Showing papers in "Journal of Rural Health in 1999"

Cardiovascular disease risk factors and obesity of rural and urban elementary school children.

Abstract: Previous studies on the influence of a rural/urban setting on the prevalence of cardiovascular disease risk factors in children have not sufficiently controlled for socioeconomic status, race, gender, and perhaps, may not have included a representative sample of rural and urban children. This study compared the cardiovascular disease risk factors and rate of obesity of children living in rural and urban settings. It also determined the magnitude of the effect of the rural/urban setting on cardiovascular disease risk factors and obesity when controlling for race, socioeconomic status, and gender. The subjects were 2,113 third- and fourth-grade children; 962 from an urban setting and 1,151 from a rural setting. Height, weight, skinfolds, resting blood pressure, and total cholesterol levels were measured. Aerobic power (pV02max) was estimated from cycle ergomerty. Physical activity and smoking history were obtained from a questionnaire. Clustering analyses using adjustment for sample error indicated that total cholesterol, blood pressure, smoking, and physical activity levels of rural and urban children were not different (P>0.10); however, body mass index and sum of skinfolds was greater for rural youth (P<0.004). Logistic regression indicated that rural children had a 54.7 percent increased risk of obesity (P=0.0001). This study's results indicate that, in children, a rural setting is associated with obesity, but not with the major risk factors associated with cardiovascular disease.

Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania.

Abstract: While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.

Multi-method assessment of access to primary medical care in rural Colorado

Abstract: The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Rural primary care providers' perceptions of their roles in the provision of mental health services: voices from the plains.

Abstract: Much has been written about the deficiencies of primary care providers in their treatment patterns, referral patterns and training for treating people with mental disorders. However, there is a growing realization that, regardless of these shortcomings, primary care providers will continue to be sought out by patients for care of mental disorders, due to patient preference, lack of alternatives or other reasons. Thus, a more recent focus has been on improving the link between primary care providers and mental health specialists. This may include integrated clinics, telecommunication links or simply enhancing the competency of primary care providers through clinical practice guidelines, utilization of screening instruments and greater contact with mental health professionals. Conspicuously absent from most of these studies, commissioned reports and policy papers is the voice of the rural primary care provider. Perhaps due to their heavy practice schedules, little has been written from their perspective. Accordingly, this paper presents the findings from a focus group held in early 1998, of a group of rural primary care providers who practice on the Western plains. It is in this forum that these providers discuss how they perceive their role, their treatment and referral patterns and their feelings and relationships with psychiatrists and the mental health system.

Community perceptions of the effects of rural hospital closure on access to care.

Abstract: The purpose of this case study was to ascertain the perceptions of health professionals who were located in six rural communities where hospital closure occurred, regarding the impact of closure on community residents. These health professionals were asked to respond to questions about effects of hospital closures on the availability of medical services such as emergency care, physician services, hospital services and nursing home care. To control for trends in medical services utilization that were unrelated to hospital closure, the study design included comparison areas where similar hospitals remained open. A standardized questionnaire was administered to three health professionals in each of the areas that experienced a hospital closure and also in the matched comparison areas. Interviews of the health professionals in closure areas provide evidence suggestive of some perceived negative effects of hospital closure on these communities. These negative effects include difficulty recruiting and retaining physicians, concern of residents about the loss of their local emergency room, and increased travel times to receive hospital services. The perceived effects of closure appeared to be mediated by the distance required for travel to the nearest hospital. Respondents perceived increased travel times to most significantly affect vulnerable populations, such as the elderly, the disabled and the economically disadvantaged. Respondents in the majority of comparison areas also reported access barriers for vulnerable populations. These barriers primarily center on problems of obtaining transportation and enduring the rigors of travel. Improvements in the availability of transportation to medical care may offer some stabilization to communities where hospitals closed; however, it also is the case that transportation improvements are needed to increase access to care in rural communities where hospitals remained open.

Treatment of depression in rural Arkansas: policy implications for improving care.

Abstract: Policy-makers have long suspected that greater barriers to care result in depressed rural residents being less likely to receive high-quality treatment. This study recruited 470 depressed community residents in a 1992 telephone survey, followed 95 percent of them through one year, and abstracted additional data on their health care utilization from insurance claims, medical and pharmacy records. Bivariate and multivariate models demonstrated that during the year following the baseline, there were no significant rural-urban differences in the rate (probability of any outpatient depression treatment), type (probability of receiving general medical depression care only), or quality (completion of guideline-concordant acute-stage care) of outpatient depression treatment. Annual expenditures for outpatient depression treatment were lower for rural subjects compared with their urban counterparts. Rural subjects had 3.05 times the odds of being admitted to a hospital for physical problems and 3.06 times the odds of being admitted to a hospital for mental health problems during the year following baseline compared with urban subjects. Cost-offset analyses demonstrate that every dollar invested in depression treatment was associated with a $2.61 decrease in the cost of treating physical problems in depressed rural residents. Limited insurance coverage and limited availability of services were the most significant barriers to specialty and general medical outpatient treatment for depression in both rural and urban residents. More than 80 percent of depressed residents in both rural and urban areas visited a primary care provider during the year following baseline. The potential cost offset of depression treatment in rural populations plus the improvement in productivity observed in both rural and urban populations indicate that it may be economically possible to improve quality of care for depression without bankrupting an already strained health care budget.

Economic impact of hospital closure on small rural counties, 1984 to 1988: demonstration of a comparative analysis approach.

Abstract: Hospital closure in a rural community may affect the locale's economic prospects as well as the health of its residents. Studies of economic effects have primarily relied on modeling techniques rather than observation of actual change. This study demonstrates the use of a comparative analysis approach for estimating the economic effects of hospital closure on small rural counties. The experiences of 103 small rural counties at which a hospital closed between 1984 and 1988 was compared with a matched group of counties at which no closure took place. "Comparable" counties were selected based on seven scales measuring the similarity between a closure county and potential comparisons. Three scales examined population and economic characteristics in the year before closure; two scales measured change throughout a three-year period preceding closure; and two scales measured change throughout a five-year period preceding closure. Closure effects were measured through a multivariate analysis of the post-closure economic history of closure and comparison counties. The key assumption is that similar counties should have similar experiences over time. If an event occurs within some of these counties but not others, this event should have visible effects. Comparative analysis suggested that earned income in closure counties (excluding farming and mining income) was lower than in comparison counties subsequent to closure and that labor force growth was similarly affected. A comparative analysis approach produces results that parallel those obtained from economic modeling and should be considered for further research.

Analysis of Tractor-related Deaths in North Carolina From 1979 to 1988

Abstract: This descriptive study examined 342 fatalities involving tractors and attachments that occurred during a 10-year period in North Carolina from 1979 to 1988. Reports of the North Carolina Office of the Chief Medical Examiner and medical examiner's certificates of death were reviewed using the public health model of causation. Data were collected on characteristics of thefatally injured (host), including age, occupation, blood alcohol concentration and length of survival; characteristics of the injury event (environment), including type of accident, weather conditions and terrain; and characteristics of the agent, including both the tractor and attachments, if any, in place at the time of injury. Ninety-eight percent of the victims were male. Victims ages 65 and older accounted for 38 percent of fatal injuries, and 11 percent were 18 years of age or younger. Only slightly more than one-half of the victims (54 percent) were full- or part-time farmers. Forty-four percent of the deaths were to nonfarmers who were not in the act of farming. Nineteen percent of tested victims had a detectable blood alcohol level. Almost three-fourths of the victims died in the first hour after injury and 87 percent within the first 24 hours. In the majority of accidents, the tractor operator was a victim of a rollover or runover. This study provided detailed characterization of the fatally injured and, to the extent possible, the tractor involved and the injury event itself. However, additional methods of data collection are needed to provide further characterization of the injury event and the injury agent to design and support prevention programs for tractor users. Language: en

Physician assistants and nurse practitioners: rural-urban settings and reimbursement for services.

Abstract: Evidence based on productivity measures, salaries and costs of medical education indicates that physician assistants and nurse practitioners are cost-effective. Managed care suggests that health maintenance organizations (HMOs) would seek to utilize these professionals. Moreover, underserved rural areas would utilize physician assistants and nurse practitioners to provide access. This study examined the role of payment sources in the utilization of physician assistants and nurse practitioners using the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the National Center for Health Statistics, U.S. Centers for Disease Control and Prevention. Rural vs. urban results were compared. The study found that significant rural-urban differences exist in the relationships between payment sources and the utilization of physician assistants and nurse practitioners. The study also found that payment source affects varied for physicians, physician assistants and nurse practitioners who saw outpatients in hospital settings. Surprisingly, prepaid and HMO types of reimbursements are shown to have no relationship with physician assistant and nurse practitioner utilization, and this finding is the same for both rural and urban patient visits. After controlling for other influences, the study shows that physicians, physician assistants and nurse practitioners are each as likely as the other to be present at a rural managed care visit. However, physicians are much more likely than physician assistants and nurse practitioners to be present at an urban managed care visit.

Are there need-based geographical differences between international medical graduates and U.S. medical graduates in rural U.S. counties?

Abstract: The objectives of this study are to compare the rural location of international medical graduates (IMGs) and U.S. medical graduates (USMGs) by specialty (primary care vs. specialty care) according to geographical measures of need. This study utilized a cross-sectional survey using the 1997 American Medical Association Physician Masterfile for all active post-resident allopathic physicians and the Area Resource File (ARF) (Bureau of Health Professions, 1996) for all active post-resident osteopathic physicians in 1995 in the rural U.S. physician work force (N = 69,065). Allopathic physician ZIP code location was matched to county data using the ARF. The key measure was the difference in proportions between USMGs and IMGs in each state's rural counties characterized by need: high infant mortality, low socioeconomic status, high proportion of nonwhite population, high proportion of population 65 years and older, and low physician-to-population ratio. Primary care and specialty care rural physicians were studied separately. A disproportion of IMGs were located in needy rural counties of more states than were USMGs. Further, IMG disproportions were generally larger than USMG disproportions when they existed. Disproportions of IMGs tended to be located more often in the central and south census regions. Disproportions of specialty care IMGs were more frequent and of greater magnitude than those of primary care IMGs. Variations in the relative and absolute numbers of IMGs and USMGs among the states was wide. Services delivered by active post-resident primary care and specialty care IMGs appeared to be disproportionate to their overall number compared with USMGs in numerous needy rural counties. The extent of the IMG "safety net" presence differed, however, by the criteria used. Still, proposed limits on IMG entry into U.S. residency training may create long-term problems of access to rural physician services absent policies to induce USMGs or midlevel practitioners to locate in such areas. State-by-state assessments of the potential impact of IMG restrictions are called for because of the wide state-level variation that existed in comparative IMG-USMG distributions.

Rural and urban physicians: does the content of their Medicare practices differ?

Abstract: Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties Overall, 144 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty Rural physicians were older and less likely to be female than urban physicians Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (eg, hypertension, diabetes) than their urban counterparts The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients

A rural cancer outreach program lowers patient care costs and benefits both the rural hospitals and sponsoring academic medical center.

Abstract: The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.

Health-related quality of life: does rurality matter?

Abstract: This study addresses the question of whether six health-related quality-of life domains are related to population density within a rural area while adjusting for the effects of demographic characteristics and social support resources. The sample consisted of 2,178 adults aged 60 years or older who resided in eastern North Carolina between 1989 and 1991. Ordinary least squares regression estimation was used to analyze this survey data. For the analyses, rural residence was broken down into five levels reflecting population density, which was compared with analyses utilizing a collapsed dichotomous residential measure. Results indicate that a more detuiled residence measure within a predominantly rural area provides valuable information that would otherwise be concealed by a dichotomous measure.

Rural Health Research: Rural Hospitals and the Local Economy: A Needed Extension and Refinement of Existing Empirical Research

Abstract: The relationship between the health care sector and the rural economy is of increasing importance. Much additional research is needed to fully understand this relationship and to address some of the limitations of the modest amount of research that already exists. In this study, data from Nebraska were used to create a four-part typology of rural hospitals. Input-output analysis was used to assess the economic effects of each type of hospital on the local economy and to simulate the effects of three different changes or scenarios: an increase or decrease in hospital utilization; the elimination of local purchases of non labor inputs; and a change in the mix or configuration of services provided. While the hospital is an important contributor to local economies, this contribution is not constant across hospital types. The total job-related effects ranged from 77 jobs for the smallest type of rural hospital to 1,332 for the largest type. Service and trade (retail plus wholesale) are the two sectors of the local economy most heavily influenced by the presence of a hospital. In today's changing and challenging environment, there is a great need for researchers to create and evaluate the economic effects of a variety of relevant and realistic scenarios (other than hospital closure).

Characterization of rural mental health service systems.

Abstract: This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on non specialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on non mental health agencies, rural mental health agencies are more interdependent.

Eliminating Primary Care Health Professional Shortage Areas: The Impact of Title VII Generalist Physician Education

Abstract: Most policy-makers and researchers agree that although the United States is headed for a significant physician surplus, problems of equity in access to care still remain To help meet this challenge, Title VII of the Public Health Service Act focuses on producing generalist physicians to serve in medically underserved areas (MUAs) This study estimates the impact Title VII support for generalist training has on reducing and eliminating health professional shortage areas (HPSAs) under multiple scenarios that vary either the Title VII funding level or the percentage of Title VII-funded program graduates who practice in MUAs For each scenario, the number of Title VII-funded residency graduates who initially practice in MUAs and the time it would take to eliminate HPSAs are estimated Using 1996 rates, the analysis predicts that 1,214 generalist physicians will enter practice in HPSAs annually, leading to elimination of HPSAs in 24 years In 1997, Title VII-funded programs increased the rate of graduates entering HPSAs, resulting in 1,357 providers and reducing the time for HPSA elimination to 15 years Doubling the funding for these programs would increase the number of Title VII-funded generalist physicians entering MUAs and could decrease the time for HPSA elimination to as little as 6 years The study concludes that eliminating HPSAs requires broader Title VII influence and continuous improvement in rates of production of graduates who practice in MUAs Without Title VII graduates and continuous improvement of Title VII program, MUA rates, the number of HPSAs and the number of Americans with reduced access to essential health care will continue to expand

Dimensions of Retention: A National Study of the Locational Histories of Physician Assistants

Abstract: This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as "all rural," "all urban," "urban to rural" or "rural to urban." The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.

Rural Health Research: Factors Affecting Use of Chiropractic Services in Seven Midwestern States of the United States

Abstract: Although chiropractic is used by approximately 10 percent of the U.S. population, predictors of its use have not been definitively described. Previous studies have suggested that chiropractic users differ from nonusers in a number of sociodemographic characteristics, but their findings are inconsistent, perhaps because of differences in populations sampled and dates of data collection, most of which are prior to 1990. Regional studies have been conducted in rural areas based on the premise that rural residents are more likely than non-rural residents to use chiropractice; however, this premise has not been definitively documented. The purpose of this study was to provide clarification of these sociodemographic predictors of chiropractic use in Illinois, Iowa, Minnesota, Missouri, Nebraska, South Dakota and Wisconsin by characterizing chiropractic users and nonusers in terms of sociodemographics, including rural or non-rural residence, and presence of low back pain. Data from 1,511 respondents to a 1994 population-based survey, conducted by the University of Iowa Social Science Institute, were analyzed. Unconditional logistic regression was used to derive odds ratios and 95 percent confidence intervals for univariate and multiple regression models. Overall, 15.1 percent of respondents had used chiropractic within the last year, most often for low back pain (57 percent). Chiropractic use was less likely in African Americans, Hispanics and Asians than whites, less likely by non-rural than rural residents, and less likely in Catholics than Protestants in states other than Iowa and South Dakota. Overall, 42.7 percent of workers with low back pain reported using chiropractic, and use increased with age but remained significantly related to race, rural or non-rural residence, state of residence and religious preference. Race, rural or non-rural residence, state of residence and religious preference, independently of low back pain, affect use of chiropractice in seven Midwestern states.

Consumer and provider evaluation of rural pharmacy services.

Abstract: This paper compares consumer and provider perceptions regarding access to pharmacy services in rural Illinois, given a decrease in the number of pharmacies. Consumer data are from the Illinois Rural Life Panel in which more than 1,800 respondents answered questions about availability and use of pharmacy services and about insurance coverage and cost. A survey of all licensed retail pharmacies in 74 rural Illinois counties and in seven non-rural counties provided pharmacy background information and was the source of data on changes in profitability and payment sources. The data provided insight on factors that affect access. Descriptive statistics were used to analyze data from both groups to compare perceptions about access. The objective was to evaluate current access to pharmacy services and implications for future access from the perspective of consumers and pharmacists. Results from rural consumers show access is currently good; 77 percent have a local pharmacy, and 64 percent prefer this source. Future access is of more concern. Pharmacy survey results show 81.5 percent of rural pharmacies are experiencing declining profits from drug sales. Restricted reimbursements from third-party payers, demands of managed care and expanded competition are seen as threats to retention of local pharmacies and continued good access. An important finding, especially given survey evidence of increased managed care penetration, is the difference in views of pharmacists and consumers regarding the effects of managed care on access. Pharmacy survey data also revealed differences between rural and non-rural pharmacies.

Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply

Abstract: Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed care for physical and behavioral health care is expanded to rural areas This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries Rural and urban Aid for Families with Dependent Children (AFDC)- and Supplemental Security Income (SSU-beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states

Rural Health Research: Do Advanced Practice Nurses and Physician Assistants Benefit Small Rural Hospitals?

Abstract: Advanced practice nurses and physician assistants have offered small, rural hospitals an alternative to scarce primary care physicians for 30 years. This paper uses survey data from 285 small rural hospitals and case studies of 36 of these hospitals to answer questions about the extent to which advanced practice nurses and physician assistants provide primary care in small, rural hospitals, the benefits that might bring to the hospitals as well as the reactions of the public. The study used survey data collected as part of an evaluation of 285 hospitals, which received a Rural Health Care Transition grant from the Health Care Financing Administration in 1993 and 1994. Most of the hospitals used the practitioners; 70 percent used nurse practitioners; 30 percent used physician assistants; and 20 percent used both. There were some negative reactions to the use of the practitioners, but, overall, there was acceptance and benefits to the hospitals in the form of reduced recruitment costs, increased revenues and increased service offerings. These practitioners are beneficial to rural hospitals, and mechanisms to encourage their acceptance should be developed and implemented.

Can community organization strategies be used to implement smoking and dietary changes in a rural manufacturing work site

Abstract: A one-year intervention project was developed and implemented to demonstrate the utility of using community organization methods to mobilize a rural, predominantly minority work site community toward smoking and dietary change. This intervention for smoking and dietary change was conducted in a rural work site (n = 235 at baseline) and guided by employees. It involved activities to change the work site environment and the behaviors of individuals. A community advisory board (n = 15) made up of members of the work site was established, and it met monthly with members from the research team to design and implement nine cancer prevention activities that were targeted to the needs of this community. Activities and information were disseminated to the employees during a nine-month period. Surveys were administered prior to and following the delivery of the intervention. This project was successful in engaging a rural manufacturing work site community in thinking about cancer prevention strategies. Results of this intervention demonstrated significant increases in numbers of smoking cessation attempts, reported fruit and vegetable consumption, self-efficacy for dietary change and perceived risk for cancer. Work site social norms changed as evidenced by employee perceptions of co-worker support of dietary and smoking change (all ts > 1.95, all Ps < 0.05). Other results with marginal statistical significance (P < .015) but potentially useful for future studies include increased intentions to reduce the fat in the diet. In light of the low-intensity and time-limited nature of this community organization intervention, the observed changes in dietary and smoking behaviors are encouraging and support the use of these strategies in rural, culturally diverse work sites.

The Medicare Critical Access Hospital program: the first year.

Abstract: The Medicare Critical Access Hospital (CAH) program, part of the Balanced Budget Act of 1997, is a nationwide limited service hospital program. Structured interviews were conducted in August and September 1998 with key people in state offices of rural health, state hospital associations, departments of health or departments of facility licensing in all 50 states to assess their progress in the development of the CAH program. The majority of states expressed interest in the CAH program. Twenty-one states were moving formally toward involvement in the program. States that had developed or were in the process of developing a state plan estimated that between 183 to 227 hospitals would convert to CAHs in the next one to two years. States that were the most successful with plan development appeared to be states that participated in the Essential Access Community Hospital/Rural Primary Care Hospital program, states where there was dialogue about the possibility of a limited service hospital program and states with widespread support in the state. A pressing need for most states is for reliable fiscal consulting or analysis that could be applied to individual hospitals that are considering conversion to CAHs. The CAH program shows promise for successful implementation based on its early results.

Risk-adjusted in-hospital death rates for peer hospitals in rural and urban regions.

Abstract: The purpose of this research project was to compare inpatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a seconday diagnosis. Eighty-three small hospitals that had a relatively unspecialized range of services constituted the study group. Patient characteristics of this study group were moderately representative of the national population. A standardized score was calculated for each hospital using a formula based on the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medical characteristics. Patients admitted to hospitals in nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk-adjusted and converted to z scores, nonmetropolitan areas had an average z of +0.16, and metropolitan areas had an average z of -0.25, where positive z scores reflect a lower-than-average adjusted mortality rate. The metropolitan-nonmetropolitan (urban-rural) difference was not statistically significant, but it is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitively ruled out. Taken together with other studies, the data are consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients.

Proposed changes to designations of medically underserved populations and health professional shortage areas: effects on rural areas.

Abstract: This paper reports an analysis of the proposed rule to combine medically underserved population (MUP) and health professional shortage area (HPSA) designations, as published by the Bureau of Primary Health Care (BPHC) in the Federal Register on Sept. 1, 1998 (Department of Health and Human Services, 1998). The effects of the proposed rule overall and on rural communities were examined, particularly with respect to current whole county HPSA designations and eligibility for federal assistance programs. National, county-level estimates of primary care provider counts and other measures included in the proposed rule were used. Different primary care provider sources were compared; results were highly dependent on the data source and the inclusions of counts of nurse practitioners and physician assistants. The projections of losses from the proposed rule were higher than those of the BPHC, probably due to the use of different sources for provider counts. Overall, the authors projected that more than 50 percent of current whole-county HPSAs would lose designation using the proposed rule. The proportion of rural counties that lost designation was not significantly greater than the proportion of urban counties, but because there are many more rural counties, more de-designations were projected to occur in rural areas. The researchers also predicted that 58 percent of rural whole-county HPSAs with National Health Service Corps providers would lose their designation, but most rural whole-county HPSAs with Community and Migrant Health Centers or Rural Health Clinics retained their MUP designation using the proposed rule. The proposed rule likely has a larger effect on current designations than originally projected by the BPHC.

Rural Health Policy Community Decision‐making About Critical Access Hospitals: Lessons Learned From Montana's Medical Assistance Facility Program

Abstract: Limited-service hospitals have been used as a means of maintaining health care services in rural communities with full-service hospitals at risk of closure. The Medical Assistance Facility (MAF) limited-service hospital model has been implemented in 12 communities in Montana and has been evaluated by the Health Care Financing Administration as a viable alternative to a full-service hospital in frontier communities. The 1997 federal Critical Access Hospital (CAH) legislation is the most recent nationwide alternative for maintaining health care in rural communities, and it incorporates many of the features of the MAF model. The purpose of this study was to examine rural community decision making regarding MAF conversion from the perspectives of key informants who were involved in the decision-making process. A descriptive multiple case study design was used. Data were obtained through interviews with community members during site visits. The research focused on identification of local issues that were influential in the decision to convert to or reopen as an MAF, features of the MAF model that made it a locally acceptable alternative, and elements that characterized the decision-making process. The issues found to be influential in the conversion decision and the features that made the MAF locally acceptable were those that made the provision of basic services more stable and sustainable. The study suggests that programs to maintain health care services in isolated communities should allow for and encourage an expanded role for non-physician providers. The lessons learned from the communities included in this study are instructive to rural communities nationwide that are considering a CAH as well as to policymakers, researchers, and regional and national health care decision makers.

Impact of Physicians' Perceptions of Malpractice and Adaptive Changes on Intention to Cease Obstetrical Practice

Abstract: Physicians who provide obstetrical care in rural areas face exposure to liability action and confront a critical decision–––whether to continue to offer these services. This paper draws upon social-psychological and decision theories to investigate this decision. Ninety four percent of all obstetricians and family and general physicians practicing in the 22 non metropolitan counties of one state responded to a mail survey that asked about their intention to continue or discontinue obstetrical practice, two dimensions of subjective risk (perceived likelihood of threats in the malpractice environment and perceived magnitude of negative consequences from being sued), and adaptive changes to protect against malpractice. The results suggest that (a) perceived extent of negative consequences (but not perceived likelihood of malpractice threats) drives intention to leave obstetrics, (b) the professional and reputational impacts of a suit–––not the dollar amount of award or settlement–––predicts intention to stop practicing obstetrics, and (c) physicians planning to continue providing obstetrical care in the future have made recent practice changes that may further exacerbate access problems.

Primary cesarean section rates in uninsured, Medicaid and insured populations of predominantly rural northern New England.

Abstract: Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age-adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age-adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.

A rural mental health research agenda: defining context and setting priorities.

Abstract: This article provides a brief overview of research perspectives on rural mental health services and suggests the importance of building an agenda to bring coherence to studies in this area. The need for sound theory and methodology to guide research is emphasized. The importance of better conceptualization of the rural context as a focus of research is addressed, and 14 propositions concerning issues the authors think will advance rural research are presented. This article is intended to stimulate discussion about a research agenda that will lead to better understanding of rural needs for mental health services as well as more responsive service models.

Emerging behavioral strategies for the prevention of HIV in rural areas.

Abstract: HIV/AIDS prevention efforts have been concentrated in urban areas, despite increases in HIV in nonmetropolitan areas. This study reviews behavioral prevention programs initiated in rural areas and programs that could be adapted for rural contexts. Outcomes from these interventions demonstrate that preventive interventions at the population, community, targeted populations subgroups, and small group levels can reduce high-risk behavior in rural environments and are cost effective to deliver.