摘要：Objectives. We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. Methods. We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. Results. Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural–urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. Conclusions . When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations. Vulnerable patient populations that live in rural settings, such as veterans, 1 the poor , 2 and the elderly 3, 4 have health care needs similar to those of their urban counterparts in several studies. But providing access to a full spectrum of health care services in a rural setting is a difficult undertaking. Access to expensive technologies 5 and specialty care 6, 7 may be limited by the high costs to the health care system associated with providing that care. Although funded federal 8 and nonfederal 9 programs have been effective at improving primary care access in rural settings, physicians may be reluctant to locate their practices in rural settings. 10– 12 The combination of limited numbers of specialists (who for economic reasons need large patient populations to thrive), similar service needs of rural and urban populations, and patients’ tendency to be loyal to local care (preferring their local secondary hospital) in rural settings may result in greater demand for primary care services and may influence primary care practice management. 13 Limitations in resources other than health care in rural settings, such as personal finances, 14, 15 may further restrict access to health care and influence the quality of life of patients. The Veterans Health Administration (VHA) provides comprehensive health care services to veterans across the United States through regional delivery networks. Because of its relatively small service population, regionalizing services within the VHA has required establishing large referral regions, with all VHA tertiary care referral centers located in urban areas. Travel distances for rural veterans who are remote from referral centers may implicitly restrict veterans’ access to these services, and restricted access may result in underutilization of services. 16, 17 If rural veterans have a lower health-related quality of life than their urban counterparts, the cost-efficient strategy of regionalization may concentrate services far away from where the greatest needs exist; such disparities would have important implications for redirecting health care resources. We therefore sought to determine whether there are disparities in the health-related quality of life between veterans who live in rural settings and their suburban or urban counterparts, nationally and at the level of coordination of health care delivery.
