Geographic Care Access Barriers Exist in Urban Areas, Impact Minorities

Even in urban areas, long travel distances contribute to geographic care access barriers, particularly for cardiac rehabilitation that’s necessary after a traumatic cardiac event, like a heart attack, researchers from Cedars-Sinai recently found.

Even though 85 percent of folks living in the urban area of Los Angeles County reside within five miles of a cardiac rehab facility, those facilities are concentrated in areas with a higher population of White, Asian, and high-income folks, carving out deep disparities in rehab access.

These findings come as healthcare experts work to understand how geographic care access barriers affect not just those in rural regions but also in urban and suburban ones. This study found that geographic care access barriers exist in urban settings, especially for racial and ethnic minorities.

“We know from prior research that in rural communities, distance to a cardiac rehab facility makes it hard for people to gain access,” Joseph E. Ebinger, MD, a clinical cardiologist and the director of Clinical Analytics at the Smidt Heart Institute, said in a statement.

“We now see that being far from cardiac rehab is not just a problem for people living in rural areas, it’s a problem even for people living in urban areas,” Ebinger, who is also first and co-corresponding author of the study, noted.

Access to cardiac rehab is important for patients who have experienced cardiac trauma, like a heart attack or heart failure. Per the Centers for Disease Control and Prevention (CDC), cardiac rehab can strengthen the heart and body after a heart attack and ease the symptoms of heart problems.

But cardiac rehab has low adherence rates, with enrollment in cardiac rehab being especially low among racial and ethnic minorities.

According to the researchers, geographic care access barriers could be the culprit.

The research team flagged the active cardiac rehab facilities in LA County in 2020, and linked those facility addresses with census-reported demographic and socioeconomic characteristics of communities in LA County. The team also crunched the numbers of how many residents per community live five miles or more from a cardiac rehab facility, a figure chosen because it represents a threshold at which care becomes too far to access.

As noted, 85 percent of the people in LA County lived within five miles of a cardiac rehab center in 2020, but those facilities were concentrated in neighborhoods with more White, Asian, and affluent people making $60,000 or more annually.

Black, Hispanic, and American Indian/Alaska Native folks were more likely to live further than five miles from a cardiac rehab center. Black people were three times more likely to live more than five miles away, while AI/AN people were twice as likely. Hispanic folks were 20 percent more likely to live greater than five miles away from a cardiac rehab facility.

Moving forward, the researchers recommended replicating this study in other locales to better understand broader trends. Additionally, future research should look closely at where there is greater need for new cardiac rehab facilities, according to Susan Cheng, MD, MPH, the director of the Institute for Research on Healthy Aging in the Departent of Cardiology at the Smidt Heart Institute.

“We hope that results from studies like this one can offer key insights for policymakers who could decide to provide incentives to the healthcare industry to open cardiac rehab facilities in communities that lack them,” Cheng, senior and co-corresponding author and the Erika J. Glazer Chair in Women's Cardiovascular Health and Population Science at Cedars-Sinai, said in the press release.

Long travel distances have long been a noted care access barrier for folks living in rural areas. After all, low population density often leads to low clinic or hospital density, meaning there’s more distance between people and their healthcare providers. When patients have a long way to travel to visit the hospital or clinic, they may forego care. And in the case of time-sensitive emergencies like stroke, long travel distances can be disastrous.

But less has been made of travel distances in urban settings. After all, five miles does not always sound like far to travel. But in addition to social determinants of health compounding that distance—it’s hard to travel five miles when you don’t have a care—these travel times become problematic because they do not affect all patients equitably.

As characterized by this study, geographic care access barriers in urban settings are a health equity problem, with people of color being more likely to experience long travel times than their White counterparts. As healthcare continues its focus on health equity, it will be important to view geographic barriers not just as a rural problem, but a health equity problem.