Association Between a Temporary Reduction in Access to Health Care and Long-term Changes in Hypertension Control Among Veterans After a Natural Disaster
Association Between a Temporary Reduction in Access to Health Care and Long-term Changes in Hypertension Control Among Veterans After a Natural Disaster
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DOI：
10.1001/jamanetworkopen.2019.15111
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发表时间：
2019-11-01
影响因子：
13.8
通讯作者：
Schwartz, Mark D.
中科院分区：
文献类型：
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作者：
Baum, Aaron;Barnett, Michael L.;Schwartz, Mark D.
卫生保健获得的暂时中断是常见的，但其与慢性病控制的关系尚不清楚。目的：评估慢性疾病控制的长期变化是否与6个月内获得卫生保健服务的暂时减少有关。设计、环境和参与者本队列研究调查了超级风暴桑迪过后，退伍军人事务部（VA）纽约港医疗保健系统曼哈顿设施关闭6个月后慢性病控制的长期变化，该地区退伍军人的医疗保健服务受到严重干扰。2010年10月29日至2014年10月29日期间，VA医疗保健系统的电子健康记录被用于确定81844名退伍军人，这些退伍军人在超级风暴“桑迪”过后的6个月里受到VA曼哈顿医疗中心的影响。其中，19 207名退伍军人被纳入暴露组，62 337名退伍军人被纳入未暴露组，其中包括同样暴露于风暴的退伍军人，但在风暴期间和之后，他们可以定期从3个退伍军人医疗中心（纽约的布鲁克林和布朗克斯以及康涅狄格州的纽黑文）获得医疗服务。采用差异中差异分析来评估在医疗保健机会减少的队列与未接触医疗保健机会减少的类似队列之间，慢性疾病控制随时间的患者内部变化。所有的分析都根据个人人口统计和社会经济特征、邮政编码之间的差异和共同的时间趋势进行了调整。数据分析时间为2016年2月1日至2019年9月30日。2012年10月29日飓风桑迪过后，VA曼哈顿医疗中心关闭了6个月。主要结局和测量结果测量的结果是不受控制的血压（定义为每例患者每季度平均血压140/90 mmHg），不受控制的糖尿病（定义为每例患者每季度平均血红蛋白A(1c) 8%），不受控制的胆固醇（定义为每例患者每季度平均低密度脂蛋白140 mg/dL）和患者体重。结果纳入研究的81 544名退伍军人平均（SD）年龄为62.1（17.6）岁，男性占93.6%，白人占62.7%，黑人占31.8%。在VA曼哈顿医疗中心6个月设施关闭的3个月中点，与关闭前47.8%的基线相比，每个季度进行任何VA初级保健访问的退伍军人百分比绝对下降了24.8%(95% CI, -26.5%至-23.0%;P < 0.001)（相对下降，51.9%;95% CI, -55.4%至-48.1%;P < 0.001）。设施重新开放一年后，暴露组与未暴露组之间接受初级保健就诊的患者百分比没有差异变化（绝对下降，-0.1%;95% CI, -1.5%至1.4%;P = 0.94）；然而，暴露组患者血压失控的可能性比未暴露组患者高25.9%（未经调整，暴露组增加5.5%，未暴露组增加1.3%；调整绝对增加5.0%;95% CI, 3.5%-6.0%; P < .001）。超级风暴桑迪两年后，暴露组患者出现血压失控的可能性比未暴露组患者高10.9%（未经调整的增加，暴露组增加5.2%，未暴露组增加3.5%；调整的绝对增加2.1%;95% CI, 0.5%-3.6%; P < .001）。与非暴露组相比，暴露组在设施关闭期间每季度每位患者的处方填写量减少6.9%（绝对减少，每季度每位患者填写-0.7张处方；95% CI, -0.9至-0.5;P < .001），在设施重新开放后每年减少2.2%（绝对减少，每季度每位患者填写-0.2张处方；95% CI, -0.4至-0.1;P = .04）。未控制的糖尿病、未控制的胆固醇或患者体重未观察到差异变化。结论和相关性在这项研究中，在曼哈顿退伍军人医院重新开放1年多后，暂时减少获得医疗保健服务的机会与不受控制的高血压发病率增加有关，但与不受控制的糖尿病或高脂血症发病率增加无关。在获得卫生保健方面的暂时差距可能与高血压患者不受控制的血压长期升高有关。
IMPORTANCE Temporary disruptions in health care access are common, but their associations with chronic disease control remain unknown.OBJECTIVE To evaluate whether long-term changes in chronic disease control were associated with a temporary 6-month decrease in access to health care services.DESIGN, SETTING, AND PARTICIPANTS This cohort study examined the long-term changes in chronic disease control associated with the 6-month closure of the Manhattan facility of the Veterans Affairs (VA) New York Harbor Healthcare System after superstorm Sandy, which caused a significant disruption in health care access for veterans in the region. Electronic health records from the VA Healthcare System between October 29, 2010, and October 29, 2014, were used to identify a total of 81 544 veterans who were and were not exposed to the 6-month closure of the VA Manhattan Medical Center after superstorm Sandy. Of those, 19 207 veterans were included in the exposed cohort and 62 337 were included in the nonexposed control cohort, which included veterans who were equally exposed to the storm but who retained regular access to health care from 3 VA medical centers (Brooklyn and the Bronx in New York and New Haven in Connecticut) during and after the storm. A difference-in-differences analysis was used to assess within-patient changes in chronic disease control over time between a cohort that was exposed to decreased health care access compared with a similar cohort that was not exposed to decreased access. All analyses adjusted for individual demographic and socioeconomic characteristics, between-zip code differences, and common time trends. Data analyses were conducted between February 1, 2016, and September 30, 2019.EXPOSURE The 6-month closure of the VA Manhattan Medical Center after superstorm Sandy on October 29, 2012.MAIN OUTCOMES AND MEASURES The outcomes measured were uncontrolled blood pressure (defined as mean blood pressure per patient per quarter >140/90 mmHg), uncontrolled diabetes (defined as mean hemoglobin A(1c) per patient per quarter >8%), uncontrolled cholesterol (defined as mean low density lipoprotein per patient per quarter >140 mg/dL), and patient weight.RESULTS Among the 81 544 veterans included in the study, the mean (SD) age was 62.1 (17.6) years, and 93.6% were men, 62.7% were white, and 31.8% were black. At the 3-month midpoint of the 6-month facility closure of the VA Manhattan Medical Center, an absolute decrease of 24.8%(95% CI, -26.5% to -23.0%; P < .001) was observed in the percentage of veterans who had any VA primary care visit per quarter compared with a baseline of 47.8% before the closure (relative decrease, 51.9%; 95% CI, -55.4% to -48.1%; P < .001). One year after the facility reopened, no differential change was observed in the percentage of patients with a primary care visit between the exposed vs nonexposed cohorts (absolute decrease, -0.1%; 95% CI, -1.5% to 1.4%; P = .94); however, patients in the exposed cohort were 25.9% more likely to have uncontrolled blood pressure than patients in the nonexposed cohort (unadjusted increase, 5.5% in the exposed cohort vs 1.3% in the nonexposed cohort; adjusted absolute increase, 5.0%; 95% CI, 3.5%-6.0%; P < .001). Two years after superstorm Sandy, patients in the exposed cohort were 10.9% more likely to experience uncontrolled blood pressure than those in the nonexposed cohort (unadjusted increase, 5.2% in the exposed cohort vs 3.5% in the nonexposed cohort; adjusted absolute increase, 2.1%; 95% CI, 0.5%-3.6%; P < .001). Compared with the nonexposed cohort, the exposed cohort also experienced a decrease in filled medication prescriptions per patient per quarter of 6.9% during the facility closure (absolute decrease, -0.7 prescriptions filled per patient per quarter; 95% CI, -0.9 to -0.5; P < .001) and of 2.2% a year after the facility reopened (absolute decrease, -0.2 prescriptions filled per patient per quarter; 95% CI, -0.4 to -0.1; P = .04). No differential changes were observed in uncontrolled diabetes, uncontrolled cholesterol, or patient weight.CONCLUSIONS AND RELEVANCE In this study, a temporary period of decreased access to health care services was associated with increased rates of uncontrolled hypertension, but not with increased rates of uncontrolled diabetes or hyperlipidemia, more than 1 year after the Manhattan VA facility reopened. Temporary gaps in access to health care may be associated with long-term increases in uncontrolled blood pressure among patients with hypertension.