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Morden NE (White River Junction VAMC/REAP), Berke EM
(White River Junction VAMC), Welsh DE
(HSRD/SMITREC), Mackenzie TA
(White River Junction VAMC), McCarthy JF
(HSRD/SMITREC), Kilbourne AM
(HSRD/SMITREC)
Objectives:
Serious mental illness (SMI) and depression are associated with lower likelihood of receiving appropriate cardiovascular disease (CVD) care. Rural residence also is associated with lower likelihood of receiving health care services. We examined whether rurality of residence is associated with disparities in quality of CVD care within the VA healthcare system, and whether mental illness mediates associations between rurality and CVD care quality.
Methods:
We identified all patients in the fiscal year 2005 (FY05) VA External Peer Review Program’s (EPRP) national, random sample chart review assessing quality of CVD care. Using VA’s National Psychosis Registry and National Registry for Depression, we identified EPRP patients with and without serious mental illness (schizophrenia, bipolar disorder, other psychoses) or depression. Using residential zip code, patients were assigned to one of three tiered rural urban commuting area (RUCA) codes. Using logistic regression, we assessed the associated between rurality and CVD care quality indicators (BP > = 160/100, BP < = 140/90, screening lipid test, and among diabetics: LDL < = 100, foot exam, retinal exam, renal testing, HbA1C < 9).
Results:
Compared to rural settings, urban areas had proportionally more subjects with SMI and substance abuse. Prevalence of depression did not vary by rurality. SMI and Depression were associated with multiple poor CVD care quality indicators. Most notably, these patients were more than twice as likely to have BP > = 160/100. Rurality was associated with less receipt of screening lipid test. More primary care visits were associated with better care quality for 7 of 9 measures.
Implications:
Rural residence does not explain lower CVD care quality. Researchers must study other potential care barriers, especially among those with mental illness who suffer disproportionately from CVD. Enhanced access and use of primary care services may improve CVD care for veterans with and without mental illness in all geographic settings.
Impacts:
Reducing care disparities and achieving high quality of care for veterans with mental illness is a priority for the VA. Further research is needed to identify interventions that enhance quality of CVD care for veterans with mental illness and to understand how rural residence is related to health and health care access.
