunteers. General practitioners or physicians from PCT provide medical care to patients [ 24 , 28 , 29 ]. New founded inpatient hospices in Germany must meet certain framework conditions and quality assurance requirements, defined by law in Social Code Book V [ 30 ]. Compared to other medical care locations, spatial accessibility to palliative care services in general, and inpatient hospices in particular, has a number of special conditions. For patients, access is mostly only relevant once, as in most cases the hospice will be the place of death. It includes the journey from the patient's place of residence or from a previous hospital stay, e.g., in a PCU, to the hospice. Transport is usually provided by ambulance or emergency vehicles. Since patients at the end of life often suffer from severe symptoms, long travel times can complicate the transportation process. Spatial accessibility is particularly relevant for relatives who wish to visit patients at the end of life. Long travel times can be perceived as stressful by patients and their relatives and friends [ 31 , 32 ] and limit visiting opportunities [ 33 ]. The number of palliative and hospice care services and their utilization in Germany has risen steadily in recent years [ 34 , 35 ]. However, little research has been done on the current state of geographical access to inpatient hospices throughout Germany. Previous studies have focused on individual federal states or care services [ 36 , 37 , 38 , 39 , 40 , 41 , 42 ] or examine either availability or accessibility as dimensions of spatial access, mostly [43, 44, 45). An earlier study conducted in Germany used euclidean distance as an indicator of accessibility [ 46 ]. Internationally, studies have been conducted in the United Kingdom [ 47 , 48 ], Canada [ 49 ], Ireland, Spain, and Switzerland [ 50 ]. No study conducted in Germany has examined spatial accessibility to inpatient hospices beyond the application of simple availability and provider-to-population ratios. FCA methods have rarely been used in the field of palliative care [ 51 ]. Studies comparing different indicators of spatial accessibility in this context are also unknown. To achieve a more precise assessment of spatial access, various indicators for operationalizing spatial access are used and compared in this study. Using the example of inpatient hospices as part of specialist palliative care in Germany, regional differences in spatial access will be identified and illustrated. Potential differences in the results caused by methodological characteristics will be discussed. Methods Data sources and data preparation The identification of hospices, including their bed capacities, was initially based on ‘Directory for Hospice and Palliative Care’ (DHPC) [ 52 ], a freely accessible web-based self-disclosure database of the German Association for Palliative Medicine (DGP). This contains numerous inpatient and outpatient palliative care and hospice facilities. Additional facilities and their bed capacities were identified using the lists of the regional associations of the German Hospice and Palliative Care Association. All information on identified facilities was manually verified (as of April 2022). The hospice locations were then geocoded. Freely available data from the Federal Agency for Cartography and Geodesy (BKG) from 2020 on municipalities and counties were used for the cartographic representation [ 53 ]. The data set also included population data. For analysis, it was necessary to convert the area-based population data into a point feature that is representative of the area (district or municipality). The population center was used for this purpose, which, in contrast to the classically used geometric centre of the area, represents the location where most people live in an administrative area [ 12 ]. Setting The study was conducted for Germany which consists of 16 federal states, 401 districts and 10,995 municipalities. The total population in 2020 was 83,155,031 with a population density of 233 inhabitants per km². Data analysis Provider to population ratio The provider-to-population ratio (PPR) per 1 million inhabitants was calculated and visualized at district level by dividing the total number of beds in hospices by the total population. A more detailed visualization at municipal level was not used for this indicator due to a lack of significance. For better comparability of the results, the data was also aggregated at federal state level. Network analysis based on travel time Using the geocoded hospice locations, a network analysis based on travel time was carried out using motorized private car transport. By setting travel time thresholds, zones of equal potential accessibility are generated. In Germany, there are no official guidelines specifying how far away inpatient hospices or other palliative care services must be located. Based on other studies, thresholds of 15, 30 and 60 minutes were set [ 43 , 47 , 50 ]. Service areas were linked to population data at the municipal level to identify the proportion of the population located within and outside the 30-minute catchment area. In contrast to the provider-to-population ratios at the district level, the municipal level was chosen for this indicator to increase its relevance by using smaller-scale data [ 12 ]. Floating catchment area methods Out of the FCA method family, the 2SFCA method [ 13 ] and the E2SFCA method [ 14 ] were applied, as they offer a balance of methodological transparency, empirical reproducibility and differentiated measurement of spatial accessibility. In particular, by integrating a distance decay function, the E2SFCA enables a more realistic representation of the decrease in accessibility with increasing distance without creating high complexity [ 15 ]. For both methods, the spatial accessibility index ( \({SPAI}_{i}\) ) was calculated in a two-step process (see Table 1 ). First, a supply-demand ratio \({PPR}_{j}\) was calculated for each inpatient hospice. Then, \({SPAI}_{i}\) was calculated for each population center at the municipal level. 2SFCA-Methode. To calculate the supply-demand ratio \({PPR}_{j}\) a maximum catchment area (𝑑 𝑚𝑎𝑥 ), in this case within 30-minute car travel time, was defined for each hospice \(j\) [ 43 , 47 , 50 ], and the catchment areas were calculated using network analysis. Then, all population centers \(i\) within the catchment areas ( \({d}_{ij}\) ≤𝑑 𝑚𝑎𝑥 ) were identified and summed up (∑𝑃 𝑖 ). The sum was set in relation to the bed capacities of the inpatient hospices \({S}_{j}\) and a supply-demand ratio \({PPR}_{j}\) was formed. In the second step, the \({SPAI}_{i}\) was created. For each population center \(i\) , a travel time radius of 30 minutes was calculated and then all provider-to-population ratios \({PPR}_{j}\) were summed up. Finally, the \({SPAI}_{i}\) was formed for each population centroid \(i\) at the municipal level. The \({SPAI}_{i}\) is higher the more beds there are in inpatient hospices, the faster the units can be reached, and the lower the population within a 30-minute radius. E2SFCA-Methode. E2SFCA method was applied in the same way as the 2SFCA. The maximum radius of 30 minutes' travel time was additionally divided into three subzones ( r 1,2,3 = 0–10, 10–20, 20–30 minutes). By defining a weighting \({W}_{r}\) for each subzone, a weighted supply-demand ratio was calculated. Similarly, the \({PPR}_{j}\) was summed up in the second step according to the weighting. The distance decay function used is based on the original work by Luo and Qi (2009), which employs a Gaussian normal distribution. Two variants were used: a slow distance decay (1.0; 0.68 and 0.22) and sharp distance decay (1.0; 0.42 and 0.03) [ 14 ]. Table 1 Calculation formula of the 2SFCA and E2SFCA method Step 1: provider-to-population ratio ( \({PPR}_{j}\) ) 2SFCA E2SFCA \({PPR}_{j}=\frac{{S}_{j}}{\sum_{i\in\left\{{d}_{ij}\le{d}_{max}\right\}}{P}_{i}}\) \({PPR}_{j}=\frac{{S}_{j}}{\sum_{i\in\left\{{d}_{ij}\le{d}_{max}\right\}}{P}_{i}{W}_{r}}\) Step 2: spatial accessibility index ( \({SPAI}_{i}\) ) \({SPAI}_{i}=\sum_{j\in\left\{{d}_{ij}\le{d}_{max}\right\}}{PPR}_{j}\) \({SPAI}_{i}=\sum_{j\in\left\{{d}_{ij}\le{d}_{max}\right\}}{PPR}_{j}{W}_{r}\) \({S}_{j}\) = supply capacity, \({P}_{i}\) =population at location \(i\) ; \({d}_{ij}\) = distance between \(i\) and \(j\) ; \({d}_{max}\) = maximum radius/maximum catchment size; \({W}_{r}\) = distance decay function/weight The results are presented as quintiles (Q1-Q5). Municipalities that do not have access to hospices within 30 minutes represent a separate additional category (“no access”). Based on literature [ 18 ], the quintiles were divided into a low (Q1 and Q2), medium (Q3), and high \({SPAI}_{i}\) (Q4 and Q5). All analyses were conducted using ArcGIS Pro 2.9 (Esri Inc., California, Redlands, USA). Results A total of N = 295 hospices with a bed capacity of 3013 and an average capacity of 10 beds (range 2–16) were identified. Most hospices were listed in the DHPC (n = 252), n = 43 were added after further research. Provider-to-population ratio 211 of the 401 districts have at least one inpatient hospice. This results in a ratio of 36.4 beds per 1 million inhabitants. Figure 1 shows the nationwide provider-to-population ratio at district level. Only the federal states of Berlin, Bremen and Hamburg (which are also city states) provide hospices in all districts. Bavaria has the fewest hospice beds with 16.8 beds per 1 million inhabitants, Brandenburg the most (64.8 beds per 1 million inhabitants; for further information, see Table 2 ). The districts with the most hospice beds per million inhabitants are Pirmasens in Rhineland-Palatinate (298.7), Eisenach in Thuringia (285.9) and Coburg in Bavaria (244.9). Apart from Berlin (n = 16), the districts of Hamburg (n = 8) and Lippe (n = 8) have the most hospice locations within a district. Table 2 Hospice beds in inpatient hospices in Germany by federal state Federal state Hospice beds Inhabitants Beds per 1 million inh. Baden-Württemberg 311 11,103,043 28.0 Bavaria 221 13,140,183 16.6 Berlin 229 3,664,088 62.5 Brandenburg 164 2,531,071 64.8 Bremen 24 680,130 35.3 Hamburg 106 1,852,478 57.2 Hesse 228 6,293,154 36.2 Mecklenburg-Vorpommern 90 1,610,774 55.9 Lower Saxony 285 8,003,421 35.6 North Rhine-Westphalia 716 17,925,570 39.9 Rhineland-Palatinate 127 4,098,391 31.0 Saarland 56 983,991 56.9 Saxony 164 4,056,941 40.4 Saxony-Anhalt 70 2,180,684 32.1 Schleswig-Holstein 124 2,910,875 42.6 Thuringia 98 2,120,237 46.2 Germany 3013 83,155,031 36.2 Network analysis based on travel time The results of the Germany-wide network analysis shown in Fig. 2 indicate regional differences in the timely accessibility of hospices. Their location is particularly concentrated in high population centers (e.g., the Ruhr area or the Rhine-Main area) and larger cities. In more rural districts, hospices are often located in the district capitals (center effect). This effect is visible in many districts in Lower Saxony, for example. In Bavaria and Mecklenburg-Western Pomerania, as well as parts of Rhineland-Palatinate and Saxony-Anhalt, there are many contiguous areas where a hospice cannot be reached within a 30-minute drive. Nevertheless, 58.8% of the population across Germany can reach a hospice within a 15-minute drive by car, while 31.5% need between 15 and 30 minutes to get there. This means that a total of 90.3% can reach a hospice within a 30-minute drive by car. 9.7% of the population need more than 30 minutes to drive to the nearest hospice. The absolute population figures are shown in Table 3 . Table 3 Percentage and total number of residents living in service areas of different driving times to inpatient hospices Travel time (in minutes) n % 0–15 48,865,956 58.8 15–30 26,171,155 31.5 Subtotal 0–30 75,037,111 90.3 30–45 7,227,549 8.7 45–60 690,687 0.8 Subtotal 30–60 7,918,236 9.5 Subtotal > 60 199,684 0.2 Total 83,155,031 100.0 FCA methods The results obtained using FCA methods show a heterogeneous pattern. Applying the 2SFCA method yields a very uniform \({SPAI}_{i}\) within municipalities located within a 30-minute travel radius of inpatient hospices (see Fig. 3 a). This results in sharp transitions between municipalities inside and outside the catchment area. In Bavaria in particular, the concentric circles can be defined as catchment areas around the hospice locations, as these are scattered across the entire state. One-third of Bavarian municipalities have no access to a hospice within 30 minutes, while 50% of municipalities have low accessibility (28% in Q1, 22% in Q2). In municipalities with an overlap of several catchment areas of hospice locations, a higher \({SPAI}_{i}\) can be observed. Another federal state with a large proportion of municipalities with low accessibility is Baden-Württemberg (Q1 + Q2 = 46%). Federal states with a particularly high proportion of municipalities with high access indices are Brandenburg (71% in Q4 and Q25), Mecklenburg-Western Pomerania (51% in Q4 and Q5), Saarland (81% in Q4 and Q5), and Saxony (63% in Q4 and Q%). In addition, there are federal states in which \({SPAI}_{i}\) is distributed almost evenly across the quintiles (Schleswig-Holstein). After applying the E2SFCA method, there are changes in the \({SPAI}_{i}\) (see Fig. 3 b and 3 c). The proportion of municipalities without access (within a 30-minute drive) remains unchanged. The catchment areas of the hospices are graded in \({SPAI}_{i}\) according to the weightings applied. Municipalities in the immediate vicinity of the hospices often have high access indices. Peripheral municipalities tend to have low \({SPAI}_{i}\) . The transitions to municipalities without access to areas outside the catchment areas appear smoother. This effect is most noticeable where the catchment areas overlap rarely (e.g., Bavaria). The E2SFCA method, particularly with a sharp distance decay function, underlines the geographical proximity to hospice locations. There is an increase in the proportion of municipalities with low access indices and a decrease in Q4 and Q5 in some federal states. This effect is seen particularly in Brandenburg, Saxony-Anhalt, and Thuringia (see Table 4 ). In Saxony, too, there is a shift toward medium values, although the proportion with high \({SPAI}_{i}\) remains high (slow distance decay function 48% in Q4 and Q5; sharp distance decay function 37% in Q4 and Q5). In Baden-Württemberg and Bavaria, in contrast, there is a shift from low towards medium \({SPAI}_{i}\) . Shown is spatial accessibility to inpatient hospices in Germany at the municipal level. Results of the Floating Catchment Area methods are presented for a) 2SFCA, b) E2SFCA with slow distance decay, and c) E2SFCA with sharp distance decay. The \({SPAI}_{i}\) is categorized into quintiles: low (Q1, Q2), medium (Q3), and high (Q4, Q5). Table 4 Proportion of municipalities by accessibility quintile (SPAI i ) by federal state 2SFCAM E2SFCAM slow distance decay E2SFCAM sharp distance decay no SPA Q1 Q2 Q3 Q4 Q5 no SPA Q1 Q2 Q3 Q4 Q5 no SPA Q1 Q2 Q3 Q4 Q5 BW 8% 27% 19% 22% 15% 10% 8% 18% 21% 27% 16% 10% 8% 16% 12% 33% 20% 11% BY 29% 28% 22% 12% 6% 3% 29% 26% 20% 10% 11% 4% 29% 29% 12% 13% 13% 5% BE 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 100% BB 24% 3% 1% 2% 16% 55% 24% 3% 9% 14% 15% 35% 24% 3% 24% 9% 12% 29% HB 50% 0% 0% 50% 0% 0% 50% 0% 0% 50% 0% 0% 50% 0% 0% 0% 50% 0% HH 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 100% 0% 0% 0% 0% 0% 100% HE 6% 8% 25% 23% 27% 12% 6% 13% 13% 28% 28% 12% 6% 12% 13% 28% 27% 14% MV 39% 0% 0% 10% 18% 33% 39% 6% 10% 9% 8% 28% 39% 11% 13% 8% 11% 19% NI 18% 17% 6% 23% 18% 18% 18% 12% 16% 16% 18% 20% 18% 10% 20% 12% 17% 22% NW 3% 16% 13% 18% 29% 20% 3% 14% 12% 19% 35% 17% 3% 11% 10% 22% 34% 21% RP 19% 13% 27% 16% 18% 7% 19% 18% 16% 18% 18% 12% 19% 17% 17% 17% 18% 13% SL 0% 4% 4% 12% 42% 39% 0% 4% 6% 6% 31% 54% 0% 4% 6% 4% 46% 40% SN 9% 5% 9% 15% 25% 38% 9% 7% 12% 24% 15% 33% 9% 9% 22% 23% 6% 31% ST 26% 13% 13% 16% 9% 23% 26% 18% 22% 6% 12% 16% 26% 18% 19% 13% 10% 14% SH 16% 14% 11% 19% 19% 21% 16% 11% 17% 16% 18% 22% 16% 9% 20% 12% 15% 29% TH 16% 13% 14% 11% 14% 33% 16% 19% 12% 10% 14% 29% 16% 19% 20% 9% 13% 23% Shown is the proportion of municipalities with low (Q1, Q2), medium (Q3), and high access (Q4, Q5) as well as no access within a 30-minute travel time to inpatient hospices (no SPA), based on the Spatial Accessibility Index (SPAI i ). BW=Baden-Württemberg; BY=Bavaria; BE=Berlin; BB=Brandenburg; HB=Bremen; HH=Hamburg; HE=Hesse; MV=Mecklenburg-Western Pomerania; NI=Lower Saxony; NW=North Rhine-Westphalia, RP=Rhineland-Palatinate; SL=Saarland; SN=Saxony; ST=Saxony-Anhalt; SH=Schleswig-Holstein; TH=Thuringia Discussion Provider-to-population ratio The study is the first national evaluation of spatial accessibility to inpatient hospices in Germany, utilizing various indicators to operationalize spatial accessibility. One of the most applied indicators is the provider-to-population ratio. With 295 hospices and a national provider-to-population ratio of 36.2 beds/1 million inhabitants, availability has increased compared to earlier studies (27.3 beds/1 million inhabitants in 217 hospices in Melching (2016); 28.2 beds/1 million inhabitants in 209 hospices in Jansky et al. (2017); 25.6 beds/1 million inhabitants in 206 hospices in Prütz and Saß (2017) [ 24 , 38 , 44 ]. The pallCompare Monitor provides approximately similar figures, although the number of hospice beds recorded (2,754 hospice beds) is lower than the figure found in this study (3,023 beds) [ 45 ]. Since all earlier studies mentioned refer solely to the DHPC as a database, which did not include all hospice locations, this may have led to an underestimation of availability. The EAPC's reference value of 40–50 beds/1 million inhabitants refers to both beds in inpatient hospices and PCU and is therefore not comparable [ 29 ]. A recent study by the EAPC estimated 1.12 specialist palliative care services per 100,000 inhabitants in Germany, which is above the median in a European comparison (0.96 services per 100,000 inhabitants), but only in the second quintile. Due to our focus on inpatient hospices in this study, it is difficult to compare the results directly. “Geographic reach”, as an indicator for the provision of specialist palliative care services used in the EAPC Atlas of Palliative Care in the European Region 2025 is rated at the highest level (integrated) for Germany. However, the ratings of “geographic reach” are based on the assessment of the experts consulted, and measurable accessibility as a spatial component was not included [ 23 ]. Overall, the existing guidelines and recommendations from the DGP and EAPC are based solely on ratios [ 29 ]. This kind of indicator is easy to understand and interpret and may provide a starting point to analyze the healthcare provision situation [ 54 , 55 ]. However, its simplicity limits its validity and does not adequately reflect the healthcare provision situation. Cross-border relationships between neighbouring regions are not taken into account, even though it is well known that people's mobility is not restricted by administrative boundaries [ 7 , 18 , 56 ]. In addition, the supply is dichotomized. A hospice is only considered accessible if it is located within the administrative unit. Furthermore, it is considered equally accessible regardless of where someone is located within the defined area [ 18 , 56 , 57 , 58 ]. If the districts cover a very large area, this can result in an overestimation of hospice availability (e.g., Mecklenburg-Western Pomerania or Brandenburg). If, on the other hand, a hospice is located in an urban district (cities which constitute a district in their own right), the surrounding area may appear to have low availability, even though a contributory effect can be assumed (e.g. Bavaria). Choosing the analytical unit therefore implies a certain degree of arbitrariness (Modifiable Area Unit Problem, MAUP) [ 18 , 56 , 59 ]. Network-based travel time Network-based travel time analysis with GIS, combined with population data, is a frequently used indicator to assess potential accessibility of care facilities. In this study, it was applied for the first time to inpatient hospice care throughout Germany. A large proportion of inhabitants (90.3%) can reach inpatient hospices within 30 minutes by motorized individual transport. Gesell et al. (2023), who examined the accessibility of specialist palliative care services (PCU and PCT) in Germany, reported similarly high results for PCU (86.0%) and PCT (87.2%) [ 43 ]. In Switzerland (95.0%), Ireland (84.0%) and Spain (79.0%), large proportions of the population also reach specialist palliative care services within 30 minutes' travel time by private motorized transport, although it is not entirely clear whether inpatient hospices were included in this study [ 50 ]. By taking into account the transport infrastructure and topographical conditions, network analyses are generally more valid than the use of Euclidean distance (as the crow flies) as in Wiese et al. (2010) [ 46 ]. However, this indicator also has some limitations. Information on availability and demand competition is not taken into account. In addition, the restriction to motorized private transport leads to a bias [ 7 , 18 , 55 ]. In Germany, 77.3% of private households have at least one car and car-sharing services are increasingly available [ 60 ]. However, general mobility decreases with increasing age. People over the age of 80 in particular are dependent on alternative mode of transportation (public transport, on-call buses, shared cabs) [ 18 , 61 , 62 ]. In addition, the perception of distance changes among older people, and their willingness to travel further distances decreases [ 63 ]. Relying on public transport can aggravate the situation, especially in rural areas [ 64 , 65 ]. There is no nationwide study in the hospice and palliative care context, but Weinhold et al. (2022) estimate that 21% of the population in Saxony can reach inpatient hospices by public transport in 30 minutes and 51% in 60 minutes [ 37 ]. FCA Methods By taking availability and accessibility into account, the 2SFCA is an important basic method for adequately mapping spatial accessibility [ 13 ]. We applied the 2SFCA and E2SFCA methods to inpatient hospices in Germany for the first time, providing a more complex methodological approach to investigate spatial accessibility. Previously, studies have only been carried out at federal state level in Saxony, which showed quite similar results regarding the distribution pattern of the \({SPAI}_{i}\) [ 37 ]. In terms of accessibility, using flexible catchment areas based on hospice and population locations is a step forward compared to the orientation towards fixed administrative boundaries. This allows the mobility behavior of the population (cross-border service-seeking behavior) to be mapped more realistically. This is particularly relevant for regions close to the border, such as between the federal states of Baden-Württemberg and Bavaria, where there is a clustering of hospice locations and high accessibility indices. At the same time, demand competition can be taken into account by considering the overlap of catchment areas and availability of hospice beds. The data used as a demand population is also relevant. The general population was used here as we considered both patients and relatives as a demand population. Other studies used the entire deceased population [ 37 ] or deceased cancer patients as a potential demand population [ 47 ]. Another limitation of the 2SFCA is the dichotomous approach to catchment areas, in other words the assumption that all areas are considered equally accessible, which generates hard transitions in the \({SPAI}_{i}\) between communities inside and outside the catchment area. In addition, the \({SPAI}_{i}\) in the periphery of a catchment area is overestimated due to overlapping catchment areas [ 14 , 18 ]. Using E2SFCA, a differentiation within the catchment areas is achieved by applying a distance decay function. A concentric pattern is created, with high access indices near the hospice locations and lower values in peripheral areas. This pattern is particularly prominent using sharp distance decay function. Slow distance decay function causes a smoothing effect. Compared to 2SFCA, it is an important step towards operationalizing spatial access more realistically [ 14 , 18 , 56 , 57 ]. In areas with low density of inpatient hospices, application of E2SFCA causes more changes in the \({SPAI}_{i}\) compared to 2SFCA. High accessibility indices occur in proximity to inpatient hospices. In areas where many hospices are clustered, accessibility indices change less (e.g. Saarland, Ruhr area, city states) compared to areas with a lower density of hospices. These are mostly urban areas where the population density is high and the supply-demand situation is complex. In a similar study on PCU, we Petzold et al. (2025) linked the municipalities with a city and municipality classification of the Federal Institute for Research on Building, Urban Affairs, and Spatial Development (BBSR). The proportion of municipalities without access within 30 min in rural municipalities was higher than in urban municipalities, while access indices in urban areas tended to be higher overall [ 51 ]. A lower availability of hospice and palliative care services in low-population areas with an older population is also described in other German [ 67 ] and international studies [ 47 , 68 ]. Finally, it is open to debate which form of distance decay function is most suitable for hospice and palliative care when using E2SFCA-method. Similar arguments to those used in discussing maximum travel time radius may be applied to this question. On the one hand, it is a highly specialist care area that is only used by a small group of people, similar to highly specialist oncological or other care, which suggests a slow distance decay function [ 14 ]. On the other hand, as previously discussed, end-of-life care is a particularly sensitive area where long travel times are less acceptable for patients and relatives. Overall, the results of the FCA methods are less intuitive to interpret, but the methodology is considered as most suitable for operationalizing spatial access to healthcare services [ 55 , 66 ]. Many studies use the methodology for descriptive purposes only, but some also use it as a potential explanatory variable for health purposes [ 15 ]. Consequently, the definition of a travel time of 30 min is a critical parameter that needs to be discussed. This applies to both network-based travel time and FCA methods, as network-based travel time forms the methodical basis for operationalizing travel time or accessibility in FCA methods. [ 15 ]. There are no regulatory requirements for the maximum size of catchment areas or valid data on actual catchment areas of hospices in Germany. Other German studies used 30 min and 60 min as the maximum travel time to care providers of specialist palliative care [ 37 , 43 ]. In Great Britain, which is very similar to the German distance dimensions, a maximum of 30 minutes was also considered acceptable [ 47 ], whereas in spacious Canada 60 minutes were considered appropriate [ 49 ]. Hospice and palliative care is a particularly sensitive area of healthcare where care should be provided close to home or the familiar living environment [ 69 , 70 ]. Long transportation routes can prevent unstable, vulnerable and burdened patients from being transferred to a hospice. Frequent visits by relatives in the last period of life can support patients emotionally, psychologically and existentially. Relatives are often involved in the decision-making process regarding changes to treatment goals as proxy caregivers and are crucial for successful symptom relief [ 71 ]. However, relatives themselves may experience high stress levels [ 72 ], resulting in long travel times to be challenging. Emotions such as sadness, anger, stress, anxiety, fatigue and overall grief can have a negative impact on the ability to drive [ 73 , 74 , 75 ]. However, it was argued that travel times of 60 min to inpatient hospices can be considered just as justified as to other specialist facilities [ 55 , 76 ]. Limitations and outlook As already discussed, the study limited travel time to a maximum of 30 minutes. A sensitivity analysis with an extension of maximum travel time could provide additional information. An extension of the analysis to consider public transportation would also be useful. Complete coverage of all inpatient hospices cannot be guaranteed, as the study shows that entries in the DHPC can be incomplete. A limiting factor is the assumption that patients potentially use the hospice closest to their place of residence, and that their relatives live in the immediate neighborhood. Due to socio-demographic and social developments as well as globalization and migration processes, grown-up children are living at greater distances to their ageing parents. Long-distance caregiving is therefore becoming increasingly important [ 77 ], and patients may chose an inpatient hospice closer to their relatives place residence, instead of their own. Furthermore, a maximum travel time of 30 minutes may also be relevant for friends, neighbors and other important people from the patients' original neighborhood. In addition, using different aggregation levels of administrative areas or population data leads to inequalities in the presentation. In case of provider-to-population ratios, a calculation and presentation at municipality level would be too small-scale. Conversely, using population data at district level would be too large-scale for FCA and network-based travel time methods, which require smaller-scale population data, e.g. at grid cell level (1 km or 100 m grid) to yield more precise results. At the time of conducting the analysis, the 2022 census data at grid cell level was not yet available. This would also have allowed including further socio-demographic characteristics, such as the proportion of over 65-year-olds in the population, and thus a more precise mapping of potential hospice patients. As such data was not available at municipal level at the time of analysis, the overall population was used, which can lead to biases in view of regional differences in age structure. Only a selection of indicators for operationalizing spatial access were presented and applied in this article. The 2SFCA method and E2SFCA method are two out of numerous, increasingly complex FCA methods. Meanwhile, there are many other methods that include numerous additional parameters and are able to model an even more realistic view of supply situations. However, these models are more complex and require an extensive presentation and discussion of methods that, in the end, will only be useful for very detailed use, but not for general consideration of stakeholders in the healthcare system [ 17 , 18 ]. Overall, the study of potential spatial accessibility to inpatient hospices is based on theoretical considerations, for example, the number of beds indicates only theoretical availability [ 18 , 66 , 78 ]. Observations from practice have shown that there are often long waiting lists in hospices in Germany and the demand for beds is high [ 37 , 38 , 79 ]. A Canadian study integrated waiting times when using the 2SFCA [ 80 ]. Further, for a more realistic mapping of care situations, an intersectoral analysis of all existing palliative and hospice care structures in Germany should be conducted. Compared to other patient groups, it is not very useful to focus on individual groups of care structures, as the treatment pathways are very complex and cross-professional. In addition, taking into account the actual occupancy situation, possible capacity restrictions due to e.g. staff shortages, or patient waiting times due to high utilization, demographic characteristics (e.g. high regional average age, proportion of people with a migration history), socio-economic factors (e.g. proportion of single households) and utilization data can help to identify areas with low access and identify gaps in care. Quantitative and qualitative surveys of patients on realized travel times and their reasonability could provide valuable information on patient preferences. A complex (cross-sectoral) access analysis, taking into account other dimensions of access, can contribute to an improvement in the planning of hospice and palliative care close to home. Conclusion This study examined the spatial accessibility of inpatient hospices in Germany using different indicators. The results show high spatial accessibility, but also illustrate that the chosen method has a considerable influence on the results. The decisive factor is which target group is to be addressed. In principle, studies on spatial accessibility to healthcare services should also take into account accessibility and mobility factors, as availability alone does not adequately reflect the spatial dimension of access to healthcare services. Methods of health geography add great value and contribute to an improvement in the planning of palliative care services. Considering demographic change and increasing demand for hospice and palliative care, this research perspective is highly relevant. Abbreviations 2SFCAM Two-Step floating catchment area BKG Federal Agency for Cartography and Geodesy BBSR Federal Institute for Research on Building, Urban Affairs, and Spatial Development DGP German Association for Palliative Medicine DHPC Directory for Hospice and Palliative Care E2SFCA Enhanced Two-Step floating catchment area EAPC European Association for Palliative Care FCA Floating catchment area MAUP Modifiable Area Unit Problem PPR provider-to-population ratio PCT home palliative care teams PCU palliative care units \({SPAI}_{i}\) Spatial accessibility index Declarations Authors‘ contributions All authors have substantially contributed to the conception of the work. TP developed the idea for the study, conducted the analysis and wrote the manuscript. FN, JA, CB, BJ and MJ advised the analysis, contributed to the manuscript and revised it critically for important intellectual content. All authors approved the final version to be published and gave their agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Open Access funding enabled and organized by Projekt DEAL. Availability of data and materials Data can be obtained from the corresponding author on reasonable request. Data on geographic information are freely available from the Service Center of the Federal Agency for Cartography and Geodesy at: https://gdz.bkg.bund.de/index.php/default/open-data.html Ethics approval and consent to participate Not applicable. Ethics approval was not required for the use of the datasets because it was based on public data. No human data was included in this study, no personal information were used, and therefore consent to participate is not applicable. All data utilized was publicly available data and address data of institutions and no administrative permissions were required to access the data. Consent for publication Not applicable. Competing interests The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication. References Guagliardo MF. Spatial accessibility of primary care: concepts, methods and challenges. Int J Health Geogr. 2004;3(1):3. https://doi.org/10.1186/1476-072X-3-3 . Penchansky R, Thomas JW. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Med Care. 1981;19(2):127–40. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18. https://doi.org/10.1186/1475-9276-12-18 . Pugh A, Castleden H, Giesbrecht M, Davison C, Crooks V. Awareness as a dimension of health care access: exploring the case of rural palliative care provision in Canada. J Health Serv Res Policy. 2019;24(2):108–15. https://doi.org/10.1177/1355819619829782 . Schweikart J, Kistemann T. Erkenntnisgewinn einer räumlichen Betrachtung von Gesundheit. In: Augustin J, Koller D, editors. Geografie der Gesundheit. Die räumliche Dimension von Epidemiologie und Versorgung. Bern: Hogrefe; 2017. pp. 15–29. Augustin J, Andrees V, Walsh D, Reintjes R, Koller D. Spatial Aspects of Health—Developing a Conceptual Framework. Int J Environ Res Public Health. 2023;20(3):1817. https://doi.org/10.3390/ijerph20031817 . Henry KA, McDonald K. Geographic Access to Health Services. In: Boscoe FP, editor. Geographic health data: fundamental techniques for analysis. Oxfordshire, Boston: CAB International; 2013. pp. 142–64. Haggerty JL, Roberge D, Lévesque JF, Gauthier J, Loignon C. An exploration of rural–urban differences in healthcare-seeking trajectories: Implications for measures of accessibility. Health Place. 2014;28:92–8. https://doi.org/10.1016/j.healthplace.2014.03.005 . Voigtländer S, Deiters T. Mindeststandards für die räumliche Erreichbarkeit hausärztlicher Versorgung: Ein systematischer Review. Gesundheitswesen. 2015;77(12):949–57. https://doi.org/10.1055/s-0035-1548805 . Stentzel U, Hoffmann W, Von Den Berg N. (2017) Mobilitätsanalysen in der Gesundheitsforschung. In: Augustin J, Koller D, editor. Geografie der Gesundheit. Die räumliche Dimension von Epidemiologie und Versorgung. Bern: Hogrefe Verlag; 2017. 81–92. Augustin J, Austermann J, Erasmi S. Netzwerkanalysen in der regionalen Versorgungsforschung: Das Beispiel der dermatologischen Versorgung in der Metropolregion Hamburg. Gesundheitswesen 2019 81:50–7. https://doi.org/10.1055/s-0042-116591 Grohmann J, Völker S, Augustin J, Rauch S, Stenzel U. Gute Praxis Erreichbarkeitsanalyse im Gesundheitswesen (GPEG). 2023. https://www.bbsr.bund.de/BBSR/DE/veroeffentlichungen/bbsr-online/2023/bbsr-online-26-2023-dl.pdf?__blob=publicationFile&v=2 . Accessed 09 Jan 2026. Luo W, Wang F. Measures of Spatial Accessibility to Health Care in a GIS Environment: Synthesis and a Case Study in the Chicago Region. Environ Plann B Plann Des. 2003;30(6):865–84. https://doi.org/10.1068/b29120 . Luo W, Qi Y. An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health Place. 2009;15(4):1100–17. https://doi.org/10.1016/j.healthplace.2009.06.002 . Stacherl B, Sauzet O. Gravity models for potential spatial healthcare access measurement: a systematic methodological review. Int J Health Geogr. 2023;22(1):34. https://doi.org/10.1186/s12942-023-00358-z . Wan N, Zou B, Sternberg T. A three-step floating catchment area method for analyzing spatial access to health services. Int J Geogr Inf Sci. 2012;26(6):1073–89. https://doi.org/10.1080/13658816.2011.624987 . Bauer J, Groneberg DA. Measuring Spatial Accessibility of Health Care Providers – Introduction of a Variable Distance Decay Function within the Floating Catchment Area (FCA) Method. PLoS ONE. 2016;11(7):e0159148. https://doi.org/10.1371/journal.pone.0159148 . Jörg R, Lenz N, Wetz S, Widmer M. Jan. Ein Modell zur Analyse der Versorgungsdichte. Herleitung eines Index zur räumlichen Zugänglichkeit mithilfe von GIS und Fallstudie zur ambulanten Grundversorgung in der Schweiz. Neuchâtel: Schweizerisches Gesundheitsobservatorium (Obsan); 2019 Report No.: 01/2019. https://www.obsan.admin.ch/de/publikationen/2019-ein-modell-zur-analyse-der-versorgungsdichte . Accessed 05 2026. Brennan F. Palliative care as an international human right. J Pain Symptom Manage. 2007;33(5):494–9. https://doi.org/10.1016/j.jpainsymman.2007.02.022 . Ezer T, Lohman D, de Luca GB. Palliative Care and Human Rights: A Decade of Evolution in Standards. J Pain Symptom Manage. 2018;55(2S):163–9. https://doi.org/10.1016/j.jpainsymman.2017.03.027 . WHO. Palliative care. 2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care . Accessed 19 Jan 2026. Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, Arreola-Ornelas H, Gómez-Dantés O, Rodriguez NM, Alleyne GAO, Connor SR, Hunter DJ, Lohman D, Radbruch L, Del Rocío Sáenz Madrigal M, Atun R, Foley KM, Frenk J, Jamison DT, Rajagopal MR, Lancet Commission on Palliative Care and Pain Relief Study Group. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018; 391(10128):1391–1454. https://doi.org/10.1016/S0140-6736(17)32513-8 Garralda-Domezain E, Tripodoro VA, Ling J, Brennan J, Montero-Calero A, Bastos F et al. EAPC Atlas of Palliative Care in the European region 2025. https://hdl.handle.net/10171/116281 . Accessed 19 Jan 2026. Prütz F, Saß AC. Data on palliative care in Germany: which data sources are available and what do they tell? [Daten zur Palliativversorgung in Deutschland Welche Datenquellen gibt es, und was sagen sie aus?]. Bundesgesundheitsbl. 2017;60:26–36. https://doi.org/10.1007/s00103-016-2483-8 . Scholten N, Günther AL, Pfaff H, Karbach U. The size of the population potentially in need of palliative care in Germany - an estimation based on death registration data. BMC Palliat Care. 2016;15(1):29. https://doi.org/10.1186/s12904-016-0099-2 . Simon ST, Gomes B, Koeskeroglu P, Higginson IJ, Bausewein C. Population, mortality and place of death in Germany (1950–2050) – Implications for end-of-life care in the future. Public Health. 2012;126(11):937–46. https://doi.org/10.1016/j.puhe.2012.06.014 . Mathers CD, Stevens GA, Boerma T, White RA, Tobias MI. Causes of international increases in older age life expectancy. Lancet. 2015;385(9967):540–8. https://doi.org/10.1016/S0140-6736(14)60569-9 . Nauck F. Palliativmedizin - Aktueller Stand in Klinik, Forschung und Lehre. Klinikarzt. 2018;47(8):348–53. https://doi.org/10.1055/a-0656-9107 . Payne S, Harding A, Williams T, Ling J, Ostgathe C. Revised recommendations on standards and norms for palliative care in Europe from the European Association for Palliative Care (EAPC): A Delphi study. Palliat Med. 2022;36(4):680–97. https://doi.org/10.1177/02692163221074547 . GKV-Spitzenverband. Framework agreement pursuant to Section 39a (1) sentence 4 of the German Social Code Book V (SGB V) on the nature, scope and quality assurance of inpatient hospice care. Version of 18 November 2024 (originally issued 13 March. 1998). Berlin: GKV-Spitzenverband; 2024. Available from: https://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/hospiz_palliativversorgung/2024-11-18_Rahmenvereinbarung_39a_Abs1_Satz_4__SGB_V_stat_Hospizversorgung_Erw.pdf . Accessed 19 Jan 2026. Stiel S, Oechsle K, Doll A, Strupp J, Herbst FA, Ullrich A. für die AG Angehörige der DGP. Bedürfnisse, Probleme und Bedarfe von Angehörigen in der Palliativversorgung. Z für Palliativmedizin. 2024;25(04):172–5. https://doi.org./10.1055/a-2322-8218 . Ülgüt R, Stiel S, Herbst FA. Experiences and support needs of informal long-distance caregivers at the end of life: a scoping review. BMJ Open. 2023;13(4):e068175. https://doi.org/10.1136/bmjopen-2022-068175 . Marshall C, Virdun C, Phillips JL. Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis. Palliat Med 1. 2024;38(9):935–50. https://doi.org/10.1177/0269216324126979 . Ditscheid B, Meissner F, Gebel C, Hennig B, Marschall U, Meißner W, Wedding U, Freytag A. Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016–2019) und regionale Variabilität. Bundesgesundheitsbl. 2023;66(4):432–42. https://doi.org/10.1007/s00103-023-03683-7 . Robert Koch Institute. Palliative care. Health in Germany. Health reporting of the federal government. Berlin: Robert Koch Institute; 2015. pp. 332–7. van den Berg N, Rehner L, Hoffmann W. Die Hospiz- und Palliativversorgung in Mecklenburg-Vorpommern. 2019. https://www.medizin.uni-greifswald.de/versorgungsepidemiologie/fileadmin/user_upload/Berichte/Bericht_Hospiz-und_Palliativversorgung_07.10.2019.pdf . Accessed 02 Jan 2026. Weinhold I, Thiesen J, Faß E, Müller M, Claus F, Kliemt R, Stark S, Samartzidis L, Fink C, Häckl D. Hospiz- und Palliativbericht Sachsen 2022. https://www.pflegenetz.sachsen.de/download/HPB22.pdf . Accessed 02 Jan 2026. Jansky M, Nauck F, Jaspers B. Gutachten zum Bedarf an Hospizbetten in Nordrhein-Westfalen. 2017. http://www.hospiz-nrw.de/files/gutachten_bedarf_hospizbetten_nrw_2017-1.pdf . Accessed 07 Jan 2026. Hesse M, Ates G. Hospiz- und Palliativversorgung in Rheinland-Pfalz: Gutachten im Auftrag des Ministeriums für Soziales, Arbeit, Gesundheit und Demografie des Landes Rheinland-Pfalz (MSAGD). 2017. https://mwg.rlp.de/fileadmin/15/Abteilung_2_Gesundheit/Krankenhauswesen/Hospizliche_und_palliative_Versorgung_in_Rheinland-Pfalz/Gutachten_Palliativversorgung.pdf . Accessed 10 Jan 2026. Leiz M, Moon K, Rehner LK, Stentzel U, Radicke F, Hoffmann W, van den Berg N. Population-based, spatial analysis of specialised ambulatory palliative care in Mecklenburg-western Pomerania, Germany, on the basis of reimbursement data. Int J Environ Res Public Health. 2023;20:2231. https://doi.org/10.3390/ijerph20032231 . van Baal K, Stiel S, Hemmerling M, Stahmeyer JT, Wiese B, Schneider N, Afshar K. Ambulante Palliativversorgung in Niedersachsen–regionale Unterschiede in der Versorgung von Menschen am Lebensende anhand von Qualitätsindikatoren. In: Versorgungsatlas vol. 21/4. Berlin: Zentralinstitut für die kassenärztliche Versorgung in Deutschland 2021:1–19. https://doi.org/10.20364/VA-21.04 Mumm R, Faß E, Thießen J, Stark S. Jan. Hospiz- und Palliativbericht Hessen 2024. https://familie.hessen.de/sites/familie.hessen.de/files/2025-10/hospiz-und_palliativbericht_hessen_2024_1.pdf . Accessed 05 2026. Gesell D, Hodiamont F, Bausewein C, Koller D. Accessibility to specialist palliative care services in Germany: a geographical network analysis. BMC Health Serv Res. 2023;23(1):786. https://doi.org/10.1186/s12913-023-09751-7 . Melching H. Faktencheck Gesundheit Palliativversorgung - Modul 2- Strukturen und regionale Unterschiede in der Hospiz- und Palliativversorgung. Bertelsmann Stiftung; 2015. https://www.bertelsmann-stiftung.de/de/publikationen/publikation/did/faktencheck-palliativversorgung-modul-2 . Accessed 05 Jan 2026. pallCompare Monitor Hospiz- und Palliativversorgung. 2025. https://www.bifg.de/projekte/pallcompare/interaktive-grafiken-pallcompare/hospizliches-und-palliatives-versorgungsangebot-wegweiser-diagramm . Accessed 19 Jan 2026. Wiese CHR, Zausig YA, Vormelker J, Orso S, Graf BM, Hanekop GG. Ambulante und stationäre palliativmedizinische Patientenversorgung in Deutschland. Anaesthesist. 2010;59(2):162–70. https://doi.org/10.1007/s00101-009-1651-8 . Gatrell AC, Wood DJ. Variation in geographic access to specialist inpatient hospices in England and Wales. Health Place. 2012;18:832–40. https://doi.org/10.1016/j.healthplace.2012.03.009 . Chukwusa E, Yu P, Verne J, Taylor R, Higginson IJ, Wei G. Regional variations in geographic access to inpatient hospices and Place of death: A Population-based study in England, UK. PLoS ONE. 2020;15(4):e0231666. https://doi.org/10.1371/journal.pone.0231666 . Cinnamon J, Schuurman N, Crooks VA. A method to determine spatial access to specialized palliative care services using GIS. BMC Health Serv Res. 2008;8:140. https://doi.org/10.1186/1472-6963-8-140 . van Steijn D, Pons Izquierdo JJ, Garralda Domezain E, Sánchez-Cárdenas MA, Centeno Cortés C. Population’s Potential Accessibility to Specialized Palliative Care Services: A Comparative Study in Three European Countries. Int J Environ Res Public Health. 2021;18(19):10345. https://doi.org/10.3390/ijerph181910345 . Petzold T, Nauck F, Banse C, Augustin J, Jansky M. Räumlicher Zugang zu Palliativstationen in Deutschland: Integrierte Analyse von Verfügbarkeit und Erreichbarkeit mittels E2SFCA-Methode. Bundesgesundheitsbl. 2025;68(10):1128–37. https://doi.org/10.1007/s00103-025-04124-3 . Directory for Hospice and Palliative Care. Inpatient hospices 2022. https://www.wegweiser-hospiz-palliativmedizin.de/ . Accessed 15 Jan 2026. Federal Agency for Cartography and Geodesy. Administrative regions of the Federal Republic of Germany 2020. https://gdz.bkg.bund.de/index.php/default/verwaltungsgebiete-1-250-000-mit-einwohnerzahlen-stand-31-12-vg250-ew-31-12.html . Accessed 20 Nov 2025. Sánchez-Cárdenas MA, Garralda E, Benítez E, Arias-Casais N, van Steijn D, Centeno C. Palliative Care Coverage across European National Health Systems: Proposal of a Synthetic Indicator. Int J Environ Res Public Health. 2021;18:10753. https://doi.org/10.3390/ijerph182010753 . Sundmacher L, Schang. Schüttig. Gutachten zur Weiterentwicklung der Bedarfsplanung i.S.d. §§ 99 ff. SGB V zur Sicherung der vertragsärztlichen Versorgung. 2018. https://www.g-ba.de/downloads/39-261-3493/2018-09-20_Endbericht-Gutachten-Weiterentwickklung-Bedarfsplanung.pdf . Accessed 05 Jan 2026. Drake C, Nagy D, Nguyen T, Kraemer KL, Mair C, Wallace D, Donohue J. A comparison of methods for measuring spatial access to health care. Health Serv Res. 2021;56(5):777–87. https://doi.org/10.1111/1475-6773.13700 . McGrail MR, Humphreys JS. Measuring spatial accessibility to primary care in rural areas: Improving the effectiveness of the two-step floating catchment area method. Appl Geogr. 2009;29(4):533–41. https://doi.org/10.1016/j.apgeog.2008.12.003 . Shah TI, Bell S, Wilson K. Spatial Accessibility to Health Care Services: Identifying under-Serviced Neighbourhoods in Canadian Urban Areas. PLoS ONE. 2016;11(12):e0168208. https://doi.org/10.1371/journal.pone.0168208 . Wong D. The Modifiable Areal Unit Problem (MAUP). In: Fotheringham AS, Rogerson PA, editors. The SAGE Handbook of Spatial Analysis. London: SAGE Publications Ltd; 2009. pp. 105–23. Umweltbundesamt. Mobilität privater Haushalte. 2025. https://www.umweltbundesamt.de/daten/private-haushalte-konsum/mobilitaet-privater-haushalte#-hoher-motorisierungsgrad . Accessed 05 Jan 2026. Kuhnimhof T, Nobis C, Hillmann K, Follmer R, Eggs J. Veränderungen im Mobilitätsverhalten zur Förderung einer nachhaltigen Mobilität. Umweltbundesamt. 2019. https://elib.dlr.de/133798/1/2019-08-29-texte_101-2019_mobilitaetsverhalten.pdf . Accessed 19 Jan 2026. Tao Z, Cheng Y. Modelling the spatial accessibility of the elderly to healthcare services in Beijing, China. Environ Plan B Urban Anal City Sci. 2019;46(6):1132–47. https://doi.org/10.1177/2399808318755145 . Weinhold I, Wende D, Schrey C, Militzer-Horstmann C, Schang L, Sundmacher L. Assessing patients’ acceptable and realised distances to determine accessibility standards for the size of catchment areas in outpatient care. Health Policy. 2022;126(11):1180–6. https://doi.org/10.1016/j.healthpol.2022.08.011 . Stentzel U, Piegsa J, Fredrich D, Hoffmann W, van den Berg N. Accessibility of general practitioners and selected specialist physicians by car and by public transport in a rural region of Germany. BMC Health Servi Res. 2016;16(1):587. https://doi.org/10.1186/s12913-016-1839-y . Rauch S, Stangl S, Haas T, Rauh J, Heuschmann PU. Spatial inequalities in preventive breast cancer care: A comparison of different accessibility approaches for prevention facilities in Bavaria. Ger J Transp Health. 2023;29:101567. https://doi.org/10.1016/j.jth.2023.101567 . McGrail MR. Spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements. Int J Health Geogr. 2012;11(1):50. https://doi.org/10.1186/1476-072X-11-50 . Apolinarski B, Stiel S, Herbst FA, Geyer S. Dünn in der Fläche? Regionale Disparitäten in der Hospiz- und Palliativversorgung in Deutschland. Z Evid Fortbild Qual Gesundhwes. 2024;190–191:53–62. https://doi.org/10.1016/j.zefq.2024.07.007 . Tobin J, Rogers A, Winterburn I, Tullie S, Kalyanasundaram A, Kuhn I, Barclay S. Hospice care access inequalities: a systematic review and narrative synthesis. BMJ Supportive Palliat Care. 2022;12(2):142–51. https://doi.org/10.1136/bmjspcare-2020-002719 . Deutsche Gfür. Palliativmedizin, Deutscher Hospiz- und Palliativverband e.V. Charta zur Betreuung schwerstkranker und sterbender Menschen in Deutschland. 2020. https://www.charta-zur-betreuung-sterbender.de/files/dokumente/2020_Charta%20Broschuere_Stand_Jan2020.pdf . Accessed 07 Jan 2026. Bundesministerium für Gesundheit. Gesetz zur Verbesserung der Hospiz- und Palliativversorgung in Deutschland (Hospiz- und Palliativgesetz, HPG). [Internet]. BGBL 2015 I Nr. 48 Dec 7. 2015. https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/detail/hospiz-und-palliativgesetz-hpg.html . Accessed 19 Jan 2026. Foley G. The supportive relationship between palliative patients and family caregivers. BMJ Supportive Palliat Care. 2018;8(2):184–6. https://doi.org/10.1136/bmjspcare-2017-001463 . Oechsle K. Current Advances in Palliative & Hospice Care: Problems and Needs of Relatives and Family Caregivers During Palliative and Hospice Care-An Overview of Current Literature. Med Sci. 2019;7(3):43. https://doi.org/10.3390/medsci7030043 . Rosenblatt PC. Grieving While Driving. Death Stud. 2004;28(7):679–86. https://doi.org/10.1080/07481180490476533 . Jallais C, Gabaude C, Paire-ficout L. When emotions disturb the localization of road elements: Effects of anger and sadness. Transp Res Part F: Traffic Psychol Behav. 2014;23:125–32. https://doi.org/10.1016/j.trf.2013.12.023 . Magaña VC, Scherz WD, Seepold R, Madrid NM, Pañeda XG, Garcia R. The Effects of the Driver’s Mental State and Passenger Compartment Conditions on Driving Performance and Driving Stress. Sensors. 2020;20(18):5274. https://doi.org/10.3390/s20185274 . Schang L, Kopetsch T, Sundmacher L. Zurückgelegte Wegzeiten in der ambulanten ärztlichen Versorgung in Deutschland. Bundesgesundheitsbl. 2017;60:1383–92. https://doi.org/10.1007/s00103-017-2643-5 . Herbst FA, Stiel S. Has Anyone Been There Now? An Interview Study on the Support Experiences and Unmet Needs of Informal Long-Distance Caregivers for Patients at the End of Life. Omega-J Death Dying. 2024. https://doi.org/10.1177/00302228241243110 . Fransen K, Neutens T, De Maeyer P, Deruyter G. A commuter-based two-step floating catchment area method for measuring spatial accessibility of daycare centers. Health Place. 2015;32:65–73. https://doi.org/10.1016/j.healthplace.2015.01.002 . Wiese M. Entscheidungsfindung zur Priorisierung von Aufnahmeanfragen für stationäre Hospize. Z Palliativmed. 2024;25(04):189–93. https://doi.org/10.1055/a-2256-8729 . Schuurman N, Amram O, Crooks VA, Johnston R, Williams A. A comparative analysis of potential spatio-temporal access to palliative care services in two Canadian provinces. BMC Health Serv Res. 2015;15(1):270. https://doi.org/10.1186/s12913-015-0909-x . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 29 Apr, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers invited by journal 02 Mar, 2026 Editor invited by journal 02 Mar, 2026 Editor assigned by journal 28 Feb, 2026 Submission checks completed at journal 28 Feb, 2026 First submitted to journal 24 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8958592","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":599639428,"identity":"574b2b85-210e-49fb-9133-e35d9fbd0e93","order_by":0,"name":"Theresa Petzold","email":"data:image/png;base64,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","orcid":"","institution":"University Medical Center Goettingen","correspondingAuthor":true,"prefix":"","firstName":"Theresa","middleName":"","lastName":"Petzold","suffix":""},{"id":599639429,"identity":"8dcb486c-ab71-45bc-9b75-e84f08dd84ab","order_by":1,"name":"Friedemann Nauck","email":"","orcid":"","institution":"University Medical Center Goettingen","correspondingAuthor":false,"prefix":"","firstName":"Friedemann","middleName":"","lastName":"Nauck","suffix":""},{"id":599639430,"identity":"427ecba3-c054-4ad6-b7e1-70d99a949df9","order_by":2,"name":"Christian Banse","email":"","orcid":"","institution":"University Medical Center Goettingen","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Banse","suffix":""},{"id":599639431,"identity":"21d21169-4d9a-4857-8228-09b3cfe02beb","order_by":3,"name":"Jobst Augustin","email":"","orcid":"","institution":"University Medical Center Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Jobst","middleName":"","lastName":"Augustin","suffix":""},{"id":599639432,"identity":"837f0e4f-dd98-4256-8baa-31310f5d08b1","order_by":4,"name":"Birgit Jaspers","email":"","orcid":"","institution":"University Medical Center Goettingen","correspondingAuthor":false,"prefix":"","firstName":"Birgit","middleName":"","lastName":"Jaspers","suffix":""},{"id":599639433,"identity":"78a054fd-a5d1-49be-aca6-8e695788ec15","order_by":5,"name":"Maximiliane Jansky","email":"","orcid":"","institution":"University Medical Center Goettingen","correspondingAuthor":false,"prefix":"","firstName":"Maximiliane","middleName":"","lastName":"Jansky","suffix":""}],"badges":[],"createdAt":"2026-02-24 14:26:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8958592/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8958592/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104007736,"identity":"e969b840-5fcf-4d6b-a18c-d9d855942bae","added_by":"auto","created_at":"2026-03-05 15:21:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":220184,"visible":true,"origin":"","legend":"\u003cp\u003eProvider to population ratio in Germany per 1,000,000 inhabitants on district level\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8958592/v1/ab52ccde6a07bab8d7a562ef.png"},{"id":104007735,"identity":"4672f31d-43c0-40d0-94d4-2e760782c0bb","added_by":"auto","created_at":"2026-03-05 15:21:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":311497,"visible":true,"origin":"","legend":"\u003cp\u003eTravel time (in minutes) to inpatient hospices in Germany\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8958592/v1/9cc5d6a204b8e1fc7205fc25.png"},{"id":104007734,"identity":"e45f3d7d-394e-4cb3-8e8b-1033d9445b24","added_by":"auto","created_at":"2026-03-05 15:21:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":692201,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSpatial accessibility to hospices at municipal level in Germany\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShown is spatial accessibility to inpatient hospices in Germany at the municipal level. Results of the Floating Catchment Area methods are presented for a) 2SFCA, b) E2SFCA with slow distance decay, and c) E2SFCA with sharp distance decay. The 〖SPAI〗_iis categorized into quintiles: low (Q1, Q2), medium (Q3), and high (Q4, Q5).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8958592/v1/5522d029b4b7f4be5ae8fe55.png"},{"id":104402326,"identity":"0966dce3-4f57-431d-a28c-49c90033aa23","added_by":"auto","created_at":"2026-03-11 12:15:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2231159,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8958592/v1/a174181b-b35e-457b-bc48-45ef25b6397b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Approaches to quantifying spatial accessibility using the example of inpatient hospices in Germany","fulltext":[{"header":"Background","content":"\u003cp\u003eAccess in a medical context is complex and understood as a multidimensional concept. In addition to the distinction between potential and realized access [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the dimensions of availability, accessibility, accommodation, affordability and acceptability are most frequently mentioned in this context [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recent concepts add further dimensions such as approachability, appropriateness or awareness [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The dimensions of availability and accessibility include among others spatial aspects of potential access and can be summarized under the term \u0026lsquo;spatial accessibility\u0026rsquo;. This is considered to be an important indicator of the quality of healthcare services and the assessment of needs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. There is a wide variety of indicators for operationalizing spatial accessibility, which consider either availability or accessibility alone, or both indicators together. The best-known indicators are the provider-to-population ratio, network-based travel time, and the floating catchment area method family.\u003c/p\u003e \u003cp\u003eThe provider-to-population ratio is the simplest and best-known way of representing the availability of healthcare services. It does not include any spatial references such as geographical distances or travel times and describes the ratio between supply and potential demand. The supply is represented by the bed capacity of the healthcare facilities examined. Potential demand is represented by the population or potential patients. The ratio is calculated based on administrative regions (districts, municipalities, etc.) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne possibility for examining accessibility is to perform a network analysis based on travel time. After setting a threshold value, zones of equal accessibility are calculated based on a service location (service areas or polygons) along a road network. Either distance or travel time is taken into account, whereas travel time has a greater influence on patients' mobility decisions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The service areas are linked to aggregated population data located within the polygons. The potential minimum travel times between the population's places of residence and the nearest service provider are mapped [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor a more realistic assessment of the healthcare situation, more complex methods are needed to equally consider both dimensions of spatial accessibility. Floating catchment area methods have been established in this context for about 20 years. The basic model is the two-step floating catchment area method (2SFCA) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This method uses population figures and the locations of healthcare facilities, including their capacities (usually expressed as the number of beds), to calculate the relationship between supply and demand. Contrary to other methods using fixed administrative boundaries, in 2SFCA catchment areas are flexible (floating catchments), and a maximum travel time is set as a threshold value. Many modifications have been developed based on the 2SFCA method. The most widely used is the Enhanced Two Step Floating Catchment Area Method (E2SFCA) by Luo and Qi [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Other variations are, for example, the Three-Step Floating Catchment Area Method (3SFCA), the integrated floating catchment method (iFCA) or the Modified Huff Model Three-Step Floating Catchment Area Method (MH3SFCA) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePalliative care is explicitly recognized under the human right to health [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and should therefore be available regardless of place of residence, financial means, or social circumstances. There are massive differences in provision of palliative and hospice care services worldwide, with Germany being among the countries with a high standard of care provision [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The demand for palliative and hospice care in Germany is expected to increase [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Due to ongoing medical advances and the wider range of medical treatment options available, people are dying at an older age and symptom patterns increase in complexity due to multimorbidity [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, the incidence of both oncological and non-oncological incurable diseases is rising. In Germany, there are numerous outpatient and inpatient, non-specialist as well as specialist palliative care services. Non-specialist palliative care services include basic care provided through general practitioners, ambulant nursing services, nursing homes, and general hospital units, with the involvement of volunteer hospice services in less complex cases. In cases where the patient's situation is highly complex, treatment is provided by specialist palliative care services through inpatient palliative care units (PCU), hospital palliative care support teams, home palliative care teams (PCT), day hospices and inpatient hospices. In Germany, hospices are inpatient facilities that provide support for the seriously ill with a life expectancy of days, weeks, or a few months if treatment in a hospital is not necessary and care at home or in a nursing facility is not possible or desired. Care is provided by multi-professional teams of nurses, psychosocial and spiritual professionals and volunteers. General practitioners or physicians from PCT provide medical care to patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. New founded inpatient hospices in Germany must meet certain framework conditions and quality assurance requirements, defined by law in Social Code Book V [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared to other medical care locations, spatial accessibility to palliative care services in general, and inpatient hospices in particular, has a number of special conditions. For patients, access is mostly only relevant once, as in most cases the hospice will be the place of death. It includes the journey from the patient's place of residence or from a previous hospital stay, e.g., in a PCU, to the hospice. Transport is usually provided by ambulance or emergency vehicles. Since patients at the end of life often suffer from severe symptoms, long travel times can complicate the transportation process. Spatial accessibility is particularly relevant for relatives who wish to visit patients at the end of life. Long travel times can be perceived as stressful by patients and their relatives and friends [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and limit visiting opportunities [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe number of palliative and hospice care services and their utilization in Germany has risen steadily in recent years [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, little research has been done on the current state of geographical access to inpatient hospices throughout Germany. Previous studies have focused on individual federal states or care services [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] or examine either availability or accessibility as dimensions of spatial access, mostly [43, 44, 45). An earlier study conducted in Germany used euclidean distance as an indicator of accessibility [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Internationally, studies have been conducted in the United Kingdom [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], Canada [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], Ireland, Spain, and Switzerland [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. No study conducted in Germany has examined spatial accessibility to inpatient hospices beyond the application of simple availability and provider-to-population ratios. FCA methods have rarely been used in the field of palliative care [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Studies comparing different indicators of spatial accessibility in this context are also unknown. To achieve a more precise assessment of spatial access, various indicators for operationalizing spatial access are used and compared in this study. Using the example of inpatient hospices as part of specialist palliative care in Germany, regional differences in spatial access will be identified and illustrated. Potential differences in the results caused by methodological characteristics will be discussed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData sources and data preparation\u003c/h2\u003e \u003cp\u003eThe identification of hospices, including their bed capacities, was initially based on \u0026lsquo;Directory for Hospice and Palliative Care\u0026rsquo; (DHPC) [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], a freely accessible web-based self-disclosure database of the German Association for Palliative Medicine (DGP). This contains numerous inpatient and outpatient palliative care and hospice facilities. Additional facilities and their bed capacities were identified using the lists of the regional associations of the German Hospice and Palliative Care Association. All information on identified facilities was manually verified (as of April 2022). The hospice locations were then geocoded.\u003c/p\u003e \u003cp\u003eFreely available data from the Federal Agency for Cartography and Geodesy (BKG) from 2020 on municipalities and counties were used for the cartographic representation [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The data set also included population data. For analysis, it was necessary to convert the area-based population data into a point feature that is representative of the area (district or municipality). The population center was used for this purpose, which, in contrast to the classically used geometric centre of the area, represents the location where most people live in an administrative area [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted for Germany which consists of 16 federal states, 401 districts and 10,995 municipalities. The total population in 2020 was 83,155,031 with a population density of 233 inhabitants per km\u0026sup2;.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eProvider to population ratio\u003c/h2\u003e \u003cp\u003eThe provider-to-population ratio (PPR) per 1\u0026nbsp;million inhabitants was calculated and visualized at district level by dividing the total number of beds in hospices by the total population. A more detailed visualization at municipal level was not used for this indicator due to a lack of significance. For better comparability of the results, the data was also aggregated at federal state level.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eNetwork analysis based on travel time\u003c/h3\u003e\n\u003cp\u003eUsing the geocoded hospice locations, a network analysis based on travel time was carried out using motorized private car transport. By setting travel time thresholds, zones of equal potential accessibility are generated. In Germany, there are no official guidelines specifying how far away inpatient hospices or other palliative care services must be located. Based on other studies, thresholds of 15, 30 and 60 minutes were set [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Service areas were linked to population data at the municipal level to identify the proportion of the population located within and outside the 30-minute catchment area. In contrast to the provider-to-population ratios at the district level, the municipal level was chosen for this indicator to increase its relevance by using smaller-scale data [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFloating catchment area methods\u003c/h2\u003e \u003cp\u003eOut of the FCA method family, the 2SFCA method [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and the E2SFCA method [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] were applied, as they offer a balance of methodological transparency, empirical reproducibility and differentiated measurement of spatial accessibility. In particular, by integrating a distance decay function, the E2SFCA enables a more realistic representation of the decrease in accessibility with increasing distance without creating high complexity [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For both methods, the spatial accessibility index (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e) was calculated in a two-step process (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). First, a supply-demand ratio \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003ewas calculated for each inpatient hospice. Then, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e was calculated for each population center at the municipal level.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2SFCA-Methode.\u003c/b\u003e To calculate the supply-demand ratio \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e a maximum catchment area (\u0026#119889;\u003csub\u003e\u0026#119898;\u0026#119886;\u0026#119909;\u003c/sub\u003e), in this case within 30-minute car travel time, was defined for each hospice \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(j\\)\u003c/span\u003e\u003c/span\u003e [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], and the catchment areas were calculated using network analysis. Then, all population centers \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(i\\)\u003c/span\u003e\u003c/span\u003e within the catchment areas (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({d}_{ij}\\)\u003c/span\u003e\u003c/span\u003e\u0026le;\u0026#119889;\u003csub\u003e\u0026#119898;\u0026#119886;\u0026#119909;\u003c/sub\u003e) were identified and summed up (\u0026sum;\u0026#119875;\u003csub\u003e\u0026#119894;\u003c/sub\u003e). The sum was set in relation to the bed capacities of the inpatient hospices \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({S}_{j}\\)\u003c/span\u003e\u003c/span\u003e and a supply-demand ratio \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e was formed.\u003c/p\u003e \u003cp\u003eIn the second step, the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e was created. For each population center \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(i\\)\u003c/span\u003e\u003c/span\u003e, a travel time radius of 30 minutes was calculated and then all provider-to-population ratios \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e were summed up. Finally, the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e was formed for each population centroid \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(i\\)\u003c/span\u003e\u003c/span\u003e at the municipal level. The \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e is higher the more beds there are in inpatient hospices, the faster the units can be reached, and the lower the population within a 30-minute radius.\u003c/p\u003e \u003cp\u003e \u003cb\u003eE2SFCA-Methode.\u003c/b\u003e E2SFCA method was applied in the same way as the 2SFCA. The maximum radius of 30 minutes' travel time was additionally divided into three subzones (\u003cem\u003er\u003c/em\u003e\u003csub\u003e\u003cem\u003e1,2,3\u003c/em\u003e\u003c/sub\u003e = 0\u0026ndash;10, 10\u0026ndash;20, 20\u0026ndash;30 minutes). By defining a weighting \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({W}_{r}\\)\u003c/span\u003e\u003c/span\u003e for each subzone, a weighted supply-demand ratio was calculated. Similarly, the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e was summed up in the second step according to the weighting.\u003c/p\u003e \u003cp\u003eThe distance decay function used is based on the original work by Luo and Qi (2009), which employs a Gaussian normal distribution. Two variants were used: a slow distance decay (1.0; 0.68 and 0.22) and sharp distance decay (1.0; 0.42 and 0.03) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCalculation formula of the 2SFCA and E2SFCA method\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStep 1: provider-to-population ratio (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2SFCA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE2SFCA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}=\\frac{{S}_{j}}{\\sum_{i\\in\\left\\{{d}_{ij}\\le{d}_{max}\\right\\}}{P}_{i}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({PPR}_{j}=\\frac{{S}_{j}}{\\sum_{i\\in\\left\\{{d}_{ij}\\le{d}_{max}\\right\\}}{P}_{i}{W}_{r}}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 2: spatial accessibility index (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}=\\sum_{j\\in\\left\\{{d}_{ij}\\le{d}_{max}\\right\\}}{PPR}_{j}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}=\\sum_{j\\in\\left\\{{d}_{ij}\\le{d}_{max}\\right\\}}{PPR}_{j}{W}_{r}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({S}_{j}\\)\u003c/span\u003e\u003c/span\u003e= supply capacity, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({P}_{i}\\)\u003c/span\u003e\u003c/span\u003e=population at location \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(i\\)\u003c/span\u003e\u003c/span\u003e; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({d}_{ij}\\)\u003c/span\u003e\u003c/span\u003e= distance between \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(i\\)\u003c/span\u003e\u003c/span\u003e and \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(j\\)\u003c/span\u003e\u003c/span\u003e; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({d}_{max}\\)\u003c/span\u003e\u003c/span\u003e= maximum radius/maximum catchment size; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({W}_{r}\\)\u003c/span\u003e\u003c/span\u003e= distance decay function/weight\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results are presented as quintiles (Q1-Q5). Municipalities that do not have access to hospices within 30 minutes represent a separate additional category (\u0026ldquo;no access\u0026rdquo;). Based on literature [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], the quintiles were divided into a low (Q1 and Q2), medium (Q3), and high \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e (Q4 and Q5).\u003c/p\u003e \u003cp\u003eAll analyses were conducted using ArcGIS Pro 2.9 (Esri Inc., California, Redlands, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of N\u0026thinsp;=\u0026thinsp;295 hospices with a bed capacity of 3013 and an average capacity of 10 beds (range 2\u0026ndash;16) were identified. Most hospices were listed in the DHPC (n\u0026thinsp;=\u0026thinsp;252), n\u0026thinsp;=\u0026thinsp;43 were added after further research.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eProvider-to-population ratio\u003c/h2\u003e \u003cp\u003e211 of the 401 districts have at least one inpatient hospice. This results in a ratio of 36.4 beds per 1\u0026nbsp;million inhabitants. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the nationwide provider-to-population ratio at district level. Only the federal states of Berlin, Bremen and Hamburg (which are also city states) provide hospices in all districts. Bavaria has the fewest hospice beds with 16.8 beds per 1\u0026nbsp;million inhabitants, Brandenburg the most (64.8 beds per 1\u0026nbsp;million inhabitants; for further information, see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The districts with the most hospice beds per million inhabitants are Pirmasens in Rhineland-Palatinate (298.7), Eisenach in Thuringia (285.9) and Coburg in Bavaria (244.9). Apart from Berlin (n\u0026thinsp;=\u0026thinsp;16), the districts of Hamburg (n\u0026thinsp;=\u0026thinsp;8) and Lippe (n\u0026thinsp;=\u0026thinsp;8) have the most hospice locations within a district.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospice beds in inpatient hospices in Germany by federal state\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFederal state\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospice beds\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInhabitants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBeds per 1\u0026nbsp;million inh.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaden-W\u0026uuml;rttemberg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11,103,043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBavaria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13,140,183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerlin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,664,088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrandenburg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,531,071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBremen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e680,130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHamburg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,852,478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHesse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e228\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6,293,154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMecklenburg-Vorpommern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,610,774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Saxony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8,003,421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth Rhine-Westphalia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17,925,570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhineland-Palatinate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,098,391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaarland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e983,991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaxony\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4,056,941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaxony-Anhalt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,180,684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchleswig-Holstein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,910,875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThuringia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,120,237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGermany\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e83,155,031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e36.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNetwork analysis based on travel time\u003c/h2\u003e \u003cp\u003eThe results of the Germany-wide network analysis shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e indicate regional differences in the timely accessibility of hospices. Their location is particularly concentrated in high population centers (e.g., the Ruhr area or the Rhine-Main area) and larger cities. In more rural districts, hospices are often located in the district capitals (center effect). This effect is visible in many districts in Lower Saxony, for example. In Bavaria and Mecklenburg-Western Pomerania, as well as parts of Rhineland-Palatinate and Saxony-Anhalt, there are many contiguous areas where a hospice cannot be reached within a 30-minute drive. Nevertheless, 58.8% of the population across Germany can reach a hospice within a 15-minute drive by car, while 31.5% need between 15 and 30 minutes to get there. This means that a total of 90.3% can reach a hospice within a 30-minute drive by car. 9.7% of the population need more than 30 minutes to drive to the nearest hospice. The absolute population figures are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercentage and total number of residents living in service areas of different driving times to inpatient hospices\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTravel time (in minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48,865,956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26,171,155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal 0\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75,037,111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7,227,549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e690,687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal 30\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7,918,236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtotal\u0026thinsp;\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e199,684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e83,155,031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFCA methods\u003c/h2\u003e \u003cp\u003eThe results obtained using FCA methods show a heterogeneous pattern. Applying the 2SFCA method yields a very uniform \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e within municipalities located within a 30-minute travel radius of inpatient hospices (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). This results in sharp transitions between municipalities inside and outside the catchment area. In Bavaria in particular, the concentric circles can be defined as catchment areas around the hospice locations, as these are scattered across the entire state. One-third of Bavarian municipalities have no access to a hospice within 30 minutes, while 50% of municipalities have low accessibility (28% in Q1, 22% in Q2). In municipalities with an overlap of several catchment areas of hospice locations, a higher \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e can be observed. Another federal state with a large proportion of municipalities with low accessibility is Baden-W\u0026uuml;rttemberg (Q1\u0026thinsp;+\u0026thinsp;Q2\u0026thinsp;=\u0026thinsp;46%). Federal states with a particularly high proportion of municipalities with high access indices are Brandenburg (71% in Q4 and Q25), Mecklenburg-Western Pomerania (51% in Q4 and Q5), Saarland (81% in Q4 and Q5), and Saxony (63% in Q4 and Q%). In addition, there are federal states in which \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e is distributed almost evenly across the quintiles (Schleswig-Holstein).\u003c/p\u003e \u003cp\u003eAfter applying the E2SFCA method, there are changes in the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). The proportion of municipalities without access (within a 30-minute drive) remains unchanged. The catchment areas of the hospices are graded in \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e according to the weightings applied. Municipalities in the immediate vicinity of the hospices often have high access indices. Peripheral municipalities tend to have low \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e. The transitions to municipalities without access to areas outside the catchment areas appear smoother. This effect is most noticeable where the catchment areas overlap rarely (e.g., Bavaria). The E2SFCA method, particularly with a sharp distance decay function, underlines the geographical proximity to hospice locations. There is an increase in the proportion of municipalities with low access indices and a decrease in Q4 and Q5 in some federal states. This effect is seen particularly in Brandenburg, Saxony-Anhalt, and Thuringia (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In Saxony, too, there is a shift toward medium values, although the proportion with high \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003eremains high (slow distance decay function 48% in Q4 and Q5; sharp distance decay function 37% in Q4 and Q5). In Baden-W\u0026uuml;rttemberg and Bavaria, in contrast, there is a shift from low towards medium \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eShown is spatial accessibility to inpatient hospices in Germany at the municipal level. Results of the Floating Catchment Area methods are presented for a) 2SFCA, b) E2SFCA with slow distance decay, and c) E2SFCA with sharp distance decay. The \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003eis categorized into quintiles: low (Q1, Q2), medium (Q3), and high (Q4, Q5).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProportion of municipalities by accessibility quintile (SPAI\u003csub\u003ei\u003c/sub\u003e) by federal state\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"19\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003e2SFCAM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c13\" namest=\"c8\"\u003e \u003cp\u003eE2SFCAM slow distance decay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c19\" namest=\"c14\"\u003e \u003cp\u003eE2SFCAM sharp distance decay\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eno SPA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eno SPA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eno SPA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c17\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c18\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c19\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e54%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e31%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"19\" nameend=\"c19\" namest=\"c1\"\u003e \u003cp\u003eShown is the proportion of municipalities with low (Q1, Q2), medium (Q3), and high access (Q4, Q5) as well as no access within a 30-minute travel time to inpatient hospices (no SPA), based on the Spatial Accessibility Index (SPAI\u003csub\u003ei\u003c/sub\u003e).\u003c/p\u003e \u003cp\u003e\u003cem\u003eBW=Baden-W\u0026uuml;rttemberg; BY=Bavaria; BE=Berlin; BB=Brandenburg; HB=Bremen; HH=Hamburg; HE=Hesse; MV=Mecklenburg-Western Pomerania; NI=Lower Saxony; NW=North Rhine-Westphalia, RP=Rhineland-Palatinate; SL=Saarland; SN=Saxony; ST=Saxony-Anhalt; SH=Schleswig-Holstein; TH=Thuringia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eProvider-to-population ratio\u003c/h2\u003e \u003cp\u003eThe study is the first national evaluation of spatial accessibility to inpatient hospices in Germany, utilizing various indicators to operationalize spatial accessibility. One of the most applied indicators is the provider-to-population ratio. With 295 hospices and a national provider-to-population ratio of 36.2 beds/1\u0026nbsp;million inhabitants, availability has increased compared to earlier studies (27.3 beds/1\u0026nbsp;million inhabitants in 217 hospices in Melching (2016); 28.2 beds/1\u0026nbsp;million inhabitants in 209 hospices in Jansky et al. (2017); 25.6 beds/1\u0026nbsp;million inhabitants in 206 hospices in Pr\u0026uuml;tz and Sa\u0026szlig; (2017) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The pallCompare Monitor provides approximately similar figures, although the number of hospice beds recorded (2,754 hospice beds) is lower than the figure found in this study (3,023 beds) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Since all earlier studies mentioned refer solely to the DHPC as a database, which did not include all hospice locations, this may have led to an underestimation of availability. The EAPC's reference value of 40\u0026ndash;50 beds/1\u0026nbsp;million inhabitants refers to both beds in inpatient hospices and PCU and is therefore not comparable [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A recent study by the EAPC estimated 1.12 specialist palliative care services per 100,000 inhabitants in Germany, which is above the median in a European comparison (0.96 services per 100,000 inhabitants), but only in the second quintile. Due to our focus on inpatient hospices in this study, it is difficult to compare the results directly. \u0026ldquo;Geographic reach\u0026rdquo;, as an indicator for the provision of specialist palliative care services used in the EAPC Atlas of Palliative Care in the European Region 2025 is rated at the highest level (integrated) for Germany. However, the ratings of \u0026ldquo;geographic reach\u0026rdquo; are based on the assessment of the experts consulted, and measurable accessibility as a spatial component was not included [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Overall, the existing guidelines and recommendations from the DGP and EAPC are based solely on ratios [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This kind of indicator is easy to understand and interpret and may provide a starting point to analyze the healthcare provision situation [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. However, its simplicity limits its validity and does not adequately reflect the healthcare provision situation. Cross-border relationships between neighbouring regions are not taken into account, even though it is well known that people's mobility is not restricted by administrative boundaries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. In addition, the supply is dichotomized. A hospice is only considered accessible if it is located within the administrative unit. Furthermore, it is considered equally accessible regardless of where someone is located within the defined area [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. If the districts cover a very large area, this can result in an overestimation of hospice availability (e.g., Mecklenburg-Western Pomerania or Brandenburg). If, on the other hand, a hospice is located in an urban district (cities which constitute a district in their own right), the surrounding area may appear to have low availability, even though a contributory effect can be assumed (e.g. Bavaria). Choosing the analytical unit therefore implies a certain degree of arbitrariness (Modifiable Area Unit Problem, MAUP) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eNetwork-based travel time\u003c/h2\u003e \u003cp\u003eNetwork-based travel time analysis with GIS, combined with population data, is a frequently used indicator to assess potential accessibility of care facilities. In this study, it was applied for the first time to inpatient hospice care throughout Germany. A large proportion of inhabitants (90.3%) can reach inpatient hospices within 30 minutes by motorized individual transport. Gesell et al. (2023), who examined the accessibility of specialist palliative care services (PCU and PCT) in Germany, reported similarly high results for PCU (86.0%) and PCT (87.2%) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In Switzerland (95.0%), Ireland (84.0%) and Spain (79.0%), large proportions of the population also reach specialist palliative care services within 30 minutes' travel time by private motorized transport, although it is not entirely clear whether inpatient hospices were included in this study [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. By taking into account the transport infrastructure and topographical conditions, network analyses are generally more valid than the use of Euclidean distance (as the crow flies) as in Wiese et al. (2010) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, this indicator also has some limitations. Information on availability and demand competition is not taken into account. In addition, the restriction to motorized private transport leads to a bias [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In Germany, 77.3% of private households have at least one car and car-sharing services are increasingly available [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. However, general mobility decreases with increasing age. People over the age of 80 in particular are dependent on alternative mode of transportation (public transport, on-call buses, shared cabs) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. In addition, the perception of distance changes among older people, and their willingness to travel further distances decreases [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Relying on public transport can aggravate the situation, especially in rural areas [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. There is no nationwide study in the hospice and palliative care context, but Weinhold et al. (2022) estimate that 21% of the population in Saxony can reach inpatient hospices by public transport in 30 minutes and 51% in 60 minutes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFCA Methods\u003c/h2\u003e \u003cp\u003eBy taking availability and accessibility into account, the 2SFCA is an important basic method for adequately mapping spatial accessibility [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. We applied the 2SFCA and E2SFCA methods to inpatient hospices in Germany for the first time, providing a more complex methodological approach to investigate spatial accessibility. Previously, studies have only been carried out at federal state level in Saxony, which showed quite similar results regarding the distribution pattern of the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In terms of accessibility, using flexible catchment areas based on hospice and population locations is a step forward compared to the orientation towards fixed administrative boundaries. This allows the mobility behavior of the population (cross-border service-seeking behavior) to be mapped more realistically. This is particularly relevant for regions close to the border, such as between the federal states of Baden-W\u0026uuml;rttemberg and Bavaria, where there is a clustering of hospice locations and high accessibility indices. At the same time, demand competition can be taken into account by considering the overlap of catchment areas and availability of hospice beds. The data used as a demand population is also relevant. The general population was used here as we considered both patients and relatives as a demand population. Other studies used the entire deceased population [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] or deceased cancer patients as a potential demand population [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Another limitation of the 2SFCA is the dichotomous approach to catchment areas, in other words the assumption that all areas are considered equally accessible, which generates hard transitions in the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003ebetween communities inside and outside the catchment area. In addition, the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003ein the periphery of a catchment area is overestimated due to overlapping catchment areas [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUsing E2SFCA, a differentiation within the catchment areas is achieved by applying a distance decay function. A concentric pattern is created, with high access indices near the hospice locations and lower values in peripheral areas. This pattern is particularly prominent using sharp distance decay function. Slow distance decay function causes a smoothing effect. Compared to 2SFCA, it is an important step towards operationalizing spatial access more realistically [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. In areas with low density of inpatient hospices, application of E2SFCA causes more changes in the \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003ecompared to 2SFCA. High accessibility indices occur in proximity to inpatient hospices. In areas where many hospices are clustered, accessibility indices change less (e.g. Saarland, Ruhr area, city states) compared to areas with a lower density of hospices. These are mostly urban areas where the population density is high and the supply-demand situation is complex. In a similar study on PCU, we Petzold et al. (2025) linked the municipalities with a city and municipality classification of the Federal Institute for Research on Building, Urban Affairs, and Spatial Development (BBSR). The proportion of municipalities without access within 30 min in rural municipalities was higher than in urban municipalities, while access indices in urban areas tended to be higher overall [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. A lower availability of hospice and palliative care services in low-population areas with an older population is also described in other German [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] and international studies [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Finally, it is open to debate which form of distance decay function is most suitable for hospice and palliative care when using E2SFCA-method. Similar arguments to those used in discussing maximum travel time radius may be applied to this question. On the one hand, it is a highly specialist care area that is only used by a small group of people, similar to highly specialist oncological or other care, which suggests a slow distance decay function [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the other hand, as previously discussed, end-of-life care is a particularly sensitive area where long travel times are less acceptable for patients and relatives. Overall, the results of the FCA methods are less intuitive to interpret, but the methodology is considered as most suitable for operationalizing spatial access to healthcare services [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Many studies use the methodology for descriptive purposes only, but some also use it as a potential explanatory variable for health purposes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsequently, the definition of a travel time of 30 min is a critical parameter that needs to be discussed. This applies to both network-based travel time and FCA methods, as network-based travel time forms the methodical basis for operationalizing travel time or accessibility in FCA methods. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. There are no regulatory requirements for the maximum size of catchment areas or valid data on actual catchment areas of hospices in Germany. Other German studies used 30 min and 60 min as the maximum travel time to care providers of specialist palliative care [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In Great Britain, which is very similar to the German distance dimensions, a maximum of 30 minutes was also considered acceptable [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], whereas in spacious Canada 60 minutes were considered appropriate [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Hospice and palliative care is a particularly sensitive area of healthcare where care should be provided close to home or the familiar living environment [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Long transportation routes can prevent unstable, vulnerable and burdened patients from being transferred to a hospice. Frequent visits by relatives in the last period of life can support patients emotionally, psychologically and existentially. Relatives are often involved in the decision-making process regarding changes to treatment goals as proxy caregivers and are crucial for successful symptom relief [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. However, relatives themselves may experience high stress levels [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e], resulting in long travel times to be challenging. Emotions such as sadness, anger, stress, anxiety, fatigue and overall grief can have a negative impact on the ability to drive [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. However, it was argued that travel times of 60 min to inpatient hospices can be considered just as justified as to other specialist facilities [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and outlook\u003c/h2\u003e \u003cp\u003eAs already discussed, the study limited travel time to a maximum of 30 minutes. A sensitivity analysis with an extension of maximum travel time could provide additional information. An extension of the analysis to consider public transportation would also be useful. Complete coverage of all inpatient hospices cannot be guaranteed, as the study shows that entries in the DHPC can be incomplete. A limiting factor is the assumption that patients potentially use the hospice closest to their place of residence, and that their relatives live in the immediate neighborhood. Due to socio-demographic and social developments as well as globalization and migration processes, grown-up children are living at greater distances to their ageing parents. Long-distance caregiving is therefore becoming increasingly important [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e], and patients may chose an inpatient hospice closer to their relatives place residence, instead of their own. Furthermore, a maximum travel time of 30 minutes may also be relevant for friends, neighbors and other important people from the patients' original neighborhood.\u003c/p\u003e \u003cp\u003eIn addition, using different aggregation levels of administrative areas or population data leads to inequalities in the presentation. In case of provider-to-population ratios, a calculation and presentation at municipality level would be too small-scale. Conversely, using population data at district level would be too large-scale for FCA and network-based travel time methods, which require smaller-scale population data, e.g. at grid cell level (1 km or 100 m grid) to yield more precise results. At the time of conducting the analysis, the 2022 census data at grid cell level was not yet available. This would also have allowed including further socio-demographic characteristics, such as the proportion of over 65-year-olds in the population, and thus a more precise mapping of potential hospice patients. As such data was not available at municipal level at the time of analysis, the overall population was used, which can lead to biases in view of regional differences in age structure.\u003c/p\u003e \u003cp\u003eOnly a selection of indicators for operationalizing spatial access were presented and applied in this article. The 2SFCA method and E2SFCA method are two out of numerous, increasingly complex FCA methods. Meanwhile, there are many other methods that include numerous additional parameters and are able to model an even more realistic view of supply situations. However, these models are more complex and require an extensive presentation and discussion of methods that, in the end, will only be useful for very detailed use, but not for general consideration of stakeholders in the healthcare system [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the study of potential spatial accessibility to inpatient hospices is based on theoretical considerations, for example, the number of beds indicates only theoretical availability [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. Observations from practice have shown that there are often long waiting lists in hospices in Germany and the demand for beds is high [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. A Canadian study integrated waiting times when using the 2SFCA [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Further, for a more realistic mapping of care situations, an intersectoral analysis of all existing palliative and hospice care structures in Germany should be conducted. Compared to other patient groups, it is not very useful to focus on individual groups of care structures, as the treatment pathways are very complex and cross-professional. In addition, taking into account the actual occupancy situation, possible capacity restrictions due to e.g. staff shortages, or patient waiting times due to high utilization, demographic characteristics (e.g. high regional average age, proportion of people with a migration history), socio-economic factors (e.g. proportion of single households) and utilization data can help to identify areas with low access and identify gaps in care. Quantitative and qualitative surveys of patients on realized travel times and their reasonability could provide valuable information on patient preferences. A complex (cross-sectoral) access analysis, taking into account other dimensions of access, can contribute to an improvement in the planning of hospice and palliative care close to home.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined the spatial accessibility of inpatient hospices in Germany using different indicators. The results show high spatial accessibility, but also illustrate that the chosen method has a considerable influence on the results. The decisive factor is which target group is to be addressed. In principle, studies on spatial accessibility to healthcare services should also take into account accessibility and mobility factors, as availability alone does not adequately reflect the spatial dimension of access to healthcare services. Methods of health geography add great value and contribute to an improvement in the planning of palliative care services. Considering demographic change and increasing demand for hospice and palliative care, this research perspective is highly relevant.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e2SFCAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTwo-Step floating catchment area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBKG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFederal Agency for Cartography and Geodesy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBBSR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFederal Institute for Research on Building, Urban Affairs, and Spatial Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGerman Association for Palliative Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDHPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirectory for Hospice and Palliative Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eE2SFCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnhanced Two-Step floating catchment area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEAPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Association for Palliative Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFloating catchment area\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAUP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eModifiable Area Unit Problem\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprovider-to-population ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehome palliative care teams\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epalliative care units\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({SPAI}_{i}\\)\u003c/span\u003e\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpatial accessibility index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026lsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have substantially contributed to the conception of the work. TP developed the idea for the study, conducted the analysis and wrote the manuscript. FN, JA, CB, BJ and MJ advised the analysis, contributed to the manuscript and revised it critically for important intellectual content. All authors approved the final version to be published and gave their agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article. Open Access funding enabled and organized by Projekt DEAL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be obtained from the corresponding author on reasonable request. Data on geographic information are freely available from the Service Center of the Federal Agency for Cartography and Geodesy at: https://gdz.bkg.bund.de/index.php/default/open-data.html\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. Ethics approval was not required for the use of the datasets because it was based on public data. No human data was included in this study, no personal information were used, and therefore consent to participate is not applicable. All data utilized was publicly available data and address data of institutions and no administrative permissions were required to access the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuagliardo MF. Spatial accessibility of primary care: concepts, methods and challenges. Int J Health Geogr. 2004;3(1):3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1476-072X-3-3\u003c/span\u003e\u003cspan address=\"10.1186/1476-072X-3-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePenchansky R, Thomas JW. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Med Care. 1981;19(2):127\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1475-9276-12-18\u003c/span\u003e\u003cspan address=\"10.1186/1475-9276-12-18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePugh A, Castleden H, Giesbrecht M, Davison C, Crooks V. Awareness as a dimension of health care access: exploring the case of rural palliative care provision in Canada. J Health Serv Res Policy. 2019;24(2):108\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1355819619829782\u003c/span\u003e\u003cspan address=\"10.1177/1355819619829782\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchweikart J, Kistemann T. Erkenntnisgewinn einer r\u0026auml;umlichen Betrachtung von Gesundheit. In: Augustin J, Koller D, editors. Geografie der Gesundheit. Die r\u0026auml;umliche Dimension von Epidemiologie und Versorgung. Bern: Hogrefe; 2017. pp. 15\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAugustin J, Andrees V, Walsh D, Reintjes R, Koller D. Spatial Aspects of Health\u0026mdash;Developing a Conceptual Framework. Int J Environ Res Public Health. 2023;20(3):1817. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph20031817\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20031817\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenry KA, McDonald K. Geographic Access to Health Services. In: Boscoe FP, editor. Geographic health data: fundamental techniques for analysis. Oxfordshire, Boston: CAB International; 2013. pp. 142\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaggerty JL, Roberge D, L\u0026eacute;vesque JF, Gauthier J, Loignon C. An exploration of rural\u0026ndash;urban differences in healthcare-seeking trajectories: Implications for measures of accessibility. Health Place. 2014;28:92\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.healthplace.2014.03.005\u003c/span\u003e\u003cspan address=\"10.1016/j.healthplace.2014.03.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoigtl\u0026auml;nder S, Deiters T. Mindeststandards f\u0026uuml;r die r\u0026auml;umliche Erreichbarkeit haus\u0026auml;rztlicher Versorgung: Ein systematischer Review. Gesundheitswesen. 2015;77(12):949\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0035-1548805\u003c/span\u003e\u003cspan address=\"10.1055/s-0035-1548805\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStentzel U, Hoffmann W, Von Den Berg N. (2017) Mobilit\u0026auml;tsanalysen in der Gesundheitsforschung. In: Augustin J, Koller D, editor. Geografie der Gesundheit. Die r\u0026auml;umliche Dimension von Epidemiologie und Versorgung. Bern: Hogrefe Verlag; 2017. 81\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAugustin J, Austermann J, Erasmi S. Netzwerkanalysen in der regionalen Versorgungsforschung: Das Beispiel der dermatologischen Versorgung in der Metropolregion Hamburg. Gesundheitswesen 2019 81:50\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0042-116591\u003c/span\u003e\u003cspan address=\"10.1055/s-0042-116591\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrohmann J, V\u0026ouml;lker S, Augustin J, Rauch S, Stenzel U. Gute Praxis Erreichbarkeitsanalyse im Gesundheitswesen (GPEG). 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bbsr.bund.de/BBSR/DE/veroeffentlichungen/bbsr-online/2023/bbsr-online-26-2023-dl.pdf?__blob=publicationFile\u0026amp;v=2\u003c/span\u003e\u003cspan address=\"https://www.bbsr.bund.de/BBSR/DE/veroeffentlichungen/bbsr-online/2023/bbsr-online-26-2023-dl.pdf?__blob=publicationFile\u0026amp;v=2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 09 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo W, Wang F. Measures of Spatial Accessibility to Health Care in a GIS Environment: Synthesis and a Case Study in the Chicago Region. Environ Plann B Plann Des. 2003;30(6):865\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1068/b29120\u003c/span\u003e\u003cspan address=\"10.1068/b29120\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo W, Qi Y. An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health Place. 2009;15(4):1100\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.healthplace.2009.06.002\u003c/span\u003e\u003cspan address=\"10.1016/j.healthplace.2009.06.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStacherl B, Sauzet O. Gravity models for potential spatial healthcare access measurement: a systematic methodological review. Int J Health Geogr. 2023;22(1):34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12942-023-00358-z\u003c/span\u003e\u003cspan address=\"10.1186/s12942-023-00358-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan N, Zou B, Sternberg T. A three-step floating catchment area method for analyzing spatial access to health services. Int J Geogr Inf Sci. 2012;26(6):1073\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13658816.2011.624987\u003c/span\u003e\u003cspan address=\"10.1080/13658816.2011.624987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer J, Groneberg DA. Measuring Spatial Accessibility of Health Care Providers \u0026ndash; Introduction of a Variable Distance Decay Function within the Floating Catchment Area (FCA) Method. PLoS ONE. 2016;11(7):e0159148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0159148\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0159148\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ\u0026ouml;rg R, Lenz N, Wetz S, Widmer M. Jan. Ein Modell zur Analyse der Versorgungsdichte. Herleitung eines Index zur r\u0026auml;umlichen Zug\u0026auml;nglichkeit mithilfe von GIS und Fallstudie zur ambulanten Grundversorgung in der Schweiz. Neuch\u0026acirc;tel: Schweizerisches Gesundheitsobservatorium (Obsan); 2019 Report No.: 01/2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.obsan.admin.ch/de/publikationen/2019-ein-modell-zur-analyse-der-versorgungsdichte\u003c/span\u003e\u003cspan address=\"https://www.obsan.admin.ch/de/publikationen/2019-ein-modell-zur-analyse-der-versorgungsdichte\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 05 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrennan F. Palliative care as an international human right. J Pain Symptom Manage. 2007;33(5):494\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpainsymman.2007.02.022\u003c/span\u003e\u003cspan address=\"10.1016/j.jpainsymman.2007.02.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzer T, Lohman D, de Luca GB. Palliative Care and Human Rights: A Decade of Evolution in Standards. J Pain Symptom Manage. 2018;55(2S):163\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpainsymman.2017.03.027\u003c/span\u003e\u003cspan address=\"10.1016/j.jpainsymman.2017.03.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Palliative care. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/palliative-care\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/palliative-care\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, Arreola-Ornelas H, G\u0026oacute;mez-Dant\u0026eacute;s O, Rodriguez NM, Alleyne GAO, Connor SR, Hunter DJ, Lohman D, Radbruch L, Del Roc\u0026iacute;o S\u0026aacute;enz Madrigal M, Atun R, Foley KM, Frenk J, Jamison DT, Rajagopal MR, Lancet Commission on Palliative Care and Pain Relief Study Group. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018; 391(10128):1391\u0026ndash;1454. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(17)32513-8\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(17)32513-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarralda-Domezain E, Tripodoro VA, Ling J, Brennan J, Montero-Calero A, Bastos F et al. EAPC Atlas of Palliative Care in the European region 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hdl.handle.net/10171/116281\u003c/span\u003e\u003cspan address=\"https://hdl.handle.net/10171/116281\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePr\u0026uuml;tz F, Sa\u0026szlig; AC. Data on palliative care in Germany: which data sources are available and what do they tell? [Daten zur Palliativversorgung in Deutschland Welche Datenquellen gibt es, und was sagen sie aus?]. Bundesgesundheitsbl. 2017;60:26\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00103-016-2483-8\u003c/span\u003e\u003cspan address=\"10.1007/s00103-016-2483-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScholten N, G\u0026uuml;nther AL, Pfaff H, Karbach U. The size of the population potentially in need of palliative care in Germany - an estimation based on death registration data. BMC Palliat Care. 2016;15(1):29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12904-016-0099-2\u003c/span\u003e\u003cspan address=\"10.1186/s12904-016-0099-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimon ST, Gomes B, Koeskeroglu P, Higginson IJ, Bausewein C. Population, mortality and place of death in Germany (1950\u0026ndash;2050) \u0026ndash; Implications for end-of-life care in the future. Public Health. 2012;126(11):937\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.puhe.2012.06.014\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2012.06.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathers CD, Stevens GA, Boerma T, White RA, Tobias MI. Causes of international increases in older age life expectancy. Lancet. 2015;385(9967):540\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(14)60569-9\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(14)60569-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNauck F. Palliativmedizin - Aktueller Stand in Klinik, Forschung und Lehre. Klinikarzt. 2018;47(8):348\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-0656-9107\u003c/span\u003e\u003cspan address=\"10.1055/a-0656-9107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayne S, Harding A, Williams T, Ling J, Ostgathe C. Revised recommendations on standards and norms for palliative care in Europe from the European Association for Palliative Care (EAPC): A Delphi study. Palliat Med. 2022;36(4):680\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/02692163221074547\u003c/span\u003e\u003cspan address=\"10.1177/02692163221074547\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGKV-Spitzenverband. Framework agreement pursuant to Section 39a (1) sentence 4 of the German Social Code Book V (SGB V) on the nature, scope and quality assurance of inpatient hospice care. Version of 18 November 2024 (originally issued 13 March. 1998). Berlin: GKV-Spitzenverband; 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/hospiz_palliativversorgung/2024-11-18_Rahmenvereinbarung_39a_Abs1_Satz_4__SGB_V_stat_Hospizversorgung_Erw.pdf\u003c/span\u003e\u003cspan address=\"https://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/hospiz_palliativversorgung/2024-11-18_Rahmenvereinbarung_39a_Abs1_Satz_4__SGB_V_stat_Hospizversorgung_Erw.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStiel S, Oechsle K, Doll A, Strupp J, Herbst FA, Ullrich A. f\u0026uuml;r die AG Angeh\u0026ouml;rige der DGP. Bed\u0026uuml;rfnisse, Probleme und Bedarfe von Angeh\u0026ouml;rigen in der Palliativversorgung. Z f\u0026uuml;r Palliativmedizin. 2024;25(04):172\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org./10.1055/a-2322-8218\u003c/span\u003e\u003cspan address=\"https://doi.org./10.1055/a-2322-8218\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Uuml;lg\u0026uuml;t R, Stiel S, Herbst FA. Experiences and support needs of informal long-distance caregivers at the end of life: a scoping review. BMJ Open. 2023;13(4):e068175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2022-068175\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2022-068175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarshall C, Virdun C, Phillips JL. Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis. Palliat Med 1. 2024;38(9):935\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0269216324126979\u003c/span\u003e\u003cspan address=\"10.1177/0269216324126979\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDitscheid B, Meissner F, Gebel C, Hennig B, Marschall U, Mei\u0026szlig;ner W, Wedding U, Freytag A. Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016\u0026ndash;2019) und regionale Variabilit\u0026auml;t. Bundesgesundheitsbl. 2023;66(4):432\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00103-023-03683-7\u003c/span\u003e\u003cspan address=\"10.1007/s00103-023-03683-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobert Koch Institute. Palliative care. Health in Germany. Health reporting of the federal government. Berlin: Robert Koch Institute; 2015. pp. 332\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Berg N, Rehner L, Hoffmann W. Die Hospiz- und Palliativversorgung in Mecklenburg-Vorpommern. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medizin.uni-greifswald.de/versorgungsepidemiologie/fileadmin/user_upload/Berichte/Bericht_Hospiz-und_Palliativversorgung_07.10.2019.pdf\u003c/span\u003e\u003cspan address=\"https://www.medizin.uni-greifswald.de/versorgungsepidemiologie/fileadmin/user_upload/Berichte/Bericht_Hospiz-und_Palliativversorgung_07.10.2019.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 02 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinhold I, Thiesen J, Fa\u0026szlig; E, M\u0026uuml;ller M, Claus F, Kliemt R, Stark S, Samartzidis L, Fink C, H\u0026auml;ckl D. Hospiz- und Palliativbericht Sachsen 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pflegenetz.sachsen.de/download/HPB22.pdf\u003c/span\u003e\u003cspan address=\"https://www.pflegenetz.sachsen.de/download/HPB22.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 02 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJansky M, Nauck F, Jaspers B. Gutachten zum Bedarf an Hospizbetten in Nordrhein-Westfalen. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.hospiz-nrw.de/files/gutachten_bedarf_hospizbetten_nrw_2017-1.pdf\u003c/span\u003e\u003cspan address=\"http://www.hospiz-nrw.de/files/gutachten_bedarf_hospizbetten_nrw_2017-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 07 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHesse M, Ates G. Hospiz- und Palliativversorgung in Rheinland-Pfalz: Gutachten im Auftrag des Ministeriums f\u0026uuml;r Soziales, Arbeit, Gesundheit und Demografie des Landes Rheinland-Pfalz (MSAGD). 2017.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mwg.rlp.de/fileadmin/15/Abteilung_2_Gesundheit/Krankenhauswesen/Hospizliche_und_palliative_Versorgung_in_Rheinland-Pfalz/Gutachten_Palliativversorgung.pdf\u003c/span\u003e\u003cspan address=\"https://mwg.rlp.de/fileadmin/15/Abteilung_2_Gesundheit/Krankenhauswesen/Hospizliche_und_palliative_Versorgung_in_Rheinland-Pfalz/Gutachten_Palliativversorgung.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 10 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeiz M, Moon K, Rehner LK, Stentzel U, Radicke F, Hoffmann W, van den Berg N. Population-based, spatial analysis of specialised ambulatory palliative care in Mecklenburg-western Pomerania, Germany, on the basis of reimbursement data. Int J Environ Res Public Health. 2023;20:2231. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph20032231\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20032231\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Baal K, Stiel S, Hemmerling M, Stahmeyer JT, Wiese B, Schneider N, Afshar K. Ambulante Palliativversorgung in Niedersachsen\u0026ndash;regionale Unterschiede in der Versorgung von Menschen am Lebensende anhand von Qualit\u0026auml;tsindikatoren. In: Versorgungsatlas vol. 21/4. Berlin: Zentralinstitut f\u0026uuml;r die kassen\u0026auml;rztliche Versorgung in Deutschland 2021:1\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.20364/VA-21.04\u003c/span\u003e\u003cspan address=\"10.20364/VA-21.04\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMumm R, Fa\u0026szlig; E, Thie\u0026szlig;en J, Stark S. Jan. Hospiz- und Palliativbericht Hessen 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://familie.hessen.de/sites/familie.hessen.de/files/2025-10/hospiz-und_palliativbericht_hessen_2024_1.pdf\u003c/span\u003e\u003cspan address=\"https://familie.hessen.de/sites/familie.hessen.de/files/2025-10/hospiz-und_palliativbericht_hessen_2024_1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 05 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGesell D, Hodiamont F, Bausewein C, Koller D. Accessibility to specialist palliative care services in Germany: a geographical network analysis. BMC Health Serv Res. 2023;23(1):786. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-023-09751-7\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-09751-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelching H. Faktencheck Gesundheit Palliativversorgung - Modul 2- Strukturen und regionale Unterschiede in der Hospiz- und Palliativversorgung. Bertelsmann Stiftung; 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bertelsmann-stiftung.de/de/publikationen/publikation/did/faktencheck-palliativversorgung-modul-2\u003c/span\u003e\u003cspan address=\"https://www.bertelsmann-stiftung.de/de/publikationen/publikation/did/faktencheck-palliativversorgung-modul-2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 05 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003epallCompare Monitor Hospiz- und Palliativversorgung. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bifg.de/projekte/pallcompare/interaktive-grafiken-pallcompare/hospizliches-und-palliatives-versorgungsangebot-wegweiser-diagramm\u003c/span\u003e\u003cspan address=\"https://www.bifg.de/projekte/pallcompare/interaktive-grafiken-pallcompare/hospizliches-und-palliatives-versorgungsangebot-wegweiser-diagramm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiese CHR, Zausig YA, Vormelker J, Orso S, Graf BM, Hanekop GG. Ambulante und station\u0026auml;re palliativmedizinische Patientenversorgung in Deutschland. Anaesthesist. 2010;59(2):162\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00101-009-1651-8\u003c/span\u003e\u003cspan address=\"10.1007/s00101-009-1651-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGatrell AC, Wood DJ. Variation in geographic access to specialist inpatient hospices in England and Wales. Health Place. 2012;18:832\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.healthplace.2012.03.009\u003c/span\u003e\u003cspan address=\"10.1016/j.healthplace.2012.03.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChukwusa E, Yu P, Verne J, Taylor R, Higginson IJ, Wei G. Regional variations in geographic access to inpatient hospices and Place of death: A Population-based study in England, UK. PLoS ONE. 2020;15(4):e0231666. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0231666\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0231666\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCinnamon J, Schuurman N, Crooks VA. A method to determine spatial access to specialized palliative care services using GIS. BMC Health Serv Res. 2008;8:140. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6963-8-140\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-8-140\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Steijn D, Pons Izquierdo JJ, Garralda Domezain E, S\u0026aacute;nchez-C\u0026aacute;rdenas MA, Centeno Cort\u0026eacute;s C. Population\u0026rsquo;s Potential Accessibility to Specialized Palliative Care Services: A Comparative Study in Three European Countries. Int J Environ Res Public Health. 2021;18(19):10345. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph181910345\u003c/span\u003e\u003cspan address=\"10.3390/ijerph181910345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetzold T, Nauck F, Banse C, Augustin J, Jansky M. R\u0026auml;umlicher Zugang zu Palliativstationen in Deutschland: Integrierte Analyse von Verf\u0026uuml;gbarkeit und Erreichbarkeit mittels E2SFCA-Methode. Bundesgesundheitsbl. 2025;68(10):1128\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00103-025-04124-3\u003c/span\u003e\u003cspan address=\"10.1007/s00103-025-04124-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDirectory for Hospice and Palliative Care. Inpatient hospices 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wegweiser-hospiz-palliativmedizin.de/\u003c/span\u003e\u003cspan address=\"https://www.wegweiser-hospiz-palliativmedizin.de/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFederal Agency for Cartography and Geodesy. Administrative regions of the Federal Republic of Germany 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gdz.bkg.bund.de/index.php/default/verwaltungsgebiete-1-250-000-mit-einwohnerzahlen-stand-31-12-vg250-ew-31-12.html\u003c/span\u003e\u003cspan address=\"https://gdz.bkg.bund.de/index.php/default/verwaltungsgebiete-1-250-000-mit-einwohnerzahlen-stand-31-12-vg250-ew-31-12.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 Nov 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026aacute;nchez-C\u0026aacute;rdenas MA, Garralda E, Ben\u0026iacute;tez E, Arias-Casais N, van Steijn D, Centeno C. Palliative Care Coverage across European National Health Systems: Proposal of a Synthetic Indicator. Int J Environ Res Public Health. 2021;18:10753. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph182010753\u003c/span\u003e\u003cspan address=\"10.3390/ijerph182010753\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundmacher L, Schang. Sch\u0026uuml;ttig. Gutachten zur Weiterentwicklung der Bedarfsplanung i.S.d. \u0026sect;\u0026sect; 99 ff. SGB V zur Sicherung der vertrags\u0026auml;rztlichen Versorgung. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.g-ba.de/downloads/39-261-3493/2018-09-20_Endbericht-Gutachten-Weiterentwickklung-Bedarfsplanung.pdf\u003c/span\u003e\u003cspan address=\"https://www.g-ba.de/downloads/39-261-3493/2018-09-20_Endbericht-Gutachten-Weiterentwickklung-Bedarfsplanung.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 05 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrake C, Nagy D, Nguyen T, Kraemer KL, Mair C, Wallace D, Donohue J. A comparison of methods for measuring spatial access to health care. Health Serv Res. 2021;56(5):777\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1475-6773.13700\u003c/span\u003e\u003cspan address=\"10.1111/1475-6773.13700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGrail MR, Humphreys JS. Measuring spatial accessibility to primary care in rural areas: Improving the effectiveness of the two-step floating catchment area method. Appl Geogr. 2009;29(4):533\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.apgeog.2008.12.003\u003c/span\u003e\u003cspan address=\"10.1016/j.apgeog.2008.12.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah TI, Bell S, Wilson K. Spatial Accessibility to Health Care Services: Identifying under-Serviced Neighbourhoods in Canadian Urban Areas. PLoS ONE. 2016;11(12):e0168208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0168208\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0168208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong D. The Modifiable Areal Unit Problem (MAUP). In: Fotheringham AS, Rogerson PA, editors. The SAGE Handbook of Spatial Analysis. London: SAGE Publications Ltd; 2009. pp. 105\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmweltbundesamt. Mobilit\u0026auml;t privater Haushalte. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.umweltbundesamt.de/daten/private-haushalte-konsum/mobilitaet-privater-haushalte#-hoher-motorisierungsgrad\u003c/span\u003e\u003cspan address=\"https://www.umweltbundesamt.de/daten/private-haushalte-konsum/mobilitaet-privater-haushalte#-hoher-motorisierungsgrad\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 05 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuhnimhof T, Nobis C, Hillmann K, Follmer R, Eggs J. Ver\u0026auml;nderungen im Mobilit\u0026auml;tsverhalten zur F\u0026ouml;rderung einer nachhaltigen Mobilit\u0026auml;t. Umweltbundesamt. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://elib.dlr.de/133798/1/2019-08-29-texte_101-2019_mobilitaetsverhalten.pdf\u003c/span\u003e\u003cspan address=\"https://elib.dlr.de/133798/1/2019-08-29-texte_101-2019_mobilitaetsverhalten.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTao Z, Cheng Y. Modelling the spatial accessibility of the elderly to healthcare services in Beijing, China. Environ Plan B Urban Anal City Sci. 2019;46(6):1132\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2399808318755145\u003c/span\u003e\u003cspan address=\"10.1177/2399808318755145\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinhold I, Wende D, Schrey C, Militzer-Horstmann C, Schang L, Sundmacher L. Assessing patients\u0026rsquo; acceptable and realised distances to determine accessibility standards for the size of catchment areas in outpatient care. Health Policy. 2022;126(11):1180\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.healthpol.2022.08.011\u003c/span\u003e\u003cspan address=\"10.1016/j.healthpol.2022.08.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStentzel U, Piegsa J, Fredrich D, Hoffmann W, van den Berg N. Accessibility of general practitioners and selected specialist physicians by car and by public transport in a rural region of Germany. BMC Health Servi Res. 2016;16(1):587. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-016-1839-y\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1839-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRauch S, Stangl S, Haas T, Rauh J, Heuschmann PU. Spatial inequalities in preventive breast cancer care: A comparison of different accessibility approaches for prevention facilities in Bavaria. Ger J Transp Health. 2023;29:101567. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jth.2023.101567\u003c/span\u003e\u003cspan address=\"10.1016/j.jth.2023.101567\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGrail MR. Spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements. Int J Health Geogr. 2012;11(1):50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1476-072X-11-50\u003c/span\u003e\u003cspan address=\"10.1186/1476-072X-11-50\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApolinarski B, Stiel S, Herbst FA, Geyer S. D\u0026uuml;nn in der Fl\u0026auml;che? Regionale Disparit\u0026auml;ten in der Hospiz- und Palliativversorgung in Deutschland. Z Evid Fortbild Qual Gesundhwes. 2024;190\u0026ndash;191:53\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.zefq.2024.07.007\u003c/span\u003e\u003cspan address=\"10.1016/j.zefq.2024.07.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTobin J, Rogers A, Winterburn I, Tullie S, Kalyanasundaram A, Kuhn I, Barclay S. Hospice care access inequalities: a systematic review and narrative synthesis. BMJ Supportive Palliat Care. 2022;12(2):142\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjspcare-2020-002719\u003c/span\u003e\u003cspan address=\"10.1136/bmjspcare-2020-002719\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeutsche Gf\u0026uuml;r. Palliativmedizin, Deutscher Hospiz- und Palliativverband e.V. Charta zur Betreuung schwerstkranker und sterbender Menschen in Deutschland. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.charta-zur-betreuung-sterbender.de/files/dokumente/2020_Charta%20Broschuere_Stand_Jan2020.pdf\u003c/span\u003e\u003cspan address=\"https://www.charta-zur-betreuung-sterbender.de/files/dokumente/2020_Charta%20Broschuere_Stand_Jan2020.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 07 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBundesministerium f\u0026uuml;r Gesundheit. Gesetz zur Verbesserung der Hospiz- und Palliativversorgung in Deutschland (Hospiz- und Palliativgesetz, HPG). [Internet]. BGBL 2015 I Nr. 48 Dec 7. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/detail/hospiz-und-palliativgesetz-hpg.html\u003c/span\u003e\u003cspan address=\"https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/detail/hospiz-und-palliativgesetz-hpg.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 19 Jan 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoley G. The supportive relationship between palliative patients and family caregivers. BMJ Supportive Palliat Care. 2018;8(2):184\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjspcare-2017-001463\u003c/span\u003e\u003cspan address=\"10.1136/bmjspcare-2017-001463\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOechsle K. Current Advances in Palliative \u0026amp; Hospice Care: Problems and Needs of Relatives and Family Caregivers During Palliative and Hospice Care-An Overview of Current Literature. Med Sci. 2019;7(3):43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/medsci7030043\u003c/span\u003e\u003cspan address=\"10.3390/medsci7030043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenblatt PC. Grieving While Driving. Death Stud. 2004;28(7):679\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/07481180490476533\u003c/span\u003e\u003cspan address=\"10.1080/07481180490476533\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJallais C, Gabaude C, Paire-ficout L. When emotions disturb the localization of road elements: Effects of anger and sadness. Transp Res Part F: Traffic Psychol Behav. 2014;23:125\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.trf.2013.12.023\u003c/span\u003e\u003cspan address=\"10.1016/j.trf.2013.12.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaga\u0026ntilde;a VC, Scherz WD, Seepold R, Madrid NM, Pa\u0026ntilde;eda XG, Garcia R. The Effects of the Driver\u0026rsquo;s Mental State and Passenger Compartment Conditions on Driving Performance and Driving Stress. Sensors. 2020;20(18):5274. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/s20185274\u003c/span\u003e\u003cspan address=\"10.3390/s20185274\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchang L, Kopetsch T, Sundmacher L. Zur\u0026uuml;ckgelegte Wegzeiten in der ambulanten \u0026auml;rztlichen Versorgung in Deutschland. Bundesgesundheitsbl. 2017;60:1383\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00103-017-2643-5\u003c/span\u003e\u003cspan address=\"10.1007/s00103-017-2643-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerbst FA, Stiel S. Has Anyone Been There Now? An Interview Study on the Support Experiences and Unmet Needs of Informal Long-Distance Caregivers for Patients at the End of Life. Omega-J Death Dying. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/00302228241243110\u003c/span\u003e\u003cspan address=\"10.1177/00302228241243110\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFransen K, Neutens T, De Maeyer P, Deruyter G. A commuter-based two-step floating catchment area method for measuring spatial accessibility of daycare centers. Health Place. 2015;32:65\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.healthplace.2015.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.healthplace.2015.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiese M. Entscheidungsfindung zur Priorisierung von Aufnahmeanfragen f\u0026uuml;r station\u0026auml;re Hospize. Z Palliativmed. 2024;25(04):189\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-2256-8729\u003c/span\u003e\u003cspan address=\"10.1055/a-2256-8729\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuurman N, Amram O, Crooks VA, Johnston R, Williams A. A comparative analysis of potential spatio-temporal access to palliative care services in two Canadian provinces. BMC Health Serv Res. 2015;15(1):270. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-015-0909-x\u003c/span\u003e\u003cspan address=\"10.1186/s12913-015-0909-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health services accessibility, palliative care, inpatient hospices, health geography, floating catchment area methods, E2SFCA, 2SFCA, GIS, network analysis","lastPublishedDoi":"10.21203/rs.3.rs-8958592/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8958592/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eSpatial access is an important indicator to assess the quality of healthcare services and the healthcare situation. Accessibility and availability are central components of this indicator. Using inpatient hospices as an example of specialist palliative care in Germany, this study will present various indicators for operationalizing spatial access, identify regional differences, and discuss possible differences in the results caused by methodological characteristics.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e \u003cp\u003eLocations of inpatient hospices were identified using a freely accessible web-based self-disclosure database, supplemented by lists from regional associations and own research. Spatial access was examined using provider-to-population ratios based on district level and network-based travel time Further, two variants of the floating catchment area methods (FCA), the Two-Step Floating Catchment Area (2SFCA) and Enhanced Two-Step Floating Catchment Area (E2SFCA) were applied. The analyses used geocoded locations, hospice bed capacities, population data, and road network data.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003e295 inpatient hospices were identified. 211 of the 401 districts have at least one hospice, resulting in an availability of 36.4 beds per 1\u0026nbsp;million inhabitants for all of Germany. 90.3% of the population can reach a hospice within 30 minutes by motorized private transport. The results of the FCA methods show a heterogeneous pattern in the spatial accessibility index (SPAI\u003csub\u003ei\u003c/sub\u003e), with the application of the slow and sharp distance decay function having different effects. Using the 2SFCA method results in uniform accessibility within the catchment areas of the hospices. While the E2SFCA method with a slow distance decay function generates smoother transition zones within the catchment areas, the sharp distance decay function induces higher spatial differentiation, particularly in rural areas, where accessibility declines sharply with distance.\u003c/p\u003e\u003ch2\u003eConclusions.\u003c/h2\u003e \u003cp\u003eThe results indicate that inpatient hospices in Germany are very accessible. However, the chosen method significantly influences the results. Indicators such as provider-to-population ratios and network-based travel time can provide a basic analysis of the care situation due to their ease of interpretation. FCA methods are more complex but also more meaningful due to their joint consideration of availability and accessibility.\u003c/p\u003e","manuscriptTitle":"Approaches to quantifying spatial accessibility using the example of inpatient hospices in Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-05 15:21:34","doi":"10.21203/rs.3.rs-8958592/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T09:19:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T04:04:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198337510702331893828047715450728013418","date":"2026-04-03T16:32:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T22:07:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205668656905642908453712227863629746218","date":"2026-03-13T13:11:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127004106737342541167695751681951082973","date":"2026-03-05T09:20:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-02T12:37:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-02T11:43:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-28T18:55:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-28T18:54:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-02-24T14:13:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"317fd914-ee56-4631-8597-5c47a27cb554","owner":[],"postedDate":"March 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T09:25:06+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-05 15:21:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8958592","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8958592","identity":"rs-8958592","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}