Geographic differences in receipt of addictions treatment in a national sample of patients with alcohol use disorders from the U.S. Veterans Health Administration

Abstract

Background: In the United States, alcohol use disorder (AUD) is common and costly but substantially undertreated. Rurality is an important determinant of health that may influence receipt of evidence-based alcohol-related care. In a large, national sample of Veterans Health Administration (VA) patients with AUD with documented and non-Hispanic Black, Hispanic, or non-Hispanic White race/ethnicity, we examine whether meeting national Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for specialty addictions care and receiving evidence-based medications for AUD differs across patients living in urban, large rural, and small rural areas. Methods: VA electronic health record data were used to identify all patients with AUD documented in Fiscal Year 2012. Rurality was measured using a three-category rural and urban commuting area (RUCA) classification linked to patient zip code. Logistic regression models with clustered standard errors—iteratively adjusted for hypothesized confounders—were used to estimate the likelihood and marginal probabilities of receiving care for patients living in small and large rural areas, relative to urban areas. Primary outcomes included HEDIS initiation (any visit within 14 days of initial AUD visit after a 60-day period of no treatment), HEDIS engagement (2 or more AUD visits within 30 days of HEDIS initiation visit) and having any filled prescription for AUD medications (naltrexone, disulfiram, acamprosate, or topiramate). Results: For all outcomes, patients living in large and small rural areas had a lower likelihood of receiving evidence-based AUD treatment than patients living in urban areas (all p-values < 0.05); differences in marginal probabilities across groups were relatively small. Conclusions: In this national sample of VA patients with AUD, those living in more rural areas were less likely to receive evidence-based treatment for AUD than those living in urban areas. Further research is needed to investigate strategies to increase receipt of specialty care and pharmacotherapy in more rural areas.

Keywords:

• Rurality
• HEDIS
• alcohol use disorder
• medications
• veterans

Disclosure statement

The authors have all approved the manuscript and have no conflicts of interest to declare. Views presented in the manuscript are those of the authors and do not reflect those of the University of Washington, the National Institute on Alcohol Abuse and Alcoholism, the National Institutes of Health, the Department of Veterans Affairs, or the United States Government.

Additional information

Funding

Ms. Edmonds is supported by the Centers for Disease Control and Prevention (CDC/NIOSH) training grant number [T42OH008433]. Dr. Bensley is supported by Award Number [T32AA007240], Graduate Research Training in Alcohol Problems: Alcohol-related Disparities, from the National Institute on Alcohol Abuse and Alcoholism. Dr. Hawkins is supported by the VA Puget Sound Center of Excellence in Substance Abuse Treatment and Education. Dr. Williams is funded through a VA Health Services Research & Development Career Development Award [CDA 12-276]. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.