Introduction

Geography has long been recognized as an access to care barrier. This problem is perhaps most apparent in those needing care from specialist physicians. Specialists are even more likely than generalists to live and work in urban environments[1]. Yet some therapies, such as mental health, human immunodeficiency virus (HIV) treatment and cancer care, that have good evidentiary support for their effect on health, require specialist participation, placing rural-residing patients at a potential access deficit[2,3]. This maldistribution has been postulated as one reason for observed urban-rural disparities in specialist utilization and health related quality of life[1,4]. Geography is not the only reason that rural residents might have impaired access to specialty care or quality deficits, however. Rural residents are also more likely to be uninsured or publicly insured [5].

The Veterans Health Administration (VHA) presents an excellent test system for disentangling these two possible mechanisms for the observed effects of rurality on specialist care. VHA has a constant national benefits structure, making access to care differences due to insurance less likely. VHA specialists, like their non-VHA counterparts, are concentrated in urban areas. VHA specialists typically work in central, usually urban, locations termed Veteran Affairs Medical Centers (VAMCs) and are the specialty referral reservoir for outlying primary care clinics, known as community based outpatient clinics (CBOCs). For example, the San Francisco Veterans Affairs Medical Center (SFVAMC) is the specialty care center for four CBOCs located 6, 60, 115 and 270 miles away. Some previous research has found that health-related quality of life may lag in rural veterans as it does in nonveterans, and that they may suffer delays in accessing specialty mental health and HIV care [3,4,6-10].

HCV provides an excellent disease model for examining the impact of rurality on specialty care access. HCV treatment regimens are increasingly effective in eradicating viremia, but are complex to manage, fraught with side effects, and require substantial specialist input [11,12]. With more than 5% of veterans chronically HCV-infected, four-fold more than the general United States (US) population, the VHA is the largest single provider of medical care to people with HCV in the US [13,14]. Without treatment, 30-40% of patients with chronic viremia eventually develop cirrhosis[15,16]. The prevalence of HCV-infected patients with cirrhosis and related sequelae is rising over the past decade, including rising hospitalization rates and an eight-fold increase in hepatocellular carcinoma (HCC) cases, a malignancy which typically develops in the setting of cirrhosis[17-19]. Studies conducted within VHA and other healthcare systems find that patients with HCV who have not received a gastroenterology (GI) or hepatology visit are less likely to receive HCV therapy and quality liver care, such as hepatitis A and B vaccinations[20-23]. However, rural populations with HCV-associated chronic liver disease have not generally been included in these studies.

We sought to determine the influence of rural residency on access to HCV specialists and quality of HCV care. We hypothesized that rural veterans would be less likely to access care, receive vaccinations, HIV screening, treatment and cirrhosis management.

Methods

Results

Discussion

The relationship between access to specialty care and rurality of patient residence is complex, influenced by patient’s health status, geography and health system structure. Our study found lower likelihood of access to GI or hepatology specialty care among rural and highly residents, consistent with previous literature and Jarvis’ law which holds that the greater the distance to care, the less likely it is accessed[30]. However, a portion of HCV treatment and management is occurring outside of specialty care clinics and these health system structural factors appear to improve among rural and highly rural residents.

Two recent trends are relevant to our work. First, in recent years, HCV care has been decentralized from specialists in large urban medical centers to generalists in community settings[31,32]. Approximately 20% of our cohort received HCV therapy outside of a GI, hepatology or infectious disease clinic suggesting that a portion of specialty liver care is delivered outside of the specialty clinics. Highly rural and rural residents with HCV were significantly more likely, compared to urban residents, to access specialty providers that are based within smaller, predominantly primary care based clinics. This shift from medical center to community clinic care possibly reflects the VHA’s broader efforts to disseminate specialty care beyond larger medical centers. However, it is not clear in our analyses whether providing HCV therapy through non-specialty clinics is what accounts for higher treatment rates among highly rural veterans with HCV.

A second factor that is important to consider in the interpretation of our results is the influence of health system structure on access to care. Urban centralization of specialists, a characteristic of the VHA’s health system structure, could potentially place distant residing residents at a significant disadvantage in specialty clinic access. Rural and highly rural veterans with HCV drive distances nearly 4.6 and 9.7 times that of urban Veterans with HCV to seek specialty care, an additional 55 and 138 minutes, respectively. These distances to specialty care clearly result in reduced access to specialty clinics, particularly among highly rural residents with cirrhosis who may be too ill to travel long distances. However, there are several important structural elements within the VHA healthcare system that may mitigate distance related barriers to specialty clinic access. The VHA staffs the large secondary/tertiary centers, termed VAMCs, as well as select small, predominantly primary care staffed clinics, termed CBOCs, with specialists. To ease the cost associated with travel, the VHA travel reimbursement program in 2008 increased its reimbursement rates from 11 cents per mile to 28 cents per mile resulting in a 10% increase in outpatient visits[33]. The VHA also provides free shuttle service for veterans with transportation, particularly distance-related, needs. Veterans who require an overnight stay due to transportation-related fatigue or recovery from procedures are provided overnight hotel-like accommodations. It is possible that these efforts have reduced the impact of geographic distance on access to specialty care in the VA.

Our study points to the need for a better conceptualization of rurality. There is little difference in quality of liver care received between rural and urban veterans with HCV, possibly a result of overlapping definitions or highly rural, rural, and urban residential areas. The lower limit quintiles in distance and time to specialty care among rural veterans with HCV approximate the upper limit quintiles of urban veterans with HCV suggesting that the rural and urban categorization is not robust. In addition to the lack of clarity in the construct of rurality, we suspect that the complex findings of our study are a result of diversity in rural populations. As US topography varies, we can anticipate that rural populations experience varying degrees of impact of geography on travel. The PSSG data file, while detail-rich, is potentially susceptible to pitfalls common to geo-coding datasets such as capturing variations in travel time due to traffic. For example, urban-residing veterans may, due to traffic or the availability of public transportation, experience similar travel times as their rural-residing counterparts. Finally, as 65% of highly rural veterans received HCV therapy in urban centers, this study may also be capturing a phenomenon known as rural hospital bypass behavior; an effect in which a subset of highly rural and rural patients who are highly motivated to pursue therapy will forgo locally available resources to pursue care in urban-based centers that are potentially perceived as more specialized [34]. Patterns of specialty care utilization among rural populations are a complex area that requires further exploration beyond quantitative analysis.

Lessons learned within the VHA population are critical for US healthcare systems restructuring into accountable care organizations that take on many of the features and incentives of integrated systems. Many US health systems are encountering a rising demand for specialist level of care in HCV and other conditions. However, our study suggests that impaired access to specialty care clinics does not necessarily translate into across-the-board quality of care deficits. This raises the possibility that certain aspects of specialty level care may be occurring outside the purview of specialists without a significant difference in quality of care delivered. Judicious and targeted use of expensive specialist management while also strengthening and expanding the skills of primary care physician and non-physician providers, may be one of the more important lessons translated from the VHA system into other healthcare systems. The policies of integrated systems like the VHA’s (e.g. shuttle service for geographically isolated veterans, expansion of video-telemedicine services, staffing specialists within primary care clinics, etc.) may mitigate quality of care deficits that could potentially be more striking in other healthcare systems that have not built as intense specialist-generalist collaboration structures. Continuing to understand the interplay between health system structure and patient level factors (e.g. rurality, comorbidities, income, and education) can inform models of care that can improve equity and accessibility of specialty care.

Acknowledgments

Preliminary data presented at American Association for the Study of Liver Diseases meeting, San Francisco, November 16, 2011.