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Distance as a barrier to addiction treatment for rural and urban veterans in the regionalized VA system

Wallace AE, Booth BM, Weeks WB, West AN. Distance as a barrier to addiction treatment for rural and urban veterans in the regionalized VA system. Poster session presented at: National Rural Health Association Annual Meeting; 2007 May 17; Anchorage, AK.


Background: Regionalization and reductions in VA addiction treatment services in the 1990s resulted in greater travel distances to most VA inpatient addiction care, especially for rural veterans. Subsequently, rural veterans were less likely than urban veterans to access inpatient addiction services. Others have shown that distance to care is a barrier to addiction aftercare completion. We examined whether distance was a barrier to inpatient addiction treatment for rural versus urban veterans. Methods: Using a comprehensive dataset of VA and private sector hospitalizations we examined records for 15,433 VA enrollees who were residents of New York State and were admitted for detoxification from 1998-2000. We matched veterans’ ZIP Codes to Rural-Urban Commuting Area (RUCA) codes and used the Washington State Department of Health’s RUCA consolidation system to classify veterans who lived in urban (areas of 500,000 persons or more) and rural settings (small towns with populations below 10,000). We calculated rates of transfer from detoxification to rehabilitation for rural and urban veterans in either the VA or private sector, and for dual users of both VA and private sector services. Using established methods to estimate travel distance and time between ZIP code centroids, we calculated average distance from veterans’ homes to addiction treatment, both detoxification and rehabilitation. We then used Kaplan-Meier survival analysis to examine rates of access to inpatient detoxification and rehabilitation for rural versus urban veterans as a function of distance to care. Results: Rural New York veterans traveled 139 miles on average to access detoxification and 153 miles for rehabilitation at VA facilities, compared to 70 miles to VA detoxification and 71 miles to VA rehabilitation for urban veterans. In the private sector, rural veterans traveled on average 57 miles to detoxification and 62 miles to rehabilitation, compared to 18 miles and 29 miles, respectively, for urban veterans. Rural veterans were only 40% as likely as urban veterans to progress from inpatient detoxification to rehabilitation in VA facilities, but 60% more like to progress from detoxification to rehabilitation in private sector facilities (Table). Survival analysis revealed that 55% of rural veterans compared to only 20% of urban veterans accessed VA detoxification when travel distance exceeded 100 miles (Figure 1). Likewise, 60% of rural veterans accessed VA rehabilitation at distances exceeding 100 miles, compared to 20% of urban veterans (Figure 2). Discussion: Between 1998 and 2000, distance appears to have been a barrier to accessing VA inpatient addiction services in New York, especially for rural veterans, who were much more likely to travel more than 100 miles to obtain care, and less likely to progress from detoxification to rehabilitation services. Rural veterans may have substituted non-inpatient treatment or shifted some addiction care to private sector hospitals, or providers may have had a different threshold for referral from inpatient detoxification to rehabilitation for rural compared to urban veterans. Regardless of cause, access to inpatient addiction treatment in the regionalized VA system is not equal for rural and urban veterans. VA should act to ensure equitable access to specialized services for veterans who live in rural settings. ng veterans with common psychiatric disorders

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