Impact of Rural Residence and Health System Structure on Quality of Liver Care

Abstract

BackgroundSpecialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care.MethodsThe study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA’s constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed.ResultsThirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider. ConclusionRural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA's efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.

Facility- and Patient-Level Factors Associated with Esophageal Variceal Screening in the USA

“…The HCV Clinical Case Registry was merged with the Planning Systems Support Group geocoded file containing urban, rural, or highly rural categorization of patient residence [15, 16]. Urban residents are defined as anyone living in a US-Census-defined urbanized area.…”

“…Rural residents include anyone not defined as urban. Highly rural residents live in counties with average population density of fewer than seven civilians per square mile [15]. Gastroenterology (GI)/hepatology clinic access was defined as at least one GI or hepatology clinic visit after cirrhosis diagnosis and before screening EGD (in those receiving EGD).…”

Implementation of telementoring for pain management in Veterans Health Administration: Spatial analysis

“…A nationwide study of Veterans eligible for liver transplant showed increasing distance to a transplant center was associated with decreasing probability of receiving a liver transplant [18]. Rural Veterans have been shown to have decreased access to hepatitis C specialty care than their urban counterparts [20]. Our findings add to this list by exploring access to technology-based specialty care in addition to in-person specialty care.…”

A Multicenter Cardiovascular MR Network for Tele-Training and Beyond: Setup and Initial Experiences

“…This effect has been proven for telemedicine use for stroke patients [18,19] and is of utmost importance for areas in North America, or in Scandinavian countries, where the next available CMR center may be far away. In these regions, availability of specialized staff and equipment was shown to be a key success factor for delivery of sufficient patient care [22,23]. A CMR network such as ours can help in addressing this need.…”