title: Quality of care for cardiometabolic disease: associations with mental disorder and rurality.
abstract: BACKGROUND
  This study examines quality of cardiometabolic care among veterans receiving care in the Veterans Affairs (VA) health system. We assess whether quality of care disparities by mental disorder status are magnified for individuals living in rural areas.
  
  
  METHODS
  We identified all patients in a 2005 national Veterans Administration cardiometabolic quality of care chart review. The intersection of this cohort and VA registries, that include patients with and without mental disorder, permitted identification of chart review patients with and without mental disorder. Using residential ZIP code, patients were assigned to rural-urban commuting area codes. We used logistic regression adjusting for age, demographics, comorbidities, and income.
  
  
  METHODS
  We assessed association between rural residence and 9 cardiometabolic care quality indicators including care processes and intermediate outcomes.
  
  
  RESULTS
  Compared with those without mental disorder, patients with mental disorder were less likely to receive diabetes sensory foot exams (OR: 0.82; 95% CI: 0.72-0.94), retinal exams (OR: 0.82; 95% CI: 0.73-0.93), and renal tests (OR: 0.79; CI: 0.74-0.90). Rural residence was associated with no differences in quality measures. Primary care visit volume was associated with significantly greater likelihood of obtaining diabetic retinal examination and renal testing, but did not explain disparities among patients with mental disorder.
  
  
  CONCLUSIONS
  Mental disorder is associated with lesser attainment of quality cardiometabolic care. In this integrated VA care system, rurality and visit volume did not explain this disparity. Other explanations for disparities must be explored to improve the health and health care of this population.
authors.affiliation: Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH, USA. Nancy.e.morden@dartmouth.edu
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Morden
authors.forename: Ethan M
authors.initials: EM
authors.lastname: Berke
authors.forename: Deborah E
authors.initials: DE
authors.lastname: Welsh
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.forename: Todd A
authors.initials: TA
authors.lastname: Mackenzie
authors.forename: Amy M
authors.initials: AM
authors.lastname: Kilbourne
mesh_terms: D000368:Aged; D003920:Diabetes Mellitus / Q000628:therapy*; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D016015:Logistic Models; D001523:Mental Disorders; D008875:Middle Aged; D011320:Primary Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data