title: Echocardiogram utilization among rural and urban veterans.
abstract: OBJECTIVE
  To compare echocardiography use among urban and rural veterans and whether differences could be accounted for by distance.
  
  
  METHODS
  We used Veterans Administration (VA) administrative data from 1999 to 2007 to identify regular users of the VA Healthcare System (VA users) who did and did not receive echocardiography. Each veteran was categorized as residing in urban, rural or highly rural areas using RUCA codes. Poisson regression was used to compare echocardiography utilization rates among veterans residing in each area after adjusting for demographics, comorbidities, clustering of patients within VA networks and distance to the nearest VA medical center offering echocardiography.
  
  
  RESULTS
  Our study included 22.7 million veterans of whom 1.3 million (5.7%) received at least 1 echocardiogram. Of echocardiography recipients, 69.2% lived in urban, 22.0% in rural and 8.8% in highly rural areas. In analyses adjusting for patient demographics, comorbidities, and clustering, utilization of echocardiography was modestly lower for highly rural and rural veterans compared with urban veterans (42.0 vs 40.1 vs 43.1 echocardiograms per 1,000 VA users per year for highly rural, rural and urban, respectively; P< .001). After further adjusting for distance, echocardiography utilization was somewhat higher for veterans in highly rural and rural areas than it was for urban areas (44.9 vs 41.8 vs 40.8 for highly rural, rural and urban, respectively; P< .001).
  
  
  CONCLUSIONS
  Echocardiography utilization among rural and highly rural veterans was marginally lower than for urban veterans, but these differences can be accounted for by the greater distance of more rural veterans from facilities offering echocardiograms.
authors.affiliation: Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA. kingston-okrah@uiowa.edu
authors.forename: Kingston
authors.initials: K
authors.lastname: Okrah
authors.forename: Mary
authors.initials: M
authors.lastname: Vaughan-Sarrazin
authors.forename: Peter
authors.initials: P
authors.lastname: Kaboli
authors.forename: Peter
authors.initials: P
authors.lastname: Cram
mesh_terms: D000368:Aged; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data*; D014505:Urban Population / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data*