title: Chronic Lower Limb Wound Outcomes Among Rural and Urban Veterans.
abstract: OBJECTIVE
  Veterans in rural areas generally have lower health care utilization than veterans in urban areas, but the impact of this difference on health outcomes has received little study. Chronic wounds provide a model for studying access to complex chronic care since they often are related to underlying health conditions and require lengthy treatment. Our goals were to describe chronic wound care utilization among rural and urban veterans and to determine the association between rural residence and wound healing.
  
  
  METHODS
  We conducted a retrospective cohort study of 160 rural and 160 urban veterans in the Pacific Northwest with an incident of chronic lower limb wound between October 1, 2006, and September 30, 2007. We followed individuals for up to 1 year, measuring wound care utilization within Veterans Health Administration and Medicare. We compared wound healing using a competing risks proportional hazards model accounting for amputation and death.
  
  
  RESULTS
  Rural veterans had fewer outpatient wound care visits (6.8 vs 9.9) than urban veterans and a similar number of inpatient wound care stays (0.9 and 0.8, respectively). During follow-up, 234 veterans' wounds healed (77% rural, 69% urban). The adjusted hazard ratio for wound healing was 1.11 (95% confidence intervals [CI]: 0.84-1.47, P = .45) for rural compared to urban veterans. The hazard of amputation was higher among rural veterans (hazard ratio [HR] = 2.65, 95% CI: 1.02-6.87, P = .045) and the hazard of death was lower (HR = 0.35, 95% CI: 0.12-0.97, P = .043).
  
  
  CONCLUSIONS
  Despite lower wound care utilization, rural veterans' wounds were as likely to heal as urban veterans' wounds.
authors.affiliation: Health Services Research & Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.|Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington.
authors.forename: Erin D
authors.initials: ED
authors.lastname: Bouldin
authors.affiliation: Health Services Research & Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Taylor
authors.affiliation: Health Services Research & Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.|Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Alyson J
authors.initials: AJ
authors.lastname: Littman
authors.affiliation: School of Medicine, University of Washington, Seattle, Washington.
authors.forename: Mahsa
authors.initials: M
authors.lastname: Karavan
authors.affiliation: Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Rice
authors.affiliation: Health Services Research & Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.|Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington.|Department of Health Services, School of Public Health, University of Washington, Seattle, Washington.
authors.forename: Gayle E
authors.initials: GE
authors.lastname: Reiber
mesh_terms: D000328:Adult; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D007869:Leg Injuries / Q000453:epidemiology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015205:Northwestern United States / Q000453:epidemiology; D016017:Odds Ratio; D012189:Retrospective Studies; D019035:Rural Health Services / Q000706:statistics & numerical data*; D019037:Urban Health Services / Q000706:statistics & numerical data*; D014728:Veterans / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: lower limb; rural health; ulcer; utilization; veterans