title: The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction.
abstract: OBJECTIVE
  To examine whether patients admitted for treatment of a myocardial infarction (MI) who live farther from their source of care are less likely to be followed in an outpatient clinic, and whether patients who receive follow-up care are less likely to die or to have a subsequent acute care admission.
  
  
  METHODS
  Department of Veterans Affairs (VA) databases to identify a national sample of 4,637 MI patients discharged in 1992, their use of care, and vital status within the subsequent year. Sociodemographics, comorbid diagnoses, invasive cardiac procedures, hospital teaching status, and distance to patients' admitting hospital were determined.
  
  
  METHODS
  Using these longitudinal data, we examined the relationship between patient characteristics, distance to care, and use of outpatient care after discharge. We then examined the relationship between the use of ambulatory care and subsequent death and readmission.
  
  
  RESULTS
  Patients living more than 20 miles from their admitting hospital were less likely to use ambulatory services. Patients receiving ambulatory care were 79 percent as likely to die within the year as those without any follow-up care (95% C.I. = 0.66, 0.94). Patients living more than 20 miles from their admitting hospital were more likely to die independent of their likelihood of receiving VA outpatient follow-up. Among patients who did not die in the subsequent year, those receiving ambulatory care were 33 percent more likely to be readmitted to a VA hospital with a cardiac diagnosis (95% C.I. = 1.12, 1.57).
  
  
  CONCLUSIONS
  Distance may pose a barrier to outpatient follow-up for some VA patients after a MI. It also may limit patients' ability to access medical care quickly in the event of a recurrent acute event. Ambulatory care after discharge may be an important factor determining survival for patients with cardiac disease.
authors.affiliation: Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park Division, CA 94025, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Piette
authors.forename: R H
authors.initials: RH
authors.lastname: Moos
mesh_terms: D000359:Aftercare; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D002391:Catchment Area, Health; D006297:Health Services Accessibility; D006302:Health Services Research; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D014195:Travel; D014481:United States / Q000453:epidemiology