title: Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers.
abstract: OBJECTIVE
  We examine the impact of two dimensions of access-geographic accessibility and availability-on VA health system and mental health treatment retention among patients with serious mental illness (SMI).
  
  
  METHODS
  Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using county-level VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored.
  
  
  RESULTS
  There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant.
  
  
  CONCLUSIONS
  Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention.
authors.affiliation: Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.forename: Frederic C
authors.initials: FC
authors.lastname: Blow
authors.forename: Marcia
authors.initials: M
authors.lastname: Valenstein
authors.forename: Ellen P
authors.initials: EP
authors.lastname: Fischer
authors.forename: Richard R
authors.initials: RR
authors.lastname: Owen
authors.forename: Kristen L
authors.initials: KL
authors.lastname: Barry
authors.forename: Teresa J
authors.initials: TJ
authors.lastname: Hudson
authors.forename: Rosalinda V
authors.initials: RV
authors.lastname: Ignacio
mesh_terms: D001714:Bipolar Disorder / Q000628:therapy; D003266:Continuity of Patient Care; D005260:Female; D005843:Geography; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000628:therapy*; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D016016:Proportional Hazards Models; D011581:Psychological Tests; D012559:Schizophrenia / Q000628:therapy; D018434:Sickness Impact Profile; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000523:psychology*