Schmajuk Gabriela, Tonner Chris, Yazdany Jinoos
Veterans Affairs Medical Center-San Francisco, 4150 Clement St, Mailstop 111R, San Francisco, CA 94121; Division of Rheumatology, University of California-San Francisco, San Francisco, CA.
Institute for Health Policy Studies, University of California, San Francisco, CA.
Semin Arthritis Rheum. 2016 Feb;45(4):511-8. doi: 10.1016/j.semarthrit.2015.07.007. Epub 2015 Jul 28.
Despite looming rheumatologist shortages and a growing number of patients with arthritis and other rheumatic conditions, nationwide estimates of access to rheumatology care have never been reported. We aimed to measure travel times as a proxy to access to care and to determine the individual and area-level factors associated with long travel times to rheumatologists in the U.S.
We used Medicare Part B claims for the 2009 Medicare Chronic Condition Warehouse 5% rheumatoid arthritis/osteoarthritis cohort. Using Google Maps we estimated driving time from the center of a beneficiary's home ZIP code to the center of their rheumatologist's office ZIP code. We examined predictors of travel time ≥90 min in a series of generalized linear mixed models adjusting for rheumatologist supply, rurality, and individual patient characteristics including age, race, gender, and income.
We included 41,693 Medicare beneficiaries with 1 or more visits to a rheumatologist in 2009. The median estimated beneficiary travel time to a rheumatologist was 22 min [interquartile range (IQR): 12-40 min]. Overall, 7% of beneficiaries traveled 90 min or longer to visit a rheumatologist. Even after adjusting for covariates, independent predictors of long travel times included living in areas with no or low supply of rheumatologists and living in the Mountain region of the U.S.
A small but significant proportion of patients in the U.S. traveled very long distances to visit a rheumatologist, and most of these individuals resided in areas with no or low supplies of rheumatologists. These data suggest that addressing shortages in rheumatology care for patients in low-supply areas is a key target for improving access to rheumatologists.
尽管风湿病医生短缺问题日益凸显，且患有关节炎和其他风湿性疾病的患者数量不断增加，但全国范围内获得风湿病护理的情况估计尚未有报道。我们旨在测量出行时间，以此作为获得护理机会的替代指标，并确定与前往美国风湿病医生处的长时间出行相关的个体和地区层面因素。
我们使用了2009年医疗保险慢性病仓库5%类风湿性关节炎/骨关节炎队列的医疗保险B部分索赔数据。利用谷歌地图，我们估算了从受益人的家庭邮政编码中心到其风湿病医生办公室邮政编码中心的驾车时间。我们在一系列广义线性混合模型中，对风湿病医生供应、农村地区情况以及包括年龄、种族、性别和收入在内的个体患者特征进行调整后，研究了出行时间≥90分钟的预测因素。
我们纳入了2009年有1次或更多次就诊于风湿病医生的41,693名医疗保险受益人。受益人前往风湿病医生处的估计中位出行时间为22分钟[四分位间距（IQR）：12 - 40分钟]。总体而言，7%的受益人前往风湿病医生处的出行时间达到或超过90分钟。即使在对协变量进行调整后，长时间出行的独立预测因素仍包括居住在风湿病医生供应不足或无供应的地区以及居住在美国山区。
美国有一小部分但比例显著的患者前往风湿病医生处的路途非常遥远，且这些患者大多居住在风湿病医生供应不足或无供应的地区。这些数据表明，解决供应不足地区患者的风湿病护理短缺问题是改善获得风湿病医生服务机会的关键目标。
