Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration

Abstract

Background: Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers.

Objective: The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented.

Design: Retrospective, observational, utilizing administrative data.

Subjects: VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT).

Main measures: Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service.

Key results: In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices.

Conclusions: Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

Keywords: Healthcare access; Sleep medicine; Telehealth; Travel burden; Travel distance.

Figure 1

Total distances are presented in millions of miles, with the median patient distance in miles shown in brackets. The total observed travel distances associated with in-person care have been down trending, while the total avoided travel distances due to virtual care have been increasing. Median distances have remained relatively constant. In-person encounter types: Office visits and sleep lab studies (PSG). Virtual encounter types: Virtual provider visits and home sleep apnea tests (HSAT). Observed and excess distances refer to in-person encounters only. Observed distance represents the distance Veterans traveled to receive in-person care. Excess distance represents the extra distance Veterans traveled to receive care if they were not seen at the closest VA facility offering the service. Avoided distances refer to virtual encounters only and represent the distance Veterans would have traveled to receive the equivalent in-person care at the nearest VA facility offering the service. It is assumed virtual care occurs in the home and no travel burden is incurred.

Figure 2

Distances are presented in miles. Most Veterans seeking in-person care have relatively short travel distances, while virtual care treats patients much further away from the VA facility. Graph width represents relative number of Veterans at the specified distance. In-person encounter types: Office visits and sleep lab studies (PSG). Virtual encounter types: Virtual provider visits and home sleep apnea tests (HSAT). Distances shown for in-person visits are the distance traveled by a Veteran to receive care. Distances shown for virtual visits are the distance a Veteran would have traveled to receive the equivalent in-person care. The 25th, 50th (median), and 75th quantiles are shown for each clinic type as horizontal lines within the violin plot. The limit of the graph is drawn at 500 miles for clarity, a small number of encounters do have distances beyond this point. PSG, polysomnography. HSAT, home sleep apnea test.

Figure 3

Total distances are presented in thousands of miles. Excess travel distance represents the difference in distance between where the Veteran received care (observed facility) and the facility closest to the Veteran’s home that offers the medical service of interest (optimal facility). When these two facilities are the same no excess travel distance in incurred, when they differ Veterans travel an excess distance to receive care. The total excess travel distance for all Veterans is shown aggregated at the county level. Only counties with a total excess travel distance of 5000 miles or greater are shown.

Figure 4

Median distances are presented in miles. Avoided travel distance represents the distance between the Veteran’s primary residence and the nearest VA healthcare facility offering the in-person equivalent of the telehealth service. It represents the distance a Veteran would have to travel to receive in-person care and was thus avoided by receiving virtual care. It is assumed that virtual care occurs in the home, and HSAT devices are mailed to the Veteran, and thus no travel burden in incurred for these encounters. The median-avoided travel distance for all Veterans is shown aggregated at the county level. Only counties that have a median avoided distance greater than zero are shown.