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.
JAMA Netw Open. 2022 Nov 1;5(11):e2240290. doi: 10.1001/jamanetworkopen.2022.40290.
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.
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.
Drive time from each patient's residential address to the closest VA facility where the service was available, measured using geocoded addresses.
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.
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.
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.
许多患者未接受推荐的服务。前往医疗保健服务的车程时间可能会影响指南推荐的护理的接受情况，但这尚未得到全面研究。
评估前往护理的车程时间与接受指南推荐的筛查、诊断和治疗干预措施之间的关联。
设计、地点和参与者：这项队列研究使用了国家退伍军人健康管理局（VA）数据与医疗保险数据合并的行政数据。符合条件的参与者是在 2016 年 1 月至 2019 年 12 月期间使用 VA 服务的患者。无潜在骨骼疾病的 65 岁及以上女性接受骨质疏松症筛查。至少有 2 次 COPD 就诊代码或至少有 1 次 COPD 相关住院治疗的新诊断为慢性阻塞性肺疾病（COPD）的患者接受诊断性肺量测定。因缺血性心脏病住院的患者接受心脏康复治疗。
使用患者住宅地址的地理编码地址来衡量每个患者到最近提供服务的 VA 设施的行车时间。
患者接受骨质疏松症筛查、肺量测定和心脏康复治疗的接受情况的二元结果。使用多变量逻辑回归模型评估行车时间与服务接受情况之间的关联。
在分析的 110780 名合格女性中，36431 名（32.9%）接受了骨质疏松症筛查（平均[SD]年龄，66.7[5.4]岁；19422 名[17.5%]黑人，63403 名[57.2%]白人）。在 281130 名新诊断为 COPD 的患者中，145249 名（51.7%）接受了肺量测定（平均[SD]年龄，68.2[11.5]岁；268999 名[95.7%]男性；37834 名[13.5%]黑人，217608 名[77.4%]白人）。在因缺血性心脏病住院的 73146 名患者中，11171 名（15.3%）接受了心脏康复治疗（平均[SD]年龄，70.0[10.8]岁；71217 名[97.4%]男性；15213 名[20.8%]黑人，52144 名[71.3%]白人）。随着行车时间的增加，接受推荐服务的可能性降低。与行车时间在 30 分钟或更短的患者相比，行车时间在 61 到 90 分钟的患者接受骨质疏松症筛查的可能性较低（调整后的优势比[aOR]，0.90；95%CI，0.86-0.95）和肺量测定（aOR，0.90；95%CI，0.88-0.92），而行车时间在 91 到 120 分钟的患者接受心脏康复治疗的可能性较低（aOR，0.80；95%CI，0.74-0.87）。在仅限于城市患者或其初级保健诊所位于三级保健中心的患者的分析中，结果相似。
在这项回顾性队列研究中，较长的行车时间与多项护理服务的推荐服务接受率降低相关。为了改善护理质量和健康结果，医疗系统和临床医生应采取策略来减轻旅行负担，即使对于城市患者也是如此。
