Mooney C, Zwanziger J, Phibbs C S, Schmitt S
Department of Community and Preventive Medicine, University of Rochester, NY 14642, USA.
Soc Sci Med. 2000 Jun;50(12):1743-55. doi: 10.1016/s0277-9536(99)00414-1.
Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.
较长的就医路程或许可以解释为何美国相对较少的退伍军人选择在退伍军人事务部（VA）医院接受住院医疗/外科护理。我们采用了两种方法来区分距离因素对退伍军人事务部就医率的影响与其他因素，如是否有其他就医选择以及退伍军人的个人特征等。第一种方法描述了前往退伍军人事务部就医路程的差异与地理区域的其他特征之间的关系。第二种方法涉及对邮政邮政编码区域（ZCAs）内退伍军人事务部就医情况的多变量分析。我们使用了多个数据源来估算有优先使用退伍军人事务部资格的退伍军人数量，以便能够估算使用率。就医便利性通过估算前往通常为每个邮政编码区域提供服务的住院医疗服务提供者的路程来衡量。结果表明，前往退伍军人事务部的路程存在差异，农村地区的退伍军人前往退伍军人事务部接受治疗的路程比人口密集地区的退伍军人远得多。然而，医疗保险受益人在人口密度低的地区就医路程也更远。在一些地区，退伍军人必须长途跋涉才能获得退伍军人事务部的护理，因为过去几十年新建的退伍军人事务部医院并不靠近20世纪90年代退伍军人居住的地区。就医路程的差异表明获取退伍军人事务部服务的机会不平等。退伍军人事务部的使用率仅在路程增加到约15英里之前随路程增加而下降，此后，使用率对路程的进一步增加相对不敏感。多变量分析表明，65岁以上的退伍军人对路程的敏感度低于年轻退伍军人，尽管65岁以上的退伍军人符合医疗保险资格，因此可以以较低成本获得其他就医选择。结果表明，靠近退伍军人事务部医院只是决定是否使用退伍军人事务部服务的众多因素之一。有必要进行进一步研究，以便针对一小部分但显然有需求的退伍军人用户群体的需求制定适当的应对措施，这些用户为了获得退伍军人事务部的护理而长途跋涉。
