The impact of geographic accessibility on the intensity and quality of depression treatment

OBJECTIVES. For depression, this research measures the impact of travel time on visit frequency and the probability of receiving treatment in concordance with AHCPR guidelines. METHODS. The medical, insurance, and pharmacy records of a community-based sample of 435 subjects with current depression were abstracted to identify those treated for depression, to determine the number of depression visits made over a 6-month period, and to ascertain whether treatment was provided in concordance with AHCPR guidelines. A Geographic Information System was used to calculate the travel time from each patient to their preferred provider. Poisson and logistic regression analyses were used to estimate the impact of travel time on visit frequency and guideline-concordance, controlling for patient casemix. RESULTS. In the community-based sample, 106 subjects were treated for depression by 105 different preferred providers. About one-third (30.7%) were treated by a mental health specialist. One average, patients made 2.8 depression visits over the 6-month period. One-third (28.9%) of the patients received guideline-concordant treatment for depression. The average number of visits for those receiving guideline-concordant care was significantly greater than for those not receiving guideline-concordant care (P < 0.01). Travel time to the preferred provider was significantly associated with making fewer visits (P < 0.0001) and having a lower likelihood of receiving guideline-concordant care (P < 0.05). DISCUSSION. For depression, both pharmacotherapy and psychotherapy treatment regimens require frequent provider contact to be effective. This study suggests that travel barriers may prevent rural patients from making a sufficient number of visits to receive effective guideline-concordant treatment.