Session number: 1088
Abstract title: Continuity of Outpatient Care Among Veterans With Psychosis: Accessibility Barriers
Author(s):
J McCarthy - SMITREC / University of Michigan School of Public Health
F Blow - SMITREC / University of Michigan Dept. of Psychiatry
J Fortney - CeMEHOR / University of Arkansas
Objectives: Health systems that emphasize primary care rely on patient accessibility. Individuals with psychoses have persistent high need and may be particularly sensitive to accessibility barriers. We present a national study of the influence of accessibility, measured in miles to nearest provider, on two outpatient continuity measures: 1) maximum period without outpatient psychiatric care, and 2) maximum period without outpatient non-psychiatric care. We adjust for institutional days and volume of care. We examine interrelationships between distance, psychosis type, and utilization.
Methods: We identified all patients with a psychosis diagnosis in FY00. We categorized each patient as having schizophrenia, bipolar disorder, or other psychoses. We assessed longest interval between outpatient psychiatric visits, and between outpatient non-psychiatric visits. We assessed straight-line distance to nearest VA provider. Exclusion criteria were: homelessness; institutional stays of at least 150 days; no FY99 utilization; death in FY00; and missing data. Analytic datasets consisted of 130,284 patients with non-psychiatric outpatient visits, and 121,766 patients with psychiatric outpatient visits. Adjusting for age, ethnicity, marital status, and site and comorbidities at initial use (Charlson), we applied least squares regression to assess the impact of distance on continuity of outpatient psychiatric care and non-psychiatric care.
Results: Distance to nearest provider was associated with longer gaps in outpatient psychiatric care and non-psychiatric care (p<0.0001). Controlling for other predictors, for every ten miles from care, the maximum days without psychiatric care was 1.7 days longer; and maximum days without non-psychiatric care was 1.1 days longer. Relative to patients between 45 and 65, being younger was associated with longer gaps (p<0.0001). Being older was associated with longer psychiatric care gaps (p<0.0001) and shorter non-psychiatric care gaps (p<0.0001). Being white (p<0.0001) and married (p<0.0001) were associated with smaller gaps. Interactions between distance and psychosis type indicate that distance impairs continuity more among patients with schizophrenia than patients with bipolar disorders, who were more negatively affected than patients with other psychoses.
Conclusions: Distance to care impairs the continuity of outpatient psychiatric and non-psychiatric care. The impact is greatest among patients with schizophrenia.
Impact statement: This work presents national data on the impact of distance on outpatient continuity of care for a special vulnerable population, veterans with psychoses. Despite expansion of CBOCs, distance to care for these patients remains a potential barrier to use.