GEOGRAPHIC ACCESS AND SERVICE USE IN RURAL DEPRESSION

我们建议1)研究地理上的可达性对 农村地区精神卫生服务的利用情况；2)发展和 检验求医行为的预测空间模型。分析 将使用以前编制的以人口为基础的 470名目前有明显症状的受试者的纵向数据集 抑郁症。地理上的可达性定义为公路旅行 从每个患者到初级保健和专科精神健康中心的距离 照顾者。为了使该构造具有可操作性，我们将收集 研究区域内每个医疗保健提供者的位置信息。 我们假设，住得离供应商更远的个人将是 不太可能为自己的抑郁症状寻求治疗。对于个人而言 在初级保健环境中治疗不成功，我们假设 对专科精神健康的地理可及性差的人 提供者将不太可能通过他们的初级保健被转介 专科精神卫生部门的医生。这些假设将是 使用寻求治疗行为的模型进行测试，这些模型是 患者易感、使能和需求特征，以及提供者 练习属性，尤其是位置。此建议的研究设计 构成了对先前研究的一个重大改进，这些研究接近于 地理上的可访问性，具有简单的农村/城市二分法 解释变量。为测试这些数据而创建的统计模型 假设将被用来开发一个集成模型系统，该系统能够 根据人口普查数据预测总体使用模式。这些预测性的 模型将通过比较预测和实际进行外部验证 在十个不同的基于治疗的患者样本中的利用 初级保健医生在阿肯色州的农村地区执业。这个 建议研究是医疗改革的政策性研究课题。 因为精神卫生保健服务的地理分布可以是 被公共政策修改。这里开发的预测模型可以 理论上用于预测总利用率的变化 在精神卫生保健提供者的空间重新分布和 设施。地理上的可达性作为一种 如果准入的其他方面，如 由于缺乏保险覆盖，在健康的支持下减少了 医疗改革。

We propose to 1) examine the effects of geographical accessibility on the utilization of mental health services in rural areas and 2) to develop and test predictive spatial models of treatment seeking behavior. Analyses will be conducted using a previously compiled population-based longitudinal dataset of 470 subjects with current substantial symptoms of depression. Geographical accessibility is defined as the road travel distance from each patient to primary care and specialty mental health care providers. To operationalize this construct we will collect locational information for every health care provider in the study area. We hypothesize that individuals living further away from providers will be less likely to seek care for their symptoms of depression. For individuals unsuccessfully treated in the primary care setting, we hypothesize that those with poor geographical accessibility to specialty mental health providers will be less likely to be referred by their primary care physician to the specialty mental health sector. These hypotheses will be tested using models of treatment seeking behavior that are a function of patient predisposing, enabling and need characteristics, and provider practice attributes especially location. This proposed research design constitutes a major improvement over prior studies which have approximated geographical accessibility with a simple rural/urban dichotomous explanatory variable. The statistical models created to test these hypotheses will be used to develop a system of integrated models able to predict aggregate utilization patterns from census data. These predictive models will be externally validated by comparing predicted and actual utilization in a different treatment-based sample of patients seen by ten primary care physicians practicing in rural areas throughout Arkansas. The proposed study is a policy relevant research topic for health care reform because the geographic distribution of mental health care services can be modified by public policy. The predictive models developed here could theoretically be used to forecast changes in aggregate utilization following a spatial redistribution of mental health care providers and facilities. The relative importance of geographical accessibility as a treatment barrier is likely to increase if other aspects of access, such as lack of insurance coverage, are reduced under the auspices of health care reform.