Rural residents face long travel times to pulmonary rehabilitation programs
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Key takeaways:
- Within the U.S. population, about 47.8% could drive to a pulmonary rehabilitation program in 15 minutes.
- This drive time was mainly seen among those living in densely populated urban areas and major cities.
Residence in a rural or sparsely populated region in the U.S. often meant a long drive to the nearest pulmonary rehabilitation program, according to a research letter published in JAMA Network Open.
“It [a pulmonary rehabilitation program] has been demonstrated across almost the entirety of pulmonary medicine to improve patient health and patient-reported outcomes,” Peter A. Kahn, MD, MPH, ThM, pulmonary and critical care fellow at Yale School of Medicine, said in a press release.
In a cross-sectional study, Kahn and Walter S. Mathis, MD, psychiatrist and health services researcher at Yale School of Medicine, evaluated travel times to pulmonary rehabilitation programs in the lower 48 U.S. states plus Washington, D.C., to compare drive times across location types (rural, urban, suburban) and different racial/ethnic groups.
Researchers determined location type based on the U.S. Census Urban Areas designation. Five-year estimates from the 2021 American Community Survey were used to collect race and ethnicity data.
Notably, technologies, such as an open source routing machine server, allowed researchers to compute minimum travel times.
The total study population included 327,534,982 individuals (median age, 38.4 years; 50.5% female) and included a high proportion of white individuals (49.5%), followed by Hispanic individuals (18.5%), Black individuals (12.3%), Asian individuals (5.5%) and American Indian or Alaska Native individuals (0.6%).
Through the livebetter.org website, researchers identified 1,759 pulmonary rehabilitation sites in their selected locations, including 1,494 (84.9%) sites located in urban areas.
Of the studied population, nearly half (47.8%) could drive to the nearest pulmonary rehabilitation program in 15 minutes. Researchers primarily observed this level of accessibility in densely populated urban areas and major cities.
In addition to the observed 47.8%, 32.5% of the entire cohort lived 30 minutes away from a pulmonary rehabilitation program by car. Individuals with this travel time mainly lived in suburban areas surrounding urban centers, according to researchers.
The drive to a pulmonary rehabilitation program was often longer than 30 minutes for individuals with homes in rural and sparsely populated areas (western and midwestern regions). Researchers even found drives that took more than an hour in rural areas that included more than 14 million individuals.
Having to travel over extended periods of time can be a major roadblock for patients in need of pulmonary rehabilitation, Kahn said in the release.
“First, many patients with chronic respiratory conditions require oxygen supplementation,” Kahn said. “Long commutes may mean they have to transport multiple oxygen tanks or battery supplies, which may cause patients to forgo the treatment. Second, because exertional intolerance is a symptom of these diseases, long travel can be incredibly taxing and also serve as a barrier to participation.”
When assessing travel times by racial/ethnic groups, researchers found that close to one-third (29.7%) of the American Indian and Alaska Native cohort would have to drive for more than an hour to reach a pulmonary rehabilitation program based on the location of their home. It should also be noted that a fair proportion of this racial/ethnic cohort (26.9%) only has to drive 15 minutes to reach a pulmonary rehabilitation program.
The remaining racial/ethnic groups had higher proportions of individuals with shorter travel times (15-minute drive).
According to the press release, telemedicine is a short-term solution for the accessibility issue observed in this study, but a long-term solution comes in the form of “more accessible in-person rehabilitation options.”
“Right now, [insurance] payers limit patients to a small number of lifetime sessions relative to the long-term burden of the disease,” Kahn said in the release. “And that needs to change.”
Reference:
- Pulmonary rehabilitation is difficult for millions of Americans to access. https://news.yale.edu/2024/02/05/pulmonary-rehabilitation-difficult-millions-americans-access. Published Feb. 5, 2024. Accessed Feb. 5, 2024.
Perspective
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Despite its known effectiveness, access to pulmonary rehabilitation (PR) services is inadequate in the U.S. The study by Khan and Mathis assessed nationwide travel time to PR programs as an indicator of PR access. The findings reveal significant disparities in access, especially in rural areas where many require more than an hour’s travel to access a PR program.
These findings are significant but not surprising. Previous studies have shown similar results that access is limited in rural areas. The main difference and strength of this study is the use of travel time, one of the many real-world measures of access. The study also implied racial disparities in PR access. However, an important methodological issue with this conclusion is that the study did not consider how racial/ethnic composition of the population can vary by rurality, which could undercut the findings in this study.
The findings, similar to previous studies, are a wake-up call for policymakers and the health care system to improve PR accessibility, particularly in rural areas. Telehealth PR is an innovative and efficient solution to the accessibility issue. There also is evidence that PR is underprescribed by providers and underutilized by patients, which could be an area for further work with awareness efforts for providers and patients.
Future research should focus on exploring the underlying causes of these disparities; for example, socioeconomic characteristics of communities and patients requiring PR. This will help in the development of interventions to ensure fair access to PR services and improve outcomes for patients with chronic respiratory diseases. Further research also should investigate systemic and long-term solutions for equitable PR access.
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