Healthcare–related Transportation Insecurity Is a Critical Social Risk Factor in Chronic Liver Disease

Healthcare–related transportation insecurity, defined as delayed, missed, or forgone medical care due to transportation barriers, is increasingly recognized as an important social determinant of health.

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Nneka N. Ufere, MD, MSCE, a physician–investigator in the Liver Center in the Division of Gastroenterology at Massachusetts General Hospital and assistant professor of Medicine at Harvard Medical School, Marina Serper, MD, MS, of the University of Pennsylvania, and colleagues recently studied the burden and outcomes of transportation insecurity in the U.S. population with chronic liver disease (CLD).

In Hepatology Communications, they estimate that 6% of adults with CLD report transportation insecurity and that it's associated with other social poor risk factors, self-reported health status, increased healthcare utilization—and mortality.

Methods

The researchers pooled five years of data (2014–2018) from the National Health Interview Survey, which conducts annual, cross-sectional surveys and provides estimates generalizable to the national U.S. population. During the study period, 3,643 non-institutionalized adults self-reported a diagnosis of CLD.

Survey participants were determined to have healthcare–related transportation insecurity if they responded affirmatively to the question, "Have you delayed getting care in the past 12 months because you did not have transportation?"

Prevalence of Transportation Insecurity

Of the 3,643 (representing 5.2 million) U.S. adults with CLD, 267 (representing 307,628) reported transportation insecurity (survey-weighed proportion, 6%). For comparison, previously reported rates are 1.8% in the general U.S. population, 3.1% among patients with cancer, and 4.5% among those with coronary artery disease.

Associations With Other Social Risk Factors

After adjustment for sociodemographic and clinical covariates, transportation insecurity was independently associated with higher odds of:

• Cost-related medication nonadherence—adjusted OR (aOR), 3.5
• Healthcare–related financial insecurity—aOR, 2.1
• Food insecurity—aOR, 3.5

Associations With Health and Work Status

Patients with CLD and transportation insecurity also had significantly higher odds of:

• Self-reported worsening health status over the past year—aOR, 2.5
• Difficulty concentrating or remembering—aOR, 2.6
• Reporting that everything feels like an effort most of the time—aOR, 2.3
• Feeling depressed on a daily basis—aOR, 2.7
• Being unable to work due to poor health—aOR, 3.1

In this cohort, the odds of employment during the past year were significantly lower (aOR, 0.5).

Associations With Healthcare Utilization

Over the preceding year, transportation insecurity was associated with:

• Needing but being unable to afford medical care (aOR, 3.0), follow-up care (aOR, 6.1), specialist care (aOR, 5.8), or mental healthcare (aOR, 6.7)
• Being in a higher-risk category group for the number of visits to the emergency department (aOR, 2.1) and hospital admission (aOR, 1.7)

Association With Mortality

Transportation insecurity among adults with CLD was independently associated with mortality (aHR, 1.7; P=0.024) even after controlling for age, income, insurance status, comorbidity burden, and the presence of other social risk factors.

This finding is important because it shows transportation insecurity is not a surrogate for poverty. It's potentially a much more modifiable social risk factor and represents a critical target for interventions by healthcare systems to improve the health of adults with CLD.

Potential Solutions

Patients who screen positive for healthcare–related transportation insecurity should also be screened for the social risk factors that often co-occur. This can be accomplished using questionnaires such as the Accountable Health Communities Screening Tool or the Supportive Needs Assessment Tool for Cirrhosis.

Expanding access to telemedicine and hospital-at-home models of care could reduce the travel burden for patients with CLD and their care partners. Rideshare-based or transportation and parking voucher programs may increase patient access to hepatology and transplant clinics as well as screening for varices and hepatocellular carcinoma.

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