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Aboumrad M, Peritz D, Friedman S, Zwain G, Watts BV, Taub C. Rural-urban trends in health care utilization, treatment, and mortality among US veterans with congestive heart failure: A retrospective cohort study. J Rural Health 2023; 39:844-852. [PMID: 37005093 DOI: 10.1111/jrh.12756] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
PURPOSE To compare longitudinal rates of health care utilization, evidence-based treatment, and mortality between rural and urban-dwelling patients with congestive heart failure (CHF). METHODS We used electronic medical record data from the Veterans Health Administration (VHA) to identify adult patients with CHF from 2012 through 2017. We stratified our cohort using left ventricular ejection fraction percentage at diagnosis (<40% = reduced ejection fraction [HFrEF]; 40%-50% = midrange ejection fraction [HFmrEF]; >50% = preserved ejection fraction [HFpEF]). Within each ejection fraction cohort, we stratified patients into rural or urban groups. We used Poisson regression to estimate annual rates of health care utilization and CHF treatment. We used Fine and Gray regression to estimate annual hazards of CHF and non-CHF mortality. FINDINGS One-third of patients with HFrEF (N = 37,928/109,110), HFmrEF (N = 24,447/68,398), and HFpEF (N = 39,298/109,283) resided in a rural area. Rural compared to urban patients used VHA facilities at similar or lower annual rates for outpatient specialty care across all ejection fraction cohorts. Rural patients used VHA facilities at similar or higher rates for primary care and telemedicine-delivered specialty care. They also had lower and declining rates of VHA inpatient and urgent care use over time. There were no meaningful rural-urban differences in treatment receipt among patients with HFrEF. On multivariable analysis, the rate of CHF and non-CHF mortality was similar between rural and urban patients in each ejection fraction cohort. CONCLUSIONS Our findings suggest the VHA may have mitigated access and health outcome disparities typically observed for rural patients with CHF.
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Affiliation(s)
- Maya Aboumrad
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - David Peritz
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Scott Friedman
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Gabrielle Zwain
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Bradley V Watts
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Cynthia Taub
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Baldomero AK, Kunisaki KM, Wendt CH, Bangerter A, Diem SJ, Ensrud KE, Nelson DB, Henning-Smith C, Bart BA, Hammett P, Hagedorn HJ, Dudley RA. Drive Time and Receipt of Guideline-Recommended Screening, Diagnosis, and Treatment. JAMA Netw Open 2022; 5:e2240290. [PMID: 36331503 PMCID: PMC9636523 DOI: 10.1001/jamanetworkopen.2022.40290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE Many patients do not receive recommended services. Drive time to health care services may affect receipt of guideline-recommended care, but this has not been comprehensively studied. OBJECTIVE To assess associations between drive time to care and receipt of guideline-recommended screening, diagnosis, and treatment interventions. DESIGN, SETTING, AND PARTICIPANTS This cohort study used administrative data from the National Veterans Health Administration (VA) data merged with Medicare data. Eligible participants were patients using VA services between January 2016 and December 2019. Women ages 65 years or older without underlying bone disease were assessed for osteoporosis screening. Patients with new diagnosis of chronic obstructive pulmonary disease (COPD) indicated by at least 2 encounter codes for COPD or at least 1 COPD-related hospitalization were assessed for receipt of diagnostic spirometry. Patients hospitalized for ischemic heart disease were assessed for cardiac rehabilitation treatment. EXPOSURES Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses. MAIN OUTCOMES AND MEASURES Binary outcome at the patient level for receipt of osteoporosis screening, spirometry, and cardiac rehabilitation. Multivariable logistic regression models were used to assess associations between drive time and receipt of services. RESULTS Of 110 780 eligible women analyzed, 36 431 (32.9%) had osteoporosis screening (mean [SD] age, 66.7 [5.4] years; 19 422 [17.5%] Black, 63 403 [57.2%] White). Of 281 130 patients with new COPD diagnosis, 145 249 (51.7%) had spirometry (mean [SD] age, 68.2 [11.5] years; 268 999 [95.7%] men; 37 834 [13.5%] Black, 217 608 [77.4%] White). Of 73 146 patients hospitalized for ischemic heart disease, 11 171 (15.3%) had cardiac rehabilitation (mean [SD] age, 70.0 [10.8] years; 71 217 [97.4%] men; 15 213 [20.8%] Black, 52 144 [71.3%] White). The odds of receiving recommended services declined as drive times increased. Compared with patients with a drive time of 30 minutes or less, patients with a drive time of 61 to 90 minutes had lower odds of receiving osteoporosis screening (adjusted odds ratio [aOR], 0.90; 95% CI, 0.86-0.95) and spirometry (aOR, 0.90; 95% CI, 0.88-0.92) while patients with a drive time of 91 to 120 minutes had lower odds of receiving cardiac rehabilitation (aOR, 0.80; 95% CI, 0.74-0.87). Results were similar in analyses restricted to urban patients or patients whose primary care clinic was in a tertiary care center. CONCLUSIONS AND RELEVANCE In this retrospective cohort study, longer drive time was associated with less frequent receipt of guideline-recommended services across multiple components of care. To improve quality of care and health outcomes, health systems and clinicians should adopt strategies to mitigate travel burden, even for urban patients.
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Affiliation(s)
- Arianne K. Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Ken M. Kunisaki
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis
| | - Chris H. Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Susan J. Diem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- General Internal Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Kristine E. Ensrud
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- General Internal Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - David B. Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | - Bradley A. Bart
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Cardiology, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Patrick Hammett
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Division of Biostatistics, University of Minnesota, Minneapolis
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - R. Adams Dudley
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
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