Showing papers in "Journal of Rural Health in 2000"

Utilization of Preventive Medical Services in the United States: A Comparison Between Rural and Urban Populations

Abstract: Differences between rural and urban residents in their utilization of three clinical preventive services--Papanicolaou screening tests (Pap smears) for women aged 18 to 65, mammograms for women aged 50 to 69 and flu shots for people aged 65 or older--were examined using a nationally representative sample from the 1994 U.S. National Health Interview Survey. Eighty-two percent of urban women and 79 percent of rural women (P = 0.11) had Pap smears. Sixty-eight percent of urban women and 61 percent of rural women (P = 0.01) had mammograms. Flu shots were received by 55 percent of urban and 58 percent of rural elderly residents (P = 0.11). Of women aged 50 to 69 who had a high school education or whose annual household income was between $15,000 and $34,999, significantly fewer rural than urban women had mammograms (P < 0.01). However, the proportion of rural women receiving mammograms was not significantly different from that of urban women after adjusting for their education, household income and health insurance status. Education level, house-hold income and health insurance coverage were positively associated with utilizing mammograms. These results suggest that differences in the utilization of preventive services between rural and urban women vary by services. Improving socioeconomic status and health insurance coverage of rural women may reduce the disparity in mammogram use between rural and urban women. Mechanisms of how a woman's socioeconomic status affects her utilization of mammograms needs further study.

Educating generalist physicians for rural practice: how are we doing?

Abstract: Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to "small rural" communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

Quality-of-care challenges for rural health.

Abstract: The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.

The role of the medical school in rural graduate medical education: pipeline or control valve?

Abstract: Although rural-based graduate medical education is critically important in the training of competent rural family physicians, the number of physicians selecting these programs is highly dependent on what happens earlier in the pipeline, i.e., during medical school. Using the experience and outcomes research from Jefferson Medical College's Physician Short-age Area Program, as well as from published literature describing six other medical school programs with similar goals, this paper addresses the important role of these programs in substantially increasing the number of physicians interested in rural family practice. Although each of these programs differs in its structure, all contain three core features: a strong institutional mission; the targeted selection of students likely to practice in rural areas, predominantly those with rural backgrounds; and a focus on primary care, especially family practice. Outcomes show that all seven programs have been highly successful. Medical schools, therefore, can have a major impact on the number of rural physicians they produce by acting not only as a pipeline or conduit to residency programs, but also as a control valve, beginning as early as the admissions process. In order to maximize their impact on the supply and training of rural family physicians, rural residency programs should understand, support, collaborate with and help develop medical school programs whose mission is to provide rural physicians.

The distribution of rural female generalist physicians in the United States

Abstract: Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.

Out-of-Area Travel From Rural and Urban Counties: A Study of Ambulatory Care Sensitive Hospitalizations for New York State Residents

Abstract: Rural patients who are admitted to hospitals outside their residence county or who travel great distances for hospitalization deprive local rural hospitals of revenue. To provide more information about such rural residents, we studied their characteristics compared to those admitted in the same county. Characteristics studied included illness severity, demographics and county resources. To validate the findings and to provide a different analytic approach, characteristics of residents who travel long distances for admission were also studied. We studied admissions for ambulatory care sensitive conditions, as they might be most responsive to policy changes such as increasing recruitment of local primary-care physicians. Hospital discharges during 1994 for 248,656 New York State residents were studied. We constructed multivariate models using logistic regression and ordinary least squares methods. The models were applied to residents in three types of geographic location along an urban-rural continuum. Outside admissions were associated with younger age, higher illness severity and fewer county hospital resources. Same county admissions were associated with nonwhite race, and lack of insurance. Surprisingly, in rural counties, outside admissions were directly associated with increased primary-care providers. Results from the distance model generally supported findings from the outside admission model.

Access to care for rural Medicare beneficiaries.

Abstract: This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.

Outcomes of Rural Training Tracks: A Review

Abstract: Rural training tracks (RTTs) have developed as a strategy to encourage family medicine resident entrance into rural practice. Because most programs are small (two to four residents), data must be aggregated to determine RTT impact on practice preparation and location. Several studies over the last decade reveal that 76 percent of RTT graduates are practicing in rural America and that graduates describe themselves as prepared for rural practice. Sixty-five percent are providing obstetrical services, and half are performing cesarean sections. From 1989 to 1999, there were a total of 107 graduates of rural training programs, making it unlikely that, without significant investment, this model could supply an adequate quantity of family physicians for rural America.

Human immunodeficiency virus infection in rural areas and small cities of the southeast: contributions of migration and behavior.

Abstract: The design of education and prevention strategies to stem the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in rural areas depends on having accurate patterns of risk behavior and transmission in local areas. Interviews were conducted with people in rural areas and small cities in Delaware, Florida, Georgia and South Carolina who were at least 18 years old and infected with HIV in order to describe demographic characteristics, migration patterns and risk behaviors. Interviews were conducted with 608 people. Most respondents were male (66 percent), black (63 percent of men, 85 percent of women) and had been infected through sexual contact (67 percent of men, 66 percent of women). Most (65 percent) had lived away from a rural area or small city for at least one month; of those, 71 percent had moved from an urban area. Twenty-seven percent of respondents indicated they had been infected locally. People with a history of injection drug use were less likely to have been infected locally than those who had no history of injection drug use (6 percent vs. 26 percent among men, 3 percent vs. 40 percent among women, P<0.001). Further understanding of the role of socioeconomic factors in HIV transmission in rural areas and small cities is needed. Programs designed to prevent HIV acquisition among people living in rural areas and small cities in the Southeast should focus on sexual behavior.

The geographic distribution of AIDS in the United States: is there a rural epidemic?

Abstract: The goal of this study was to examine where people with acquired immune deficiency syndrome (AIDS) in the United States live and the degree to which AIDS is present in rural areas. AIDS cases reported to the Centers for Disease Control and Prevention (CDC) in 1996 were categorized by metropolitan statistical area (MSA) size and compared to the general population. Data were analyzed by region, race/ethnicity and risk exposure; AIDS incidence rates were compared over time by MSA size. Relative to the U.S. population, AIDS cases were disproportionately black (43 percent vs. 11 percent), male (80 percent vs. 48 percent), and from the Northeast (32 percent vs. 20 percent). In all regions, a greater proportion of AIDS cases reside in large MSAs compared with the general population. Risk exposures differ little by MSA size, except in the Northeast. The proportion of people with AIDS who reside in large MSAs exceeds the proportion of the population in those areas, especially when race/ethnicity is considered. AIDS rates have increased in non-MSAs relative to large MSAs, yet do not indicate that the epidemic is increasing rapidly in rural areas. Fewer AIDS cases are reported from smaller communities, yet require medical and social services that may burden the rural health care system.

Socioeconomic distress and health status: the urban-rural dichotomy of services utilization for people with sickle cell disorder in North Carolina.

Abstract: Research on sickle cell disorder has not focused attention on the socioeconomic background and geographic distribution of people with the disease. This study examines 1,189 persons with sickle cell disorder in North Carolina during 1991 to 1995. Three indices were developed using clients' medical, psychosocial and socioeconomic characteristics for the purpose of analyzing the urban-rural difference in treatment for sickle cell disease. The study observed a wide disparity in these indices between urban and rural population groups. Also, differences were observed in the utilization of services and clients' health status. The findings suggest that utilization of services is directly related to socioeconomic condition facing clients and clinic distance from clients. They further suggest that people in rural areas who have high distress levels and are far from clinics have limited access to health care. The limited availability of medical and health care in rural areas, as well as other support systems calls for an increase in community based healthcare services. These findings should be of particular interest to the state level sickle cell disorder program in North Carolina and other areas with a large rural population. Enhanced support for all persons with sickle cell disorder in North Carolina, particularly those in rural areas, is critical.

Quality oversight: why are rural hospitals less likely to be JCAHO accredited?

Abstract: There is a large rural-urban disparity in the proportion of hospitals that are accredited by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO). Several factors can influence whether a hospital participates in the accreditation process. A few of those factors include the hospital's size, case mix and ownership. However, even after controlling for many of these factors, hospitals in the most rural locations are less likely to be accredited by the JCAHO than urban hospitals. A survey was conducted to explore why rural hospitals are not participating in the accreditation process. Survey results show that the largest factor contributing to rural hospital deterrence to seeking accreditation is cost. Without accreditation by the JCAHO and compliance with their movement into performance measurement, quality monitoring of rural hospitals will fall further behind that of urban hospitals. Policy initiatives that make accreditation more financially feasible should be considered.

Using the American Medical Association physician masterfile to measure physician supply in small towns.

Abstract: The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.

Why rural residents migrate for family physician care.

Abstract: Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.

How many rural doctors do we have

Abstract: The number of physicians practicing in the nonmetropolitan areas of the United States in relation to population has increased over the past two decades, but more slowly than the number of physicians in metropolitan counties. During the same period, there was a growing acceptance of the perception that the physician work force in the United States exceeded the number necessary to meet the requirements of an efficient health care system. This has caused policy-makers to consider reforming the incentives for training physicians and restricting the entry of physicians from other countries into the United States. The supply figures on which these assessments of oversupply were made are based on "head counts" of the number of licensed, active physicians. By using more detailed data describing the licensed practicing physicians in the states of North Carolina and Washington, and by using estimates of professional activity collected as part of the Socioeconomic Monitoring System of the American Medical Association, estimates of the number of full-time equivalent physicians actually in practice in the two states and the comparative productivity of those physicians were made. Based on the state-level data, the estimates of actively practicing physicians are approximately 14 percent lower than the head-count number in North Carolina and, by using a more conservative estimation method, are approaching a 10 percent lower number than the head-count number in Washington. Using national productivity data, the effective supply of nonmetropolitan physicians appears to have not grown significantly over the past 10 years, and for family physicians the supply has declined by 9 percent. These estimates of the effective physician supply support long-held claims that rural communities continue to experience a severe undersupply of practitioners. These results suggest that the way in which physicians are counted needs to be re-examined, especially in rural places where the ratios of providers to population are more sensitive to small changes in supply.

Medical training debt and service commitments: the rural consequences.

Abstract: This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

A primary care intervention for depression

Abstract: To assess a guideline-based intervention's impact on depression care provided in rural vs. urban primary care settings, 12 community primary care practices (four rural, eight urban) were randomized to enhanced (i.e., intervention) and usual care study conditions. The study enrolled 479 depressed patients, with 432 (90.2 percent) completing telephone follow-up at six months. Multilevel analytic models revealed that rural enhanced care patients had 2.70 times the odds (P = 0.02) of rural usual care patients of taking a three-month course of antidepressant medication at recommended dosages in the six months following baseline; urban enhanced care patients had 2.43 times the odds compared with their urban usual care counterparts (P = 0.007). Rural enhanced care patients had 3.00 times the odds of rural usual care patients of making eight or more visits to a mental health specialist for counseling in the six months following baseline (P = 0.03). Comparisons of patients in enhanced care practices showed that rural enhanced care patients had 2.00 times the odds (P = 0.12) of urban enhanced care patients of making at least one visit to a mental health specialist for counseling in the six months following baseline and had comparable odds to urban enhanced care patients (odds ratio [OR] = 1.06, P = 0.77) of making eight or more visits to such specialists during that interval. The study's intervention improved the care received by both rural and urban depressed primary care patients. Moreover, the intervention's effect appears to have been greater in rural settings, particularly in terms of increasing depressed rural patients' use of mental health specialists for counseling.

Influence of a rural primary care clerkship on medical students' intentions to practice in a rural community.

Abstract: The purpose of this study is to examine the relationship of a rural clerkship to medical students' interest in establishing careers in rural communities. The Association of American Medical Colleges Medical School Graduation Questionnaire (GQ) for years 1988 through 1997 was examined to compare the career plans of students graduating from Morehouse School of Medicine (MSM) with those of all students graduating from United States medical schools before the period 1988 through 1992 and after the period 1993 through 1997, after the inception of the rural clerkship at MSM. Select GQ data items examined include student demographics, medical school experiences, and career plans. Statistical analyses were used to compare pre- and post-clerkship responses for MSM students and to compare their responses with the national trends. Results indicate that, following a transition period, MSM students showed an increased preference for a future career in a rural community. A smaller upward trend in the national data was observed. There appears to be an association between the rural clerkship experience at MSM and the stated preferred career choices of the students.

Graduate medical education for rural physicians: curriculum and retention.

Abstract: The chronic shortage of rural physicians prompts further consideration of the educational interventions that have been developed to address this issue Despite rural admission strategies and a variety of undergraduate, graduate and postgraduate curricular innovations, the recruitment and retention of family physicians into many rural areas has not kept pace with the retirement of older general practice physicians This paper reviews the 1994 American Academy of Family Physicians' rural training recommendations in the light of several recent educational needs assessments These studies affirm the need for rural residency rotations and the need to maintain and better implement the established rural clinical training guidelines However, although preparation for rural medical practice has been addressed and is being adequately accomplished in the clinical knowledge and procedural skills areas, instruction and experiences relating to the "realities of rural living" need to be enhanced to increase the retention duration of rural physicians This can be accomplished with more curricular emphasis on developing community health competencies, including community-oriented primary care (COPC) Physicians who know how to collaborate with community members on health improvement projects have skills that can also facilitate integration and, hence, retention

Maternal complications of normal deliveries: variation among rural hospitals.

Abstract: This study examined variation in maternal complication rates fallowing normal vaginal delivery among 282 rural hospitals throughout the United States. Using a risk-adjusted model to control far case mix, discharge abstracts of more than 84,000 women were analyzed to determine whether there were differences in outcomes resulting from, or concomitant with, their hospital stay. After risk adjustment, the majority of hospitals were found to be performing at an acceptable level; however, there were some factors associated with poor performance. Hospital volume and the availability of obstetricians in the county in which the hospital was located were found to have an inverse association with complication rates, whereas low county per capita income was found to have a positive association with poor facility performance. No association was found between complication rates and general practitioners and the degree of remoteness as defined by distance from the nearest tertiary care facility. The results demonstrate a relationship between volume and outcome and a threshold point at which volume becomes a significant factor in predicting facility performance. As well, a relationship is seen between physician specialty and outcome, in which obstetricians are significantly associated with facility performance at expected or better-than-expected levels. Normal vaginal delivery is an important service provided by rural hospitals. The relationships among volume, physician specialty and outcome suggested by these findings require further in-depth examination of specific factors that affect patient outcomes and overall facility performance.

Impact of rural training on physician work force: the role of postresidency education.

Abstract: Many innovative strategies have been developed over the years to improve the recruitment and retention of physicians in the shortage areas of rural America. These strategies have met with varying success. Postresidency education, or fellowship training, for family physicians is yet another strategy that has been developed for the same purpose. Most applicants have been interested in obstetrical and rural health fellowship programs as a means for preparing for rural practice. This paper describes these programs (demographics, funding, applicant pool, curriculum) and reviews their graduate outcomes (practice location after matriculation, clinical privileges). Twenty-nine obstetrical and nine rural health fellowships are currently operational in the United States. Fellows who complete a rural health fellowship have a higher tendency to locate in rural settings. Almost all graduates from obstetrical and rural health programs attain general hospital privileges in family practice, including low-risk obstetrics. A significant number of graduates from both types of programs attain privileges in high-risk and operative obstetrics as well. Fellowship training can play an integral role in the preparation of family physicians for rural practice.

Postgraduate medical education for rural family practice in Canada.

Abstract: Canada is a large country with a diverse and spread-out rural population. Compared to their urban counterparts, rural Canadians have fewer family doctors and dramatically fewer specialists, and they face other significant geographic barriers to accessing health care. This paper describes the milieu of the rural physician in Canada and reports on efforts to develop a postgraduate medical education model for rural family practice that will produce more physicians with the knowledge, skills and interest to practice in small and mid-sized communities. Key recommendations of the College of Family Physicians of Canada include: providing earlier and more extensive rural medicine experience for all undergraduate medical students, developing rural postgraduate training programs, providing third-year optional special and advanced rural family medicine skills training and making advanced family medicine skills training competency-based and nationally accredited.

Safe handling of agricultural pesticides in Minnesota: results of a county-wide educational intervention.

Abstract: Safe pesticide handling in a group of Minnesota farmers, aged 40 years and older, was influenced through the use of a multifaceted, countywide educational intervention. Two intervention counties and two control counties were involved in this effort. The intervention consisted of mailed pesticide information to farm households, educational programs on pesticides for county physicians, elementary school training modules on pesticides and the use of safe pesticide handling displays in key business areas by agricultural extension agents. Five hundred eight farmers were identified as pesticide users (186 in the intervention counties and 322 in the control counties). The use of gloves and other protective clothing while handling pesticides increased in the intervention group. Improvement was greater in those who had used protective equipment the least before the intervention. From these results, it appears that a broad-based educational intervention might have a modest impact in how farmers protect themselves when using pesticides.

The Effectiveness of a Rural Nursing Center in Improving Health Care Access in a Three‐County Area

Abstract: The purpose of this article is to describe an innovative nurse-managed health center that has been effective in improving access to primary health care for residents of a Midwestern three-county rural area. Penchansky and Thomas's (1981) framework for evaluating health care access was used to analyze client satisfaction and utilization data. Findings clearly indicate success in improving access. Client satisfaction surveys consistently show a high level of satisfaction across all framework dimensions, including overall satisfaction with the health care received. Utilization data indicate a steady increase in the number of clients served, especially those who are uninsured or underinsured. This article demonstrates that key dimensions of access can be effectively measured using the Penchansky and Thomas framework and concludes with recommendations for enhancing the model.

Delivering mental health services to the persistently and seriously mentally ill in frontier areas.

Abstract: Frontier areas (defined as six or fewer persons per square mile) are at the extreme end of the urban-rural continuum. Whereas they occupy almost half of the land mass of the United States, they constitute only about 2 percent of the population. Exigencies of harsh climate and vast distances make the delivery of health and human services even more difficult than in other rural areas. This paper describes several innovative models for delivering mental health services to the persistently and seriously mentally ill in rural areas.

The role of critical access hospital status in mitigating the effects of new prospective payment systems under Medicare.

Abstract: This article examines rural hospitals that potentially qualify as critical access hospitals (CAH) and identifies facilities at substantial financial risk as a result of Medicare's expansion of prospective payment systems (PPS) to nonacute settings. Using Health Care Financing Administration (HCFA) cost reports from the federal year ending Sept. 30, 1996, combined with county-level sociodemographic data from the Area Resource File (ARF), characteristics of potential CAHs were identified and their finances analyzed to determine whether they could benefit from the cost-based reimbursement rules applicable to CAH status. Rural hospitals were identified as potential CAHs if they met a combination of federal and state criteria for necessary providers. Rural facilities were classified as “at risk” if they had poor financial ratios in conjunction with high levels of dependence on outpatient, home-care or skilled nursing services. Almost 30 percent of all rural hospitals were identified as potential CAHs. Ninety percent of potential CAH facilities were identified as “at risk” by at least one of five possible risk criteria, and one-third were identified by at least three. Of those classified “at risk,” 48 percent might not benefit from conversion to CAH because their inpatient Medicare reimbursement would likely be less under CAH payment rules than under their current PPS payment rules. Many potential CAHs were doing well under inpatient PPS because they were sole community hospitals (SCH) and were therefore eligible for special adjustments to the PPS rates. The Rural Hospital Flexibility Act would be more beneficial to the population of isolated rural hospitals if those eligible for both CAH and SCH status were given the option of retaining their SCH inpatient payment arrangements while still qualifying for outpatient cost-based reimbursement.

The national Area Health Education Center program and primary care residency training.

Abstract: The Area Health Education Center (AHEC) program was established in 1972 to improve the supply, distribution, retention and quality of primary care and other health practitioners in medically underserved areas. Through academic/community partnerships, regional AHECs offer a broad array of educational programs for students, residents and practicing health professionals. With primary care medical education a core part of AHEC programs, AHECs have been involved in decentralized residency training from the outset, with particular attention to family medicine. This paper provides an overview of the national AHEC program, its core components and its support for primary care residency training. Although AHECs have achieved considerable success in training primary care physicians for their respective states, continued refinements of programs are needed to address the needs of the most rural and underserved communities.

Critical access hospitals: how many rural hospitals will meet the requirements?

Abstract: Although the Medicare Rural Hospital Flexibility Program (MRHFP), which establishes a new designation for limited-service hospitals called critical access hospitals (CAH), intends to assist small rural hospitals having financial difficulty, it is unclear how many hospitals will qualify for the program. Potential CAHs are identified and the strategic issues that will impact actual participation in the program are discussed. Potential CAHs are identified by applying the legislative criteria for designation to a data set created from both the 1992–1995 Medicare Hospital Cost Report Information System and the 1993 and 1995 Prospective Payment Systems Impact files. Descriptive analyses are used to identify potential CAHs by three parameters: distance to nearest hospital, average daily census and operating margin. Results indicate that the majority of potential CAHs have low volume and report poorer operating margins than other rural hospitals. Findings also show that the mileage requirements significantly impact the number of potential CAHs. There is more than a ninefold difference between the 93 hospitals that meet the mileage criterion and the 864 hospitals that might be eligible if certified by the state as “necessary providers,” regardless of distance to the nearest hospital. The MRHFP is designed to prevent small, isolated hospitals from closing and thus to ensure continued access to care for rural residents. However, the number of potential CAHs that participate will clearly hinge on the flexibility of the program and the ability of states to determine “necessary providers.”