title: Travel time and attrition from VHA care among women veterans: how far is too far?
abstract: BACKGROUND
  Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care.
  
  
  OBJECTIVE
  We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients.
  
  
  METHODS
  This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients.
  
  
  METHODS
  In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009.
  
  
  METHODS
  An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates.
  
  
  RESULTS
  Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality.
  
  
  CONCLUSIONS
  Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.
authors.affiliation: *Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto †Department of Health Policy and Management, University of California Los Angeles, Los Angeles ‡Women's Health Section, Medical Service, VA Palo Alto Health Care System, Palo Alto §Division of General Medical Disciplines ∥Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford ¶VA Greater Los Angeles Healthcare System, VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles #Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles **Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles ††VA Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Palo Alto ‡‡Department of Epidemiology, University of California Los Angeles, Los Angeles §§Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto ∥∥Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Friedman
authors.forename: Susan M
authors.initials: SM
authors.lastname: Frayne
authors.forename: Eric
authors.initials: E
authors.lastname: Berg
authors.forename: Alison B
authors.initials: AB
authors.lastname: Hamilton
authors.forename: Donna L
authors.initials: DL
authors.lastname: Washington
authors.forename: Fay
authors.initials: F
authors.lastname: Saechao
authors.forename: Natalya C
authors.initials: NC
authors.lastname: Maisel
authors.forename: Julia Y
authors.initials: JY
authors.lastname: Lin
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Hoggatt
authors.forename: Ciaran S
authors.initials: CS
authors.lastname: Phibbs
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001334:Automobile Driving / Q000706:statistics & numerical data*; D006233:Persons with Disabilities; D005260:Female; D006297:Health Services Accessibility; D006305:Health Status Indicators; D006801:Humans; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D012424:Rural Population; D013997:Time Factors; D014195:Travel; D014481:United States; D014505:Urban Population; D058014:Veterans Health; D016387:Women's Health