Delayed access to health care and mortality

Abstract

Objective: To measure the relationship between time spent waiting for health care services and patients' mortality.

Data source: Data on the number of days until the next available appointment at 89 Veterans Affairs (VA) medical centers in 2001 were extracted from a VA administrative database. These facility-level data were merged with individual-level data for a sample of veterans who visited a VA geriatric outpatient clinic in 2001. The merged dataset includes facility-level data on waiting times and individual-level data on demographics, health status (e.g., diagnoses), and mortality.

Study design: This was a retrospective observational study using secondary data from administrative sources. The dependent variable was mortality within a 6-month follow-up period. The main explanatory variable of interest was VA facility-level wait times for outpatient visits measured in number of days. Random effects logistic regression models were risk adjusted for prior individual health status and facility-level differences in case mix.

Principal findings: Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio=1.21, p=0.027) compared with veterans who visited a VA medical center with facility-level wait times of <31 days.

Conclusions: Our findings support the largely assumed association between long wait times for outpatient health care and negative health outcomes, such as mortality. Future research should focus on the causes of long waits for health care (e.g., physician reimbursement levels), the consequences of long waits in other populations, and effective policies to decrease long waits for health care services.

Figure 1

Distribution of Individual-Level Wait Times between July 1, 2001 and September 30, 2001 by Mortality Status (n = 33,043)*. *Individualized wait times were calculated by averaging together the wait times in days for all types of clinic visits made by an individual between July 1, 2001 and September 30, 2001.⁴ Three hundred and seventy-four individuals died in this time period.

Figure 2

Ratio of Observed Facility-Level Mortality Rates to Expected Facility-Level Mortality Rates by Wait Time, Weighted by Individuals (n = 37,489) *In the y-axis, the observed facility-level mortality rate was the number of individuals who died at each VA facility over the number of individuals who visited each VA facility (numerator). For the denominator, we predicted mortality rates by the individual risk adjustors and for each individual we predicted the probability of dying. This probability was averaged for all individuals in a facility to get the average expected facility-level risk-adjusted mortality rate. **Wait times for each facility between July and September 2001 were averaged together. ^All individual-level data points were used to compute the smoothed regression line. However, to highlight the regression line, we excluded from the figure points where this ratio was > 2 (n = 524; 1.3 percent). The smoothed regression line was calculated using lowess smoothing (lowess command in STATA) with a bandwidth of 0.4.