Does distance to hospital affect emergency department presentations and hospital length of stay among COPD patients?

Association of the Driving Distance, Driving Time, and Public Transit Time to the Hospital with the Persistence of Tumor Necrosis Factor Inhibitors in Patients With Ankylosing Spondylitis: A Retrospective Cohort Study

Purpose

Research on the impact of geographical distance from or travel time to healthcare facilities on treatment adherence among patients with rheumatic diseases is lacking. Therefore, we investigated the association of the driving distance, driving time, and public transit time to the hospital with the persistence of tumor necrosis factor-alpha (TNF-α) inhibitors in patients with ankylosing spondylitis (AS).

Patients and Methods

This 19-year retrospective cohort study was performed in the rheumatology department of a tertiary hospital in Korea and analyzed 313 adult patients with AS who were newly initiated on TNF-α inhibitors. The driving distance, driving time, and public transit time to the hospital were calculated using the Naver Map application. Drug persistence of TNF-α inhibitors was defined as the time duration between the index date and the date of discontinuation without exceeding a treatment gap of 90 days.

Results

The most commonly prescribed TNF-α inhibitor in patients with AS was adalimumab (69.3%), followed by etanercept (21.4%) and infliximab (9.3%). The median driving distance, driving time, and public transit time to the hospital were 16 kilometers (km), 0.6 hours, and 0.8 hours, respectively. In total, 120 (38.3%) patients with AS stopped TNF-α inhibitors over a median follow-up period of 67.1 months. After adjusting confounding factors, the driving distance to the hospital per 10-km increase (hazard ratio [HR]=1.09, p=0.017) and the driving distance to hospital ≧16 km (HR=1.9, p=0.001) were significantly associated with a higher risk of TNF-α inhibitor discontinuation. Neither the driving time nor the public transit time to the hospital was significantly associated with TNF-α inhibitor persistence.

Conclusion

Longer driving distances significantly increased the risk of treatment discontinuation, highlighting the need for healthcare systems to address these barriers.

Impact of Telehealth on Health Disparities Associated With Travel Time to Hospital for Patients With Recurrent Admissions: 4-Year Panel Data Analysis

BACKGROUND

Geographic, demographic, and socioeconomic differences in health outcomes persist despite the global focus on these issues by health organizations. Barriers to accessing care contribute significantly to these health disparities. Among these barriers, those related to travel time-the time required for patients to travel from their residences to health facilities-remain understudied compared with others.

OBJECTIVE

This study aimed to explore the impact of telehealth in addressing health disparities associated with travel time to hospitals for patients with recurrent hospital admissions. It specifically examined the role of telehealth in reducing in-hospital length of stay (LOS) for patients living farther from the hospital.

METHODS

We sourced the data from 4 datasets, and our final effective sample consisted of 1,600,699 admissions from 536,182 patients from 63 hospitals in New York and Florida in the United States from 2012 to 2015. We applied fixed-effect models to examine the direct effects and the interaction between telehealth and patients' travel time to hospitals on LOS. We further conducted a series of robustness checks to validate our main models and performed post hoc analyses to explore the different effects of telehealth across various patient groups.

RESULTS

Our summary statistics show that, on average, 22.08% (353,396/1,600,699) of patients were admitted to a hospital with telehealth adopted, with an average LOS of 5.57 (SD 5.06) days and an average travel time of about 16.89 (SD 13.32) minutes. We found that telehealth adoption is associated with a reduced LOS (P<.001) and this effect is especially pronounced as the patients' drive time to the hospital increases. Specifically, the coefficient for drive time is -0.0079 (P<.001), indicating that for every additional minute of driving time, there is a decrease of 0.0079 days (approximately 11 minutes) in the expected LOS. We also found that telehealth adoption has a larger impact on patients frequently needing health services, patients living in high internet coverage areas, and patients who have high virtualization potential diseases.

CONCLUSIONS

Our findings suggest that telehealth adoption can mitigate certain health disparities for patients living farther from hospitals. This study provides key insights for health care practitioners and policy makers on telehealth's role in addressing distance-related disparities and planning health care resources. It also has practical implications for hospitals in resource-limited countries that are in the early stages of implementing telehealth.

Exploring Factors Contributing to Chronic Obstructive Pulmonary Disease (COPD) Guideline Non-Adherence and Potential Solutions in the Emergency Department: Interdisciplinary Staff Perspective

Purpose

Acute exacerbations of chronic obstructive pulmonary disease (COPD) have a significant and prolonged impact on health-related quality of life, patient outcomes, and escalation of pulmonary function decline. COPD-X guidelines published in 2003 subsist to facilitate a shift from the emphasis on pharmacological treatment to a more holistic multi-disciplinary interventions approach. Despite the existing comprehensive recommendations, readmission rates have increased in the last decade. Evidence to date has reported sub-optimal COPD guidelines adherence in emergency departments. This qualitative study explored contributing factors to interdisciplinary staff non-adherence and utilisation of COPD-X guidelines in a major Southern Queensland Emergency Department.

Methods

Semi-structured qualitative interviews with interdisciplinary staff were conducted in an emergency department. A purposive sample of doctors, nurses, physiotherapists, pharmacist and a social worker were recruited. Interviews were digitally recorded, de-identified and transcribed verbatim. Data analysis followed a coding process against the Theoretical Domains Framework (TDF) to examine implementation barriers and potential solutions. Identified factors affecting non-adherence and underutilisation of guidelines were then mapped to the capability, opportunity, motivation, behaviour model (COM-B) and behaviour change wheel (BCW) to inform future implementation recommendations.

Results

Prominent barriers influencing the clinical uptake of COPD guidelines were identified using TDF analysis and included knowledge, professional role clarity, clinical behaviour regulation, memory, attention, and decision process, beliefs about departmental capabilities, environmental context and resources. Potential interventions included education, training, staffing, funding and time-efficient digitalised referrals and systems management reminders to prevent COPD readmissions, remissions and improve patient health-related quality of life.

Conclusion

Implementation strategies such as electronic interdisciplinary COPD proforma that facilitates a multimodal approach with appropriate patient/staff resources and referrals prior to discharge from an ED require further exploration. Greater clarity around which components of the COPD X guidelines must be applied in ED settings needs to stem from future research.