Showing papers in "Journal of Rural Health in 2010"

Defining “Rural” for Veterans’ Health Care Planning

Abstract: Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.

Diabetes burden and access to preventive care in the rural United States.

Abstract: Context: National databases can be used to investigate diabetes prevalence and health care use. Guideline-based care can reduce diabetes complications and morbidity. Yet little is known about the prevalence of diabetes and compliance with diabetes care guidelines among rural residents and whether different national databases provide similar results. Purpose: To examine rural-urban differences in the prevalence of diabetes and compliance with guidelines, and to compare the Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditures Panel Survey (MEPS). Methods: Data for 2001-2002 were analyzed and compared by rural-urban status. Prevalence was calculated as simple unadjusted, weighted unadjusted, and weighted adjusted using a multivariate approach. Results from the 2 databases were compared. Findings: A slightly higher prevalence of diabetes among rural residents, 7.9% versus 6.0% in MEPS and 7.6% versus 6.6% in BRFSS, was found and persisted after adjustment for age, BMI, insurance coverage, and other demographic characteristics (adjusted OR 1.16 [1.02-1.31] in MEPS; 1.19 [1.01-1.20] in BRFSS). Rural persons in MEPS were less likely to receive an annual eye examination (aOR = 0.85) and a feet check (aOR = 0.89). A significantly (P < .05) smaller proportion of rural residents in BRFSS received an annual eye examination (aOR = 0.88), feet check (aOR = 0.85), or diabetes education (aOR = 0.83). Rural residents in both datasets were more likely to get a quarterly HbA1c test done. Conclusion: Rural residents in both datasets had higher prevalence of diabetes. Though not always statistically significant, the trend was to less guideline compliance in rural areas.

Access to Rural Mental Health Services: Service Use and Out-of-Pocket Costs

Abstract: Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services. Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type. Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services. Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.

Use of Psychotherapy by Rural and Urban Veterans

Abstract: Purpose: To examine whether differences exist between rural and urban veterans in terms of initiation of psychotherapy, delay in time from diagnosis to treatment, and dose of psychotherapy sessions.Methods: Using a longitudinal cohort of veterans obtained from national Veterans Affairs databases (October 2003 through September 2004), we extracted veterans with a new diagnosis of depression, anxiety, or posttraumatic stress disorder (PTSD) (n = 410,923). Veterans were classi?ed as rural (categories 6-9; n = 65,044) or urban (category 1; n = 149,747), using the US Department of Agriculture Rural-Urban Continuum Codes. Psychotherapy encounters were identi?ed using Current Procedural Terminology codes for the 12 months following patients’ initial diagnosis.Findings: Newly diagnosed rural veterans were signi?cantly less likely (P < .0001) to receive psychotherapy (both individual and group). Urban veterans were roughly twice as likely as rural veterans to receive 4 or more (9.46% vs 5.08%) and 8 or more (5.59% vs 2.35%) psychotherapy sessions (P < .001). Conclusions: Rural veterans are signi?cantly less likely to receive psychotherapy services, and the dose of the psychotherapy services provided for rural veterans is limited relative to their urban counterparts. Focused efforts are needed to increase access to psychotherapy services provided to rural veterans with depression, anxiety, and PTSD.

Practicing Preventive Health: The Underlying Culture Among Low-Income Rural Populations

Abstract: Context: Health disparities on the basis of geographic location, social economic factors and education levels are well documented. However, even when health care services are available, there is no guarantee that all persons will take preventive health measures. Understanding the cultural beliefs, practices, and lifestyle choices that determine utilization of health services is an important factor in combating chronic diseases. Purpose: The purpose of this study was to investigate personal, cultural, and external barriers that interfered with participating in a community-based preventive outreach program that included health screening for obesity, diabetes, heart diseases, and hypertension when cost and transportation factors were addressed. Methods: Six focus groups were conducted in a rural community of Louisiana. Focus groups were divided into 2 categories: participants and nonparticipants. Three focus groups were completed with Dubach Health Outreach Project (DUHOP) participants and 3 were completed with nonparticipants. The focus group interviews were moderated by a researcher experienced in focus group interviews; a graduate student assisted with recording and note-taking during the sessions. Findings: Four main themes associated with barriers to participation in preventive services emerged from the discussions: (1) time, (2) low priority, (3) fear of the unknown, and (4) lack of companionship or support. Health concerns, free services, enjoyment, and free food were identified as motivators for participation. Conclusions: The findings of this study indicated that the resulting synergy between low-income status and a lack of motivation regarding health care prevention created a complicated practice of health care procrastination, which resulted in unnecessary emergency care and disease progression. To change this practice to proactive disease prevention and self care, a concerted effort will need to be implemented by policy makers, funding agents, health care providers, and community leaders and members.

The association between rural residence and the use, type, and quality of depression care.

Abstract: Objective: To assess the association between rurality and depression care. Methods: Data were extracted for 10,319 individuals with self-reported depression in the Medical Expenditure Panel Survey. Pharmacotherapy was defined as an antidepressant prescription fill, and minimally adequate pharmacotherapy was defined as receipt of at least 4 antidepressant fills. Psychotherapy was defined as an outpatient counseling visit, and minimally adequate psychotherapy was defined as ≥ 8 visits. Rurality was defined using Metropolitan Statistical Areas (MSAs) and Rural Urban Continuum Codes (RUCCs). Results: Over the year, 65.1% received depression treatment, including 58.8% with at least 1 antidepressant prescription fill and 24.5% with at least 1 psychotherapy visit. Among those in treatment, 56.2% had minimally adequate pharmacotherapy treatment and 36.3% had minimally adequate psychotherapy treatment. Overall, there were no significant rural-urban differences in receipt of any type of formal depression treatment. However, rural residence was associated with significantly higher odds of receiving pharmacotherapy (MSA: OR 1.16 [95% CI, 1.01-1.34; P= .04] and RUCC: OR 1.04 [95% CI, 1.00-1.08; P= .05]), and significantly lower odds of receiving psychotherapy (MSA: OR 0.62 [95% CI, 0.53-0.74; P < .01] and RUCC: OR 0.91 [95% CI, 0.88-0.94; P < .001]). Rural residence was not significantly associated with the adequacy of pharmacotherapy, but it was significantly associated with the adequacy of psychotherapy (MSA: OR 0.53 [95% CI, 0.41-0.69; P < .01] and RUCC: OR 0.92 [95% CI, 0.86-0.99; P= .02]). Psychiatrists per capita were a mediator in the psychotherapy analyses. Conclusions: Rural individuals are more reliant on pharmacotherapy than psychotherapy. This may be a concern if individuals in rural areas turn to pharmacotherapy because psychotherapists are unavailable rather than because they have a preference for pharmacotherapy.

Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community.

Abstract: Purpose To evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in a rural community. Methods In 2008, the Montana Diabetes Control Program worked collaboratively with Holy Rosary Healthcare to implement an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (N = 101). Participants set targets to reduce fat intake and increase physical activity (> or = 150 mins/week) in order to achieve a 7% weight loss goal. Findings Eighty-three percent (n = 84) of participants completed the 16-session core program and 65 (64%) participated in 1 or more after-core sessions. Of those completing the core program, the mean participation was 14.4 +/- 1.6 and 3.9 +/- 1.6 sessions during the core and after core, respectively. Sixty-five percent of participants met the 150-min-per-week physical activity goal during the core program. Sixty-two percent achieved the 7% weight loss goal and 78% achieved at least a 5% weight loss during the core program. The average weight loss per participant was 7.5 kg (range, 0 to 19.7 kg), which was 7.5% of initial body weight. At the last recorded weight in the after core, 52% of participants had met the 7% weight loss goal and 66% had achieved at least a 5% weight loss. Conclusion Our findings suggest that it is feasible to implement a group-based DPP in a rural community and achieve weight loss and physical goals that are comparable to those achieved in the DPP.

Does rurality affect quality of life following treatment for breast cancer

Abstract: As reviewed by Bettencourt and colleagues,1 a number of studies have considered psychosocial issues as they relate to the experiences of rural dwelling women who have been treated for breast cancer. While many concerns reported by rural women are commensurate with those identified by urban women (eg, body image, effects of cancer diagnosis and treatment on family members), some differences seem to be emerging. In general, women living in rural areas may be more likely to experience distress than women living in urban communities.2 In addition to a recognized shortage of mental health care in rural communities,3 issues of stigma related to mental health care and expectations of self-sufficiency may limit acceptance of mental health services in rural areas.4 Among rural women living with cancer, high levels of depression and hopelessness/helplessness have been noted.5 Rural women living with cancer report lower than average quality of life6 and may have particular concerns about being stigmatized within their communities as a result of their cancer diagnosis.7 One way in which rural and urban areas may differ is in the availability of community-based social support. The importance of social support as a buffer to emotional distress has been widely studied among a variety of medical populations8 including individuals living with cancer.9 Potential effects of rural versus urban residence have been noted, although findings are somewhat equivocal, as both benefits and hindrances to well-being have been identified. For example, given the shortage of mental health care providers in rural communities,3 geographic distance may limit availability of professional social support for rural women.10 On the other hand, several characteristics of rural communities may be of benefit to individuals coping with cancer. Rural communities often value close relationships with family, community members and religious institutions,4,11 all of which can be excellent sources of social support. In fact, studies have highlighted the perceived benefit of increased community support experienced by female cancer survivors living in rural compared to urban areas.12 Thus, while there may be limited cancer-specific support services in many rural communities, women living in rural areas may have community networks which make general social support readily available.13 Due to unanswered questions regarding whether rurality may affect quality of life among cancer survivors, and recognizing the importance of social support in quality of life outcomes regardless of residence, analyses presented herein were conducted to examine the extent to which rural residence and social support seeking affect quality of life among breast cancer survivors in the early post-treatment period.

HIV testing and HIV/AIDS treatment services in rural counties in 10 southern states: service provider perspectives.

Abstract: Context: Forty percent of AIDS cases are reported in the southern United States, the region with the largest proportion of HIV/AIDS cases from rural areas. Data are limited regarding provider perspectives of the accessibility and availability of HIV testing and treatment services in southern rural counties. Purpose: We surveyed providers in the rural south to better understand: (1) the accessibility and availability, and (2) the facilitators and barriers of HIV testing and treatment services. Methods: All county health departments (N = 326) serving populations of <50,000 persons, within 10 southern states, were mailed surveys. Responding health departments identified up to 3 HIV testing sites and up to 3 HIV treatment sites to which they refer clients. Findings: Overall, 243 of 326 (75%) health departments, 133 of 250 (53%) HIV testing sites, and 73 of 152 (48%) HIV treatment sites responded to the surveys. The number of testing sites per county ranged from 0 to 20; the number of treatment sites ranged from 0 to 4. An average distance of 50 miles for clients to travel for HIV treatment was reported by health department respondents as a barrier. Facilitators of HIV testing were (1) integrating HIV testing into other health services; (2) using rapid HIV testing; and (3) establishing easily accessible HIV testing locations and free testing services. Conclusion: Providers perceive that distance from local health departments to HIV treatment sites presents a barrier to HIV care for their clients. Future studies should ascertain clients’ perspectives to ensure appropriate service provisions.

Issues in Rural Palliative Care: Views From the Countryside

Abstract: Context: Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation. Purpose: To better understand experiences and issues related to rural palliative care. Methods: Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique. Findings: Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care. Conclusion: Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

The Rural-Urban Divide: Health Services Utilization among Older Mexicans in Mexico.

Abstract: The epidemiological transition has progressed through much of Mexico and, as a result, the population in Mexico is aging quickly.1 Mexico has now reached the juncture where health and quality of life in older age are a public health focus, yet little effort has been made to address the specific needs of this population.2,3 Most government programs to improve health are geared toward the poor in general, only benefiting poor older Mexicans. For example, one of the biggest efforts to improve the health of poor Mexicans, health care reform—a universal program in its infancy stage—primarily benefits infants and children.4 In addition to health care reform, municipalities and the federal government have set up social programs to alleviate the negative effects of poverty on nutrition for the poor and elderly. For instance, in Mexico City, a public health program for the elderly was established to provide a small pension and staple food allocation for those aged 65 years and older.5 Food banks are also becoming more pervasive, providing poor Mexicans free or low-cost food.6 Despite these efforts, much of the older Mexican population continues to live without any reliable source of health care or social resources when they become ill.2 In addition, no attempt has been made to narrow the disparities between rural and urban older Mexicans in health care access. In 2006, Mexico had a population of approximately 107 million people, mostly urban (75.7%).7 However, while younger individuals move to urban areas for employment; the elderly tend to remain in their traditional locations. Data from the 2000 census shows that nearly 40% (38.1%) of Mexicans aged 65 and over live in towns with populations of 14 999 people or fewer, a greater proportion than any other age group.8 Given the elevated levels of poverty and lack of services in smaller towns and villages, older Mexicans are at greater risk for experiencing the negative health consequences associated with material disadvantage.

A longitudinal analysis of rural and urban veterans' health-related quality of life.

Abstract: Context: Cross-sectional studies have identified rural-urban disparities in veterans’ health-related quality-of-life (HRQOL) scores. Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans’ HRQOL scores persisted. Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans’ HRQOL scores were changing at different rates over the time period examined. Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.

Pollution Sources and Mortality Rates across Rural-Urban Areas in the United States.

Abstract: Purpose: To conduct an assessment of rural environmental pollution sources and associated population mortality rates. Methods: The design is a secondary analysis of county-level data from the Environmental Protection Agency (EPA), Department of Agriculture, National Land Cover Dataset, Energy Information Administration, Centers for Disease Control and Prevention, the US Census, and others. We described the types of pollution sources present in metropolitan and nonmetropolitan counties and examined the associations between these sources and rates of all-cause, cardiovascular, respiratory, and cancer mortality while controlling for age, race, and other covariates. Findings: Rural counties had 65,055 EPA-monitored pollution discharge sites. As expected, rural counties had significantly greater exposure to potential agriculture-related pollution. Regression models specific to rural counties indicated that greater density of water pollution sources was significantly associated with greater total and cancer mortality. Rural air pollution sources were associated with greater cancer mortality rates. Rural coal mining areas had higher total, cancer, and respiratory disease mortality rates. Agricultural production was generally associated with lower mortality rates. Greater levels of human development were significantly related to higher adjusted total and cancer mortality. Conclusions: The association between pollution sources and mortality risk is not a phenomenon limited to metropolitan areas. Results carry policy implications regarding the need for effective environmental standards and monitoring. Further research is needed to better understand the types and distributions of pollution in rural areas, and the health consequences that result.

Associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis, South Carolina 2001-2005.

Abstract: Context: Rural areas in the southern United States face many challenges, including limited access to health care services and stigma, which may lead to later HIV diagnosis among rural residents. Purpose: To investigate the associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis. Methods: Timing of HIV diagnosis was categorized as a diagnosis of acquired immune deficiency syndrome within 1 year of a first positive HIV test or HIV-only. Stage of disease was based on initial CD4+ T-cell count taken within 1 year of diagnosis. County of residence at HIV diagnosis was classified as urban if the population of the largest city was at least 25,000; it was classified as rural otherwise. Logistic regression was used to analyze timing of HIV diagnosis, and analysis of covariance was used to analyze stage of disease. Findings: From 2001 to 2005, 4,137 individuals were diagnosed with HIV infection. Of these, 1,129 (27%) were rural and 3,008 (73%) were urban residents. Among rural residents, 533 (47%) were diagnosed late, compared with 1,258 (42%) urban residents. Rural residents were significantly more likely to be diagnosed late (OR 1.19 [95% CI, 1.02-1.38]). Rural residence was associated with lower initial CD4+ T-cell count in crude analysis (P= .01) but not after adjustment (P > .05). Conclusions: Rural residence is a risk factor for late HIV diagnosis. This may lead to reduced treatment response to antiretroviral medications, increased morbidity and mortality, and greater HIV transmission risks among rural residents. New testing strategies are needed that address challenges to HIV testing and diagnosis specific to rural areas.

Rural-Urban Differences in Preventable Hospitalizations among Community-Dwelling Veterans with Dementia.

Abstract: Context: Alzheimer's patients living in rural communities may face significant barriers to effective outpatient medical care Purpose: We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia Methods: Medicare and Veteran Affairs inpatient claims for 1,186 US veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey ACSH were identified in inpatient claims over a 1-year period following collection of independent variables Urban Influence Codes were used to classify care recipients into 4 categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and noncore rural counties We used the Andersen Behavioral Model of Health Services to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH Findings: Thirteen percent of care recipients had at least 1 ACSH The likelihood of an ACSH was greater for patients in noncore rural counties versus large metropolitan areas (226% vs 128%, unadjusted odds ratio [OR]= 199; P < 01) The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 197; P < 05) Conclusions: We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care recipient, or community factors Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care

The role of interorganizational partnerships in health services provision among rural, suburban, and urban local health departments.

Abstract: Context: With limited resources and increased public health challenges facing the US, the Centers for Disease Control and Prevention and others have identified partnerships between local health departments (LHDs) and nongovernmental organizations (NGOs) as critical to the public health system. LHDs utilize financial, human, and informational resources and develop partnerships with local NGOs to provide public health services. Purpose: Our study had 2 primary goals: (1) compare resources and partnerships characterizing rural, suburban, and urban LHDs, and (2) determine whether partnerships play a mediating role between LHD resources and the services LHDs provide. Methods: We conducted secondary data analysis using the National Association of County and City Health Officials 2005 Profile Study. We used chi-squared and analysis of variance (ANOVA) to examine differences between rural, suburban, and urban LHDs. We used regression-based mediation methods to test whether partnerships mediated the relationship between resources and service provision. Findings: We found significant differences between LHDs. Urban LHDs serve larger jurisdictions, have larger budgets and more staff, cultivate more partnerships with local NGOs, and provide more health services than suburban or rural LHDs. We found that partnerships were a partial mediator between resources and service provision. In playing a mediating role, partnerships reduce differences in service provision between rural, suburban, and urban LHDs. Conclusions: Partnerships mediate the relationship between resources and service provision in LHDs. LHDs could place more emphasis on cultivating relationships with local NGOs in order to increase service provision. This strategy may be especially useful for rural LHDs facing limited resources and numerous health disparities.

All-terrain vehicle safety and use patterns in central Illinois youth

Abstract: CONTEXT: All-terrain vehicles' (ATVs) popularity and associated injuries among children are increasing in the United States. Currently, most known ATV use pattern data are obtained from injured youth and little documented data exist characterizing the typical ATV use patterns and safety practices among American children in general. PURPOSE: To describe the typical ATV safety and use patterns of rural youth. METHODS: A cross-sectional anonymous mail survey was conducted of youth participants (ages 8-18) in the 4-H Club of America in four Central Illinois counties. Questions examined ATV use patterns, safety knowledge, safety equipment usage, crashes, and injuries. FINDINGS: Of 1,850 mailed surveys, 634 were returned (34% response rate) with 280 surveys (44% of respondents) eligible for analysis. Respondents were principally adolescent males from farms or rural locations. Most drove Language: en

Urban-rural disparities in injury mortality in China, 2006.

Abstract: CONTEXT: Urban-rural disparity is an important issue for injury control in China. Details of the urban-rural disparities in fatal injuries have not been analyzed. PURPOSE: To target key injury causes that most contribute to the urban-rural disparity, we decomposed total urban-rural differences in 2006 injury mortality by gender, age, and cause. METHODS: Mortality data came from the Chinese Vital Registration data, covering a sample of about 10% of the total population. The chi-square test was used to test the significance of urban-rural disparities. FINDINGS: For all ages combined, the injury death rate for males was 60.1/100,000 in rural areas compared with 40.9 in urban areas; for females, the respective rates were 31.5 and 23.6/100,000. The greatest disparity was at age Language: en

Quality of care for myocardial infarction in rural and urban hospitals.

Abstract: Improving the quality of care for acute myocardial infarction (AMI) has garnered considerable attention for over a decade. The American College of Cardiology (ACC), the American Heart Association (AHA), the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the Agency for Healthcare Research and Quality have collaborated since 1993 to develop objective performance measures to track the care of inpatients with AMI at the state and national levels.1 Quality improvement interventions for AMI have been developed by the ACC (Guidelines Applied in Practice) and the AHA (Get With the Guidelines), and been applied by hospitals nationally.2–5 These efforts are reaping benefits. Across the nation, the quality of AMI care has improved, though substantial gaps remain between actual and recommended care.6–8 Whether patients cared for in rural and urban hospitals are reaping similar benefits is unknown. In the mid-1990s, quality of AMI care lagged significantly in rural hospitals.9–11 AMI admissions to rural hospitals were less likely than urban hospital admissions to receive recommended life-saving treatments such as aspirin and reperfusion. Hospital patients in small rural and isolated small rural areas were least likely to receive many of these treatments. Rural hospitals have well-documented and unique challenges (eg, low volume, limited resources)12 to implementing resource-intensive quality improvement programs such as those noted above. In this study, we use the most recent national data on AMI care to examine whether differences in the quality of AMI care have persisted between urban hospitals and hospitals in 3 types of rural area. Identification of remaining gaps can help organizations tailor quality improvement efforts to hospitals in smaller and more isolated rural areas.

County-Level Poverty Is Equally Associated with Unmet Health Care Needs in Rural and Urban Settings.

Abstract: Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.

Didgeridoo Playing and Singing to Support Asthma Management in Aboriginal Australians

Abstract: Context: Asthma affects over 15% of Australian Aboriginal people. Compliance in asthma management is poor. Interventions that will increase compliance are required. Purpose: The purpose of the study was to determine whether Aboriginal children, adolescents and adults would engage in music lessons to increase their knowledge of asthma and support management of their asthma. Methods: Participants were recruited from schools and through the local Aboriginal Medical Service. All participants identified as Aborigines and were diagnosed as being asthmatic. The intervention was a 6-month program of once weekly music lessons using a culturally significant wind instrument, the didgeridoo, for males and singing lessons for females. Findings: High school students enthusiastically engaged and had excellent retention in what they considered to be a most enjoyable program. Respiratory function improved significantly in both junior and senior boys who also reported a noticeable improvement in their health. Similar but less significant improvement was seen in the high school girls, although like the boys, they too perceived an improvement in their asthma. Conclusions: The project demonstrated that music has great potential for engaging and thus supporting asthma. Furthermore, cultural awareness was increased by those playing the didgeridoo and social skills were noticeably improved in the girls. Similar culturally appropriate activities have applications far beyond Aboriginal communities in Australia.

Rural-Urban Differences in Health Insurance Coverage and Patterns Among Working-Age Adults in Kentucky

Abstract: Context: Past studies show that rural populations are less likely than urban populations to have health insurance coverage, which may severely limit their access to needed health services. Purpose: To examine rural-urban differences in various aspects of health insurance coverage among working-age adults in Kentucky. Methods: Data are from a household survey conducted in Kentucky in 2005. The respondents include 2,036 individuals ages 18-64. Bivariate analyses were used to compare the rural-urban differences in health insurance coverage by individual characteristics. Logistic regression analyses were used to examine the independent impact of rural-urban residence on the various aspects of health insurance coverage, while controlling for the individuals’ health status and sociodemographic characteristics. Findings: The overall rate of working-age adults with health insurance did not differ significantly between the rural and urban areas of Kentucky. However, there were significant rural-urban differences in insurance for specific types of health care and in patterns of insurance coverage. Rural adults were less likely than urban adults to have coverage for vision care, dental care, mental health care, and drug abuse treatment. Rural adults were also less likely to obtain insurance through employment, and their current insurance coverage was, on average, of shorter duration than that of urban adults. Conclusions: In Kentucky, the overall health insurance rate of working-age adults is influenced more by employment status and income than by whether these individuals reside in rural or urban areas. However, coverage for specific types of care, and coverage patterns, differ significantly by place of residence.

Influence of place of residence in access to specialized cancer care for African Americans

Abstract: Context: Disparities in cancer care for rural residents and for African Americans have been documented, but the interaction of these factors is not well understood. Purpose: The authors examined the simultaneous influence of race and place of residence on access to and utilization of specialized cancer care in the United States. Methods: Access to specialized cancer care was measured using: (1) travel time to National Cancer Institute (NCI) Cancer Centers, academic medical centers, and any oncologist for the entire continental US population, and (2) per capita availability of oncologists for the entire United States. Utilization was measured as attendance at NCI Cancer Centers, specialized hospitals, and other hospitals in the Surveillance, Epidemiology, and End Results (SEER) program Medicare population from 1998-2004. Findings: In urban settings, travel times were shorter for African Americans compared with Caucasians for all three cancer care settings, but they were longer for rural African Americans traveling to NCI Cancer Centers. Per capita oncologist availability was not significantly different by race or place of residence. Urban African American patients were almost 70% more likely to attend an NCI Cancer Center than urban Caucasian patients (OR = 1.66; 95% CI 1.51-1.83), whereas rural African American patients were 58% less likely to attend an NCI Cancer Center than rural Caucasian patients (OR = 0.42; 95% CI 0.26-0.66). Conclusions: Urban African Americans have similar or better access to specialized cancer care than urban Caucasians, but rural African Americans have relatively poor access and lower utilization compared with all other groups.

Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural Veterans

Abstract: Introduction: Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition Methods: This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables Results: URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 096; 95% CI, 094-100) and highly rural veterans (HR, 113; 096-131) relative to urban veterans In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 089; 083-095) as well as veterans from isolated towns (HR, 086; 078-093) Conclusion: Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized These findings suggest potentially lower rates of revascularization for rural veterans

Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel Outside Local Markets

Abstract: Purpose: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum. Methods: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA. Findings: Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity. Conclusions: Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.

Rural Idaho Family Physicians’ Scope of Practice

Abstract: Context: Scope of practice is an important factor in both training and recruiting rural family physicians. Purpose: To assess rural Idaho family physicians’ scope of practice and to examine variations in scope of practice across variables such as gender, age and employment status. Methods: A survey instrument was developed based on a literature review and was validated by physician educators, practicing family physicians and executives at the state hospital association. This survey was mailed to rural family physicians practicing in Idaho counties with populations of less than 50,000. Descriptive, bivariate and multivariate analyses were employed to describe and compare scope of practice patterns. Results: Responses were obtained from 92 of 248 physicians (37.1% response rate). Idaho rural family physicians reported providing obstetrical services in the areas of prenatal care (57.6%), vaginal delivery (52.2%) and C-sections (37.0%); other operating room services (43.5%); esophagogastroduodenoscopy (EGD) or colonoscopy services (22.5%); emergency room coverage (48.9%); inpatient admissions (88.9%); mental health services (90.1%); nursing home services (88.0%); and supervision to midlevel care providers (72.5%). Bivariate analyses showed differences in scope of practice patterns across gender, age group and employment status. Binomial logistic regression models indicated that younger physicians were roughly 3 times more likely to provide prenatal care and perform vaginal deliveries than older physicians in rural areas. Conclusion: Idaho practicing rural family physicians report a broad scope of practice. Younger, employed and female rural family medicine physicians are important subgroups for further study.

Recruiting and retaining physicians in very rural areas.

Abstract: Context: Recruiting and retaining physicians is a challenge in rural areas. Growing up in a rural area and completing medical training in a rural area have been shown to predict decisions to practice in rural areas. Little is known, though, about factors that contribute to physicians’ decisions to locate in very sparsely populated areas. Purpose: In this study, we investigated whether variables associated with rural background and training predicted physicians’ decisions to practice in very rural areas. We also examined reasons given for plans to leave the study state. Methods: Physicians in the State of Wyoming (N = 693) completed a questionnaire assessing their background, current practice, and future practice plans. Findings: Being raised in a rural area and training in nearby states predicted practicing in very rural areas. High malpractice insurance rates predicted planning to move one's practice out of state rather than within state. Conclusions: Rural backgrounds and training independently predict practice location decisions, but high malpractice rates are the most crucial factor in future plans to leave the state.

Strength of Tobacco Control in Rural Communities

Abstract: Largely as a result of socioeconomic disparities, rural populations are at increased risk for smoking and resultant poorer health outcomes than their urban counterparts.1,2 Adults living in rural communities are generally more likely to smoke cigarettes compared to those in urban areas.1,3–5 Furthermore, those living in rural communities are more likely to be exposed to secondhand smoke than those living in urban areas.6 Despite the fact that smoke-free and other tobacco control laws are gaining popularity in the United States and globally, rural communities have fewer smoke-free laws and voluntary restrictions than do their urban counterparts.6,7 Further, smaller towns are less likely than larger ones to enact smoke-free policies.8,9 As efforts to enact smoke-free laws and other tobacco control policies increase, assessing local efforts, capacity and resources for tobacco control grows more important, especially in rural, underserved communities that may be late in adopting these laws. Mobilizing local communities to enact tobacco control policies is recommended in the Centers for Disease Control and Prevention’s (CDC) community-based model for tobacco control.10 The premise of the model, currently implemented in several states, is to promote policy development at both local and state levels to change social norms related to tobacco control. The Strength of Tobacco Control (SoTC) instrument was initially developed to evaluate the effectiveness of state-level efforts related to tobacco control. The SoTC, developed by the American Stop Smoking Intervention Study (ASSIST), measured state-level tobacco control efforts and indirectly assessed the effectiveness of the ASSIST program.11 The overall objective of ASSIST was to effect change in tobacco use through policy promotion and alterations in the social-political environment related to tobacco use.12 Although the SoTC measure has been tested only at the state level, it may have utility as a measure of strength of tobacco control at the local level.

Access to and use of eye care services in rural arkansas.

Abstract: Context: Rural residents are more likely to be uninsured and have low income. Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents. Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations. Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit. Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.

Occurrence of conotruncal heart birth defects in Texas: a comparison of urban/rural classifications

Abstract: Purpose: (1) Determine if there is an association between 3 conotruncal heart birth defects and urban/rural residence of mother. (2) Compare results using different methods of measuring urban/rural status. Methods: Data were taken from the Texas Birth Defects Registry, 1999-2003. Poisson regression was used to compare crude and adjusted birth prevalence. Findings: Based on residences of births in Texas, the values for urban influence code (UIC), rural urban continuum code (RUCC), and rural urban commuting area (RUCA) were highly correlated with each other and, less highly, to percentage of land in crops. For tetralogy of Fallot, the most rural category consistently showed the highest prevalence ratio for all measures. The adjusted prevalence ratio for highest percentage cropland was 1.73 [95% CI, 1.14-2.51] using natural breaks and 1.42 [95% CI, 1.07-1.86] using quartiles. The trend with cropland percentage was significant (P < .03), whether crude or adjusted. The crude trend was also significant using RUCC. Neither truncus arteriosus nor transposition of the great arteries exhibited consistent associations with urban or rural residence. Conclusions: The urban/rural measures were generally correlated with each other; as a broad measure, RUCA has advantages for many health studies. Tetralogy of Fallot was most prevalent in rural areas; that pattern was strongest using percentage of land in crops.