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Title: Impact of rural residence and health system structure on quality of liver care
Authors: Rongey C.
Shen H. 
Hamilton N.
Backus L.I.
Asch S.M.
Knight S.
Keywords: adult
antiviral therapy
cohort analysis
health care access
health care disparity
health care quality
health care system
hepatitis C
major clinical study
rural area
rural population
urban population
urban rural difference
clinical trial
hepatitis C
middle aged
multicenter study
rural health care
United States
veterans health
Hepatitis C
Middle Aged
Quality of Health Care
Rural Health Services
Rural Population
United States
United States Department of Veterans Affairs
Veterans Health
Issue Date: 2013
Citation: Rongey C., Shen H., Hamilton N., Backus L.I., Asch S.M., Knight S. (2013). Impact of rural residence and health system structure on quality of liver care. PLoS ONE 8 (12) : e84826. ScholarBank@NUS Repository.
Abstract: Background: Specialist physician concentration in urban areas can affect access and quality of care for rural patients. As effective drug treatment for hepatitis C (HCV) becomes increasingly available, the extent to which rural patients needing HCV specialists face access or quality deficits is unknown. We sought to determine the influence of rural residency on access to HCV specialists and quality of liver care. Methods: The study used a national cohort of 151,965 Veterans Health Administration (VHA) patients with HCV starting in 2005 and followed to 2009. The VHA's constant national benefit structure reduces the impact of insurance as an explanation for observed disparities. Multivariate cox proportion regression models for each quality indicator were performed. Results: Thirty percent of VHA patients with HCV reside in rural and highly rural areas. Compared to urban residents, highly rural (HR 0.70, CI 0.65-0.75) and rural (HR 0.96, CI 0.94-0.97) residents were significantly less likely to access HCV specialty care. The quality indicators were more mixed. While rural residents were less likely to receive HIV screening, there were no significant differences in hepatitis vaccinations, endoscopic variceal and hepatocellular carcinoma screening between the geographic subgroups. Of note, highly rural (HR 1.31, CI 1.14-1.50) and rural residents (HR 1.06, CI 1.02-1.10) were more likely to receive HCV therapy. Of those treated for HCV, a third received therapy from a non-specialist provider. Conclusion: Rural patients have less access to HCV specialists, but this does not necessarily translate to quality deficits. The VHA's efforts to improve specialty care access, rural patient behavior and decentralization of HCV therapy beyond specialty providers may explain this contradiction. Lessons learned within the VHA are critical for US healthcare systems restructuring into accountable care organizations that acquire features of integrated systems.
Source Title: PLoS ONE
ISSN: 1932-6203
DOI: 10.1371/journal.pone.0084826
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