Johannson Kerri A, Lethebe Brendan C, Assayag Deborah, Fisher Jolene H, Kolb Martin, Morisset Julie, Shapera Shane, Gershon Andrea S, Hambly Nathan, Khalil Nasreen, To Teresa, Fell Charlene D, Cox Gerard, Manganas Hélène, Halayko Andrew J, Marcoux Veronica, Sadatsafavi Mohsen, Wilcox Pearce G, Bertazzon Stefania, Ryerson Christopher J
Department of Medicine.
Department of Community Health Sciences.
Ann Am Thorac Soc. 2022 Jan;19(1):20-27. doi: 10.1513/AnnalsATS.202102-216OC.
Early access to subspecialty care is associated with improved outcomes for patients with fibrotic interstitial lung disease (ILD). Access to ILD care may be limited for patients living far from subspecialty clinics. To test the hypothesis that greater travel distance to access ILD clinical care would be associated with more severe disease at time of referral and worse clinical outcomes. Patients with fibrotic ILD were recruited from a multicenter national pulmonary fibrosis registry. Residential postal codes were geocoded to estimate travel distance from the home to the clinic. Travel distance was dichotomized at ⩽70 km (near) and >70 km (far). Demographics and disease severity at the initial referral, changes in lung function, and the risk of death or lung transplant were analyzed in unadjusted and adjusted models for their association with travel distance. The cohort included 1,162 patients, of whom 856 lived near to their ILD clinic and 306 lived far from their ILD clinic. Patients residing farther from their clinic were younger, more likely to have smoked, had a greater 6-minute-walk distance, and had lower composite risk scores than patients residing closer to their clinic. In models adjusted for age, sex, and baseline forced vital capacity, patients from farther away had a greater risk of death or lung transplant than patients residing closer (hazard ratio, 1.52; 95% confidence interval [CI], 1.10-2.11), a finding predominantly driven by patients with connective tissue disease-related ILD (hazard ratio, 2.14; 95% CI, 1.16-3.94). Patients with fibrotic ILD with a longer travel distance to their ILD clinic had better prognostic indices at baseline but had a higher risk of death or lung transplant in the total cohort and in patients with connective tissue disease-related ILD. Assuming that disease epidemiology and severity are distributed evenly across geographic regions, these findings raise important questions about equitable access to patient care in large healthcare regions with centralized subspecialty programs.
早期获得专科护理与纤维化间质性肺病（ILD）患者的预后改善相关。对于居住在远离专科诊所的患者来说，获得ILD护理可能会受到限制。为了验证这一假设，即前往接受ILD临床护理的路途距离越远，在转诊时疾病就会越严重，临床预后也会越差。从一个多中心全国性肺纤维化登记处招募了纤维化ILD患者。对居住邮政编码进行地理编码，以估计从家到诊所的路途距离。路途距离在70公里及以内（近）和超过70公里（远）处进行二分法划分。在未调整和调整模型中，分析了初始转诊时的人口统计学和疾病严重程度、肺功能变化以及死亡或肺移植风险与路途距离的关联。该队列包括1162名患者，其中856名居住在离ILD诊所较近的地方，306名居住在离ILD诊所较远的地方。与居住在离诊所较近的患者相比，居住在离诊所较远的患者更年轻，更有可能吸烟，6分钟步行距离更长，综合风险评分更低。在根据年龄、性别和基线用力肺活量进行调整的模型中，来自较远地方的患者比居住在较近地方的患者有更高的死亡或肺移植风险（风险比，1.52；95%置信区间[CI]，1.10 - 2.11），这一发现主要由结缔组织病相关ILD患者驱动（风险比，2.14；95%CI，1.16 - 3.94）。路途距离较长前往ILD诊所就诊的纤维化ILD患者在基线时有较好的预后指标，但在整个队列以及结缔组织病相关ILD患者中，死亡或肺移植风险更高。假设疾病流行病学和严重程度在地理区域内均匀分布，这些发现引发了关于在设有集中专科项目的大型医疗区域中患者获得公平护理的重要问题。
