Accessibility barriers to care among individuals with psychoses: Distance effects on health services volume and continuity.

Abstract

Accessibility, which refers to the relationship of the physical locations of potential clients and health care providers, has taken on increased policy significance in the past twenty years. The U.S. health care system has shifted emphasis to primary care services provided for populations at risk. Providers actively seek to maintain patient well-being and to avoid costly acute care episodes, particularly among vulnerable patient subpopulations with chronic needs for services. Access barriers may affect utilization along multiple dimensions. Many studies simply evaluate access to care by assessing whether there was any contact with providers. However, this approach masks access differentials among individuals who had some contact; contact indicates merely some minimal level of access. This study examines the impact of accessibility barriers, approximated by straight-line distance to nearest Veterans Affairs (VA) provider, on volume and continuity of health services over a one-year period among 142,055 individuals with psychoses who had some contact with VA providers in two consecutive years. Separate random intercepts mixed models were used to evaluate distance effects on four measures of volume and seven measures of continuity of care. Random intercept mixed models allow for correlation among individuals who share the same nearest provider. Model covariates included patient predisposing (age, gender, and race/ethnicity), enabling (marital status), and need characteristics (psychosis category, and Charlson comorbidities and treatment location during initial treatment of the study year). Results indicate that increases in distance to nearest provider limits volume of inpatient and outpatient psychiatric and non-psychiatric services and disrupts the timing, post-discharge aftercare, and coordination of care. The impact of distance was generally found to be curvilinear, with smaller effects at greater distance. In seven of the eleven models, patients with schizophrenia were found to be more susceptible to distance barriers than were patients with bipolar disorder or other psychoses. The VA is a committed to assuring health care services to veterans with psychoses. Despite major expansion of outpatient service sites, distance to care remains a significant and substantial barrier among VA patients with psychoses. Accessibility barriers may be even greater among individuals with psychoses who rely on non-VA providers.