title: Older patients with serious mental illness: sensitivity to distance barriers for outpatient care.
abstract: OBJECTIVE
  To inform health services delivery and to demonstrate the appropriateness of understanding access at the individual's level, we evaluated how patient characteristics affect sensitivity to access barriers. We examined one dimension of access: geographic accessibility. We assessed age differences in sensitivity to distance barriers for outpatient psychiatric and nonpsychiatric care among active Department of Veterans Affairs (VA) patients with serious mental illness.
  
  
  METHODS
  Among 142,055 VA patients with bipolar disorder, schizophrenia, or other psychoses in fiscal year 2000, separate random intercepts mixed models were estimated (cluster: nearest site) for outpatient psychiatric and nonpsychiatric visit day volume. In addition to distance and age group (<45, 45-65, or >65), covariates included gender, ethnicity, rural location, psychiatric diagnosis type, Charlson comorbidity level, initial treatment location, and psychiatric diagnosis X distance interactions. Differential distance effects by age were assessed using age X distance interaction terms.
  
  
  RESULTS
  Among VA patients with serious mental illness, distance limits the volume of VA outpatient visits. For nonpsychiatric outpatient care, patients older than 65 were substantially more sensitive to distance barriers (P < 0.0001). For psychiatric outpatient care volume, patients aged 45-65 had slightly increased sensitivity; however, this difference did not have clinical significance.
  
  
  CONCLUSIONS
  The impact of geographic accessibility barriers depended on personal characteristics of the individual and the outpatient service type. For nonpsychiatric outpatient care, older VA patients were most negatively affected by distance barriers. Results may inform efforts to reduce barriers to health care among patients with serious mental illness.
authors.affiliation: Department of Veterans Affairs, VA National Serious Mental Illness Treatment Research and Evaluation Center Ann Arbor, MI 48113-0170, USA. John.McCarthy2@med.va.gov
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.forename: Frederic C
authors.initials: FC
authors.lastname: Blow
mesh_terms: D017677:Age Distribution; D000368:Aged / Q000706:statistics & numerical data*; D001714:Bipolar Disorder / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data*; D044469:Racial Groups / Q000706:statistics & numerical data; D012559:Schizophrenia / Q000628:therapy; D017678:Sex Distribution; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*