Wong Edwin S, Rinne Seppo T, Hebert Paul L, Cook Meredith A, Liu Chuan-Fen
Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.
Department of Health Services, University of Washington, Seattle, Washington.
J Rural Health. 2016 Sep;32(4):377-386. doi: 10.1111/jrh.12191. Epub 2016 Jul 18.
Geographic access to inpatient care at the Veterans Affairs (VA) Health Care System is challenging for many veterans with chronic obstructive pulmonary disease (COPD) given relatively few VA hospitals nationwide. Veterans with lengthy travel distances may obtain non-VA care, particularly those dually enrolled in Medicare. Our primary objective was to assess whether distance from VA patients' residence to the nearest VA and non-VA hospitals was associated with 30-day all-cause readmission and the system where patients were readmitted (VA or Medicare).
Using VA and Medicare administrative data, we identified 21,273 patients hospitalized for COPD between October 2008 and September 2011 and dually enrolled in VA and fee-for-service Medicare. Outcome variables were dichotomous measures denoting readmission for any cause within 30 days following discharge and whether the readmission occurred in a non-VA hospital through Medicare. Distance to the nearest hospital was defined as the number of miles between patients' residence ZIP code and the ZIP code of the nearest VA and non-VA hospital accepting Medicare, respectively. Probit models with sample selection were applied to examine the relationship between hospital distance and outcome measures.
Respective distances to the nearest VA and non-VA hospital were not associated with 30-day all-cause readmission. Greater distance to the nearest VA hospital was associated with a greater conditional probability of choosing non-VA hospitals for readmission.
COPD patients with poor geographic access to VA hospitals did not forgo subsequent inpatient care following their index hospitalization, but they were more likely to seek non-VA substitutes.
鉴于美国退伍军人事务部（VA）医疗系统在全国范围内的医院相对较少，对于许多患有慢性阻塞性肺疾病（COPD）的退伍军人来说，获得住院治疗的地理便利性具有挑战性。行程距离较长的退伍军人可能会接受非VA系统的治疗，尤其是那些同时参加医疗保险的人。我们的主要目标是评估从VA患者住所到最近的VA医院和非VA医院的距离是否与30天全因再入院以及患者再次入院的系统（VA或医疗保险）相关。
利用VA和医疗保险的行政数据，我们确定了2008年10月至2011年9月期间因COPD住院且同时参加VA和按服务收费医疗保险的21273名患者。结果变量是二分法测量指标，分别表示出院后30天内任何原因的再入院情况以及再入院是否通过医疗保险在非VA医院发生。到最近医院的距离分别定义为患者居住邮政编码与接受医疗保险的最近VA医院和非VA医院邮政编码之间的英里数。应用带样本选择的概率模型来检验医院距离与结果指标之间的关系。
到最近的VA医院和非VA医院的距离与30天全因再入院均无关联。到最近VA医院的距离越远，选择非VA医院进行再入院的条件概率越高。
在地理上难以进入VA医院的COPD患者在首次住院后并未放弃后续的住院治疗，但他们更有可能寻求非VA系统的替代治疗。
