Bridging the Rural-Urban Care Chasm in Tobacco Treatment

showed that even in an integrated delivery system like the Veterans Health Administration (VHA), barriers persist in accessing evidence-based tobacco dependence treatments (TDT), in this case exacerbated by geographic distance to specialty care.Overall, TDT rates were low among patients with ongoing tobacco use at the time of diagnosis of chronic obstructive pulmonary disease (COPD) throughout the US Department of Veterans Affairs (VA), with comprehensive treatment plans below 5%.The authors 1 further demonstrated a monotonic association between the distance an eligible veteran lives from a pulmonology specialty clinic and the appropriate provision of TDT, even after controlling for demographics and medical comorbidities.With TDT known as one of the most effective means of prolonging life and preserving lung function among patients with COPD, 2 this finding highlights a critical care gap and an essential area for targeting improvement efforts.Indeed, it is concerning that even in an integrated delivery system with known parity with the private sector on health care quality, 3 rates of appropriate TDT lag far behind the optimal numbers needed to quell the ongoing rise in tobacco-related disease.TDT among those with COPD is particularly salient for veterans, who experience high rates of ongoing tobacco use.Complex associations between service-related tobacco uptake and mental health conditions like posttraumatic stress disorder all influence the prevalence of smoking. 4This is also highly relevant as the VA continues to see rising rates of COPD related to tobacco use and possibly toxic deployment-related exposures, impacting approximately 1.25 million former servicemembers. 5Additionally, more than 2.7 million VA beneficiaries live outside major metropolitan areas where large VA medical centers are located, and patients in rural areas tend to be more medically complex and older than those in nonrural communities. 6This pattern is likely to persist if housing costs in cities rise faster than VA benefits, further exacerbating this disparity.Ongoing research questions remain.Baldomero et al 1 highlight an ongoing opportunity to improve care delivery to ensure appropriate tobacco cessation services are provided in this group of patients with substantial burden of use, including via community care referrals (ie, payment by VHA for services provided by non-VHA clinicians) which have expanded under the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act) of 2018.A limitation of this study is that the data were collected from 2012 to 2019, which impairs the capacity to infer whether increased community care access influenced TDT rates related to an increase in non-VA provided primary or specialty care.This will be an important area for further study, particularly as the VA attempts to balance improvements in access to care through community referrals with the challenges of care fragmentation and high costs provided outside its integrated system.Additionally, telehealth utilization rose dramatically within the VA, as it did in many other health care delivery systems, in response to the COVID-19 pandemic, 7 which immediately followed the analysis period of this study.Telehealth has been touted as an essential mode of care for treatment delivery and may be particularly relevant for veterans who live a long distance from specialty care.Additional research over a longer period will be necessary to draw meaningful conclusions about the impact of these changes on care delivery.One critical limitation of telehealth in the private sector is that practitioners are generally required to be licensed in the state where a patient resides, although with some exceptions due to a patchwork of state regulations, which limits their use for individuals accessing services across state lines.Importantly, the VA has been a leader in the use of telehealth and has implemented policies to allow VA health care professionals to practice across state lines, regardless of the practitioner's or the veteran's location within the US (ie, the Anywhere to Anywhere