Original research| Volume 98, ISSUE 2, P341-346, February 2017

Geographic Variation in Outpatient Health Care Service Utilization After Spinal Cord Injury

Published:October 27, 2016DOI:



      To assess whether travel distances between patients and providers predict the frequency in which outpatient health care services are accessed after spinal cord injury (SCI).


      A retrospective cohort study was carried out in South Carolina among employee health plan and Medicaid insurance recipients.


      Research center.


      Two years of outpatient claimant data were evaluated from patients (N=243) aged ≥18 years who were hospitalized between 2010 and 2012.


      Travel distances were estimated by geocoding provider and patient address information onto street network files.

      Main Outcome Measures

      Variation in service utilization use was assessed using negative binomial regression. Outpatient visits for physical medicine and rehabilitation, physician and specialty clinic, radiology, internal medicine, behavioral mental health, and “other” were evaluated.


      Longer travel distances were statistically significant predictors of decreased physician/specialty clinic (relative risk [RR]=.87; 95% confidence interval [CI], .79–.96) and physiotherapy (RR=.57; 95% CI, .46–.71) utilization, with mixed findings for other providers. Secondary analyses in which differences in service use were analyzed using census-defined classifications of urban and rural status did not demonstrate any geographic pattern.


      There are significant geographic variations in the use of select outpatient services among SCI populations across the state that are related to longer travel distances. That these patterns were only visible when using travel distance models as opposed to census-based classifications of urban and rural status adds support to augmenting routine data collection and surveillance with spatial analytical models.


      List of abbreviations:

      CI (confidence interval), PEBA (Public Employee Benefit Authority), RFA (Revenue and Fiscal Affairs), RR (relative risk), SC (South Carolina), SCI (spinal cord injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Snow J.
        On the mode of communication of cholera.
        John Churchill, London1855
        • Gubler D.J.
        Dengue and dengue hemorrhagic fever.
        Clin Microbiol Rev. 1998; 11: 480-496
        • Snow R.W.
        • Guerra C.A.
        • Noor A.M.
        • Myint H.Y.
        • Hay S.I.
        The global distribution of clinical episodes of Plasmodium falciparum malaria.
        Nature. 2005; 434: 214-217
        • Kawachi I.
        • Kennedy B.P.
        • Wilkinson R.G.
        Crime: social disorganization and relative deprivation.
        Soc Sci Med. 1999; 48: 719-731
        • Gieryn T.F.
        A space for place in sociology.
        Annu Rev Sociol. 2000; 26: 463-496
        • Nyberg F.
        • Gustavsson P.
        • Jarup L.
        • et al.
        Urban air pollution and lung cancer in Stockholm.
        Epidemiology. 2000; 11: 487-495
        • Clougherty J.E.
        • Levy J.I.
        • Kubzansky L.D.
        • et al.
        Synergistic effects of traffic-related air pollution and exposure to violence on urban asthma etiology.
        Environ Health Perspect. 2007; 115: 1140-1146
        • Wennberg J.
        • Gittelso A.
        Small area variations in health-care delivery.
        Science. 1973; 182: 1102-1107
        • Chassin M.R.
        • Brook R.H.
        • Park R.E.
        • et al.
        Variations in the use of medical and surgical services by the Medicare population.
        N Engl J Med. 1986; 314: 285-290
        • Newhouse J.P.
        • Garber A.M.
        Geographic variation in Medicare services.
        N Engl J Med. 2013; 368: 1465-1468
        • Weissman J.S.
        • Gatsonis C.
        • Epstein A.M.
        Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.
        JAMA. 1992; 268: 2388-2394
        • Margolis D.J.
        • Hoffstad O.
        • Nafash J.
        • et al.
        Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes.
        Diabetes Care. 2011; 34: 2363-2367
        • Will J.C.
        • Nwaise I.A.
        • Schieb L.
        • Zhong Y.N.
        Geographic and racial patterns of preventable hospitalizations for hypertension: Medicare beneficiaries, 2004-2009.
        Public Health Rep. 2014; 129: 8-18
        • Mercier G.
        • Georgescu V.
        • Bousquet J.
        Geographic variation in potentially avoidable hospitalizations in France.
        Health Aff (Millwood). 2015; 34: 836-843
        • Lund B.C.
        • Abrams T.E.
        • Bernardy N.C.
        • Alexander B.
        • Friedman M.J.
        Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder.
        Psychiatr Serv. 2013; 64: 21-27
        • Marcum Z.A.
        • Driessen J.
        • Thorpe C.T.
        • Donohue J.M.
        • Gellad W.F.
        Regional variation in use of a new class of antidiabetic medication among Medicare Beneficiaries: the case of incretin mimetics.
        Ann Pharmacother. 2015; 49: 285-292
        • Wennberg J.E.
        • Barnes B.A.
        • Zubkoff M.
        Professional uncertainty and the problem of supplier-induced demand.
        Soc Sci Med. 1982; 16: 811-824
        • Birkmeyer J.D.
        • Sharp S.M.
        • Finlayson S.R.
        • Fisher E.S.
        • Wennberg J.E.
        Variation profiles of common surgical procedures.
        Surgery. 1998; 124: 917-923
        • Durkin M.S.
        • Davidson L.L.
        • Kuhn L.
        • Oconnor P.
        • Barlow B.
        Low-income neighborhoods and the risk of severe pediatric injury—a small-area analysis in northern Manhattan.
        Am J Public Health. 1994; 84: 587-592
        • Cubbin C.
        • LeClere F.B.
        • Smith G.S.
        Socioeconomic status and injury mortality: individual and neighbourhood determinants.
        J Epidemiol Community Health. 2000; 54: 517-524
        • Haynes R.
        • Reading R.
        • Gale S.
        Household and neighbourhood risks for injury to 5-14 year old children.
        Soc Sci Med. 2003; 57: 625-636
        • Bell N.
        • Schuurman N.
        • Hameed S.M.
        A multilevel analysis of the socio-spatial pattern of assault injuries in greater Vancouver, British Columbia.
        Can J Public Health. 2009; 100: 73-77
        • LaScala E.A.
        • Gerber D.
        • Gruenewald P.J.
        Demographic and environmental correlates of pedestrian injury collisions: a spatial analysis.
        Accid Anal Prev. 2000; 32: 651-658
        • Treno A.J.
        • Johnson F.W.
        • Remer L.G.
        • Gruenewald P.J.
        The impact of outlet densities on alcohol-related crashes: a spatial panel approach.
        Accid Anal Prev. 2007; 39: 894-901
        • Schuurman N.
        • Cinnamon J.
        • Crooks V.A.
        • Hameed S.M.
        Pedestrian injury and the built environment: an environmental scan of hotspots.
        BMC Public Health. 2009; 9: 233
        • Yiannakoulias N.
        • Bennet S.A.
        • Scott D.M.
        Mapping commuter cycling risk in urban areas.
        Accid Anal Prev. 2012; 45: 164-172
        • Cudnik M.T.
        • Newgard C.D.
        • Wang H.
        • Bangs C.
        • Herrington R.
        Distance impacts mortality in trauma patients with an intubation attempt.
        Prehosp Emerg Care. 2008; 12: 459-466
        • Bell N.
        • Simons R.
        • Hameed S.M.
        • Schuurman N.
        • Wheeler S.
        Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001-2006.
        Can J Surg. 2012; 55: 110-116
        • Doumouras A.G.
        • Haas B.
        • Gomez D.
        • et al.
        The impact of distance on triage to trauma center care in an urban trauma system.
        Prehosp Emerg Care. 2012; 16: 456-462
        • Champion H.R.
        • Copes W.S.
        • Sacco W.J.
        • et al.
        The Major Trauma Outcome Study: establishing national norms for trauma care.
        J Trauma. 1990; 30: 1356-1365
        • Yates D.W.
        • Woodford M.
        • Hollis S.
        Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom Major Trauma Outcome Study.
        BMJ. 1992; 305: 737-740
        • Hukkelhoven C.
        • Steyerberg E.W.
        • Farace E.
        • Habbema J.D.
        • Marshall L.F.
        • Maas A.I.R.
        Regional differences in patient characteristics, case management, and outcomes in traumatic brain injury: experience from the tirilazad trials.
        J Neurosurg. 2002; 97: 549-557
        • MacKenzie E.J.
        • Weir S.
        • Rivara F.P.
        • et al.
        The value of trauma center care.
        J Trauma. 2010; 69: 1-10
        • Obirieze A.C.
        • Gaskin D.J.
        • Villegas C.V.
        • et al.
        Regional variations in cost of trauma care in the United States: who is paying more?.
        J Trauma Acute Care Surg. 2012; 73: 516-522
        • Hamlat C.A.
        • Arbabi S.
        • Koepsell T.D.
        • Maier R.V.
        • Jurkovich G.J.
        • Rivara F.P.
        National variation in outcomes and costs for splenic injury and the impact of trauma systems: a population-based cohort study.
        Ann Surg. 2012; 255: 165-170
        • Botticello A.L.
        • Rohrbach T.
        • Cobbold N.
        Disability and the built environment: an investigation of community and neighborhood land uses and participation for physically impaired adults.
        Ann Epidemiol. 2014; 24: 545-550
        • Booth S.
        • Kendall M.
        Benefits and challenges of providing transitional rehabilitation services to people with spinal cord injury from regional, rural and remote locations.
        Aust J Rural Health. 2007; 15: 172-178
        • Goodridge D.
        • Rogers M.
        • Klassen L.
        • et al.
        Access to health and support services: perspectives of people living with a long-term traumatic spinal cord injury in rural and urban areas.
        Disabil Rehabil. 2015; 37: 1401-1410
        • Guilcher S.J.
        • Munce S.E.
        • Couris C.M.
        • et al.
        Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2010; 48: 45-50
        • Jaglal S.B.
        • Munce S.E.
        • Guilcher S.J.
        • et al.
        Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2009; 47: 604-609
        • Munce S.E.
        • Guilcher S.J.
        • Couris C.M.
        • et al.
        Physician utilization among adults with traumatic spinal cord injury in Ontario: a population-based study.
        Spinal Cord. 2009; 47: 470-476
        • Schmitt S.K.
        • Phibbs C.S.
        • Piette J.D.
        The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment.
        Addict Behav. 2003; 28: 1183-1192
        • LaVela S.L.
        • Smith B.
        • Weaver F.M.
        • Miskevics S.A.
        Geographical proximity and health care utilization in veterans with SCI&D in the USA.
        Soc Sci Med. 2004; 59: 2387-2399
        • Mental Health America
        Parity or disparity: the state of mental health in America 2015.
        Mental Health America, Alexandria2014
      1. South Carolina Department of Health and Environmental Control. South Carolina mental health HPSA by type. Available at: Accessed June 1, 2016.

        • Jones T.
        • Ugalde V.
        • Franks P.
        • Zhou H.
        • White R.H.
        Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children.
        Arch Phys Med Rehabil. 2005; 86: 2240-2247
        • Janjua M.B.
        • Yarbrough C.
        • Gamble P.
        • et al.
        Patient demographics, insurance status, and race predict morbidity and mortality after spinal cord injury.
        J Neurosurg. 2015; 123: A520-A521
        • Piatt J.H.
        Pediatric spinal injury in the US: epidemiology and disparities.
        J Neurosurg Pediatr. 2015; 16: 463-471