Showing papers in "Journal of Rural Health in 2020"
TL;DR: Although densely populated large cities and their surrounding metropolitan areas are hotspots of the pandemic, it is counterintuitive that incidence and mortality rates in some small cities and nonmetropolitan counties approximate those in epicenters such as New York City.
Abstract: Purpose This ecological analysis investigates the spatial patterns of the COVID-19 epidemic in the United States in relation to socioeconomic variables that characterize US counties. Methods Data on confirmed cases and deaths from COVID-19 for 2,814 US counties were obtained from Johns Hopkins University. We used Geographic Information Systems (GIS) to map the spatial aspects of this pandemic and investigate the disparities between metropolitan and nonmetropolitan communities. Multiple regression models were used to explore the contextual risk factors of infections and death across US counties. We included population density, percent of population aged 65+, percent population in poverty, percent minority population, and percent of the uninsured as independent variables. A state-level measure of the percent of the population that has been tested for COVID-19 was used to control for the impact of testing. Findings The impact of COVID-19 in the United States has been extremely uneven. Although densely populated large cities and their surrounding metropolitan areas are hotspots of the pandemic, it is counterintuitive that incidence and mortality rates in some small cities and nonmetropolitan counties approximate those in epicenters such as New York City. Regression analyses support the hypotheses of positive correlations between COVID-19 incidence and mortality rates and socioeconomic factors including population density, proportions of elderly residents, poverty, and percent population tested. Conclusions Knowledge about the spatial aspects of the COVID-19 epidemic and its socioeconomic correlates can inform first responders and government efforts. Directives for social distancing and to "shelter-in-place" should continue to stem the spread of COVID-19.
193 citations
TL;DR: There is an immediate need to know specific types of susceptibilities and vulnerabilities ahead of time to allow local and state health officials to plan and allocate resources accordingly, and in rural areas it is essential to shelter‐in‐place vulnerable populations, whereas in large metropolitan areas general closure orders are needed to stop community spread.
Abstract: PURPOSE: This study creates a COVID-19 susceptibility scale at the county level, describes its components, and then assesses the health and socioeconomic resiliency of susceptible places across the rural-urban continuum. METHODS: Factor analysis grouped 11 indicators into 7 distinct susceptibility factors for 3,079 counties in the conterminous United States. Unconditional mean differences are assessed using a multivariate general linear model. Data from 2018 are primarily taken from the US Census Bureau and CDC. RESULTS: About 33% of rural counties are highly susceptible to COVID-19, driven by older and health-compromised populations, and care facilities for the elderly. Major vulnerabilities in rural counties include fewer physicians, lack of mental health services, higher disability, and more uninsured. Poor Internet access limits telemedicine. Lack of social capital and social services may hinder local pandemic recovery. Meat processing facilities drive risk in micropolitan counties. Although metropolitan counties are less susceptible due to healthier and younger populations, about 6% are at risk due to community spread from dense populations. Metropolitan vulnerabilities include minorities at higher health and diabetes risk, language barriers, being a transportation hub that helps spread infection, and acute housing distress. CONCLUSIONS: There is an immediate need to know specific types of susceptibilities and vulnerabilities ahead of time to allow local and state health officials to plan and allocate resources accordingly. In rural areas it is essential to shelter-in-place vulnerable populations, whereas in large metropolitan areas general closure orders are needed to stop community spread. Pandemic response plans should address vulnerabilities.
170 citations
TL;DR: Findings show a rapid spread of COVID‐19 across urban and rural areas in 21 days and the role of social determinants of health on CO VID‐19 prevalence is explained.
Abstract: Purpose There are growing signs that the COVID-19 virus has started to spread to rural areas and can impact the rural health care system that is already stretched and lacks resources. To aid in the legislative decision process and proper channelizing of resources, we estimated and compared the county-level change in prevalence rates of COVID-19 by rural-urban status over 3 weeks. Additionally, we identified hotspots based on estimated prevalence rates. Methods We used crowdsourced data on COVID-19 and linked them to county-level demographics, smoking rates, and chronic diseases. We fitted a Bayesian hierarchical spatiotemporal model using the Markov Chain Monte Carlo algorithm in R-studio. We mapped the estimated prevalence rates using ArcGIS 10.8, and identified hotspots using Gettis-Ord local statistics. Findings In the rural counties, the mean prevalence of COVID-19 increased from 3.6 per 100,000 population to 43.6 per 100,000 within 3 weeks from April 3 to April 22, 2020. In the urban counties, the median prevalence of COVID-19 increased from 10.1 per 100,000 population to 107.6 per 100,000 within the same period. The COVID-19 adjusted prevalence rates in rural counties were substantially elevated in counties with higher black populations, smoking rates, and obesity rates. Counties with high rates of people aged 25-49 years had increased COVID-19 prevalence rates. Conclusions Our findings show a rapid spread of COVID-19 across urban and rural areas in 21 days. Studies based on quality data are needed to explain further the role of social determinants of health on COVID-19 prevalence.
132 citations
TL;DR: Among rural counties, the average daily increase in COVID-19 mortality rates has been significantly higher in counties with the largest shares of Black and Hispanic residents, and the CO VID-19 race penalty is not restricted to cities.
Abstract: Purpose This study compared the average daily increase in COVID-19 mortality rates by county racial/ethnic composition (percent non-Hispanic Black and percent Hispanic) among US rural counties. Methods COVID-19 daily death counts for 1,976 US nonmetropolitan counties for the period March 2-July 26, 2020, were extracted from USAFacts and merged with county-level American Community Survey and Area Health Resource File data. Covariates included county percent poverty, age composition, adjacency to a metropolitan county, health care supply, and state fixed effects. Mixed-effects negative binomial regression with random intercepts to account for repeated observations within counties were used to predict differences in the average daily increase in the COVID-19 mortality rate across quartiles of percent Black and percent Hispanic. Findings Since early March, the average daily increase in the COVID-19 mortality rate has been significantly higher in rural counties with the highest percent Black and percent Hispanic populations. Compared to counties in the bottom quartile, counties in the top quartile of percent Black have an average daily increase that is 70% higher (IRR = 1.70, CI: 1.48-1.95, P Conclusion COVID-19 mortality risk is not distributed equally across the rural United States, and the COVID-19 race penalty is not restricted to cities. Among rural counties, the average daily increase in COVID-19 mortality rates has been significantly higher in counties with the largest shares of Black and Hispanic residents.
92 citations
TL;DR: More than half of rural residents are at increased risk of hospitalization and death if infected with COVID‐19, and policy makers need to consider supply chain modifications, regulatory changes, and financial assistance policies to assist rural communities in caring for people affected by CO VID‐19.
Abstract: Purpose During the COVID-19 epidemic, it is critical to understand how the need for hospital care in rural areas aligns with the capacity across states. Methods We analyzed data from the 2018 Behavioral Risk Factor Surveillance System to estimate the number of adults who have an elevated risk of serious illness if they are infected with coronavirus in metropolitan, micropolitan, and rural areas for each state. Study data included 430,949 survey responses representing over 255.2 million noninstitutionalized US adults. For data on hospital beds, aggregate survey data were linked to data from the 2017 Area Health Resource Files by state and metropolitan status. Findings About 50% of rural residents are at high risk for hospitalization and serious illness if they are infected with COVID-19, compared to 46.9% and 40.0% in micropolitan and metropolitan areas, respectively. In 19 states, more than 50% of rural populations are at high risk for serious illness if infected. Rural residents will generate an estimated 10% more hospitalizations for COVID-19 per capita than urban residents given equal infection rates. Conclusion More than half of rural residents are at increased risk of hospitalization and death if infected with COVID-19. Experts expect COVID-19 burden to outpace hospital capacity across the country, and rural areas are no exception. Policy makers need to consider supply chain modifications, regulatory changes, and financial assistance policies to assist rural communities in caring for people affected by COVID-19.
49 citations
TL;DR: Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined, suggesting that poverty is a key policy lever that may mitigate the burden of ACE exposure.
Abstract: Purpose The purpose of this study was to examine the prevalence of adverse childhood experiences (ACEs) exposure in 34 states and the District of Columbia, and whether exposure differs between rural and urban residents. Methods This cross-sectional study used data from the 2016 National Survey of Children's Health (NSCH), restricted to states in which rural versus urban residence was indicated in the public use data (n = 25,977 respondents). Bivariate analyses were used to estimate unadjusted associations. Multivariable regression models were run to examine the association between residence (rural or urban) and ACE counts of 4 or more. Findings Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined: parental separation/divorce, parental death, household incarceration, household violence, household mental illness, household substance abuse, and economic hardship. In adjusted analysis, there was no significant difference for rural children compared to urban children. The odds of 4 or more ACEs decrease as poverty levels decline, with children residing 0%-99% below the federal poverty line more likely to have reported 4 or more ACEs, compared to children residing 400% or above the federal poverty line (aOR 4.02; CI: 2.65-6.11). Conclusions Our findings suggest that poverty is a key policy lever that may mitigate the burden of ACE exposure. The findings of this study may be instructive for policymakers and program planners as they develop interventions to stop, reduce, or mitigate ACE exposure and the long-term impact of ACEs among children in rural America.
38 citations
TL;DR: Caution is warranted when attributing rural-urban designation to individuals based on geographic unit, since perceived rurality/urbanicity of their community that relates to health behaviors may not be reflected.
Abstract: Purpose This study examined the concordance between individuals' self-reported rural-urban category of their community and ZIP Code-derived Rural-Urban Commuting Area (RUCA) category. Methods An Internet-based survey, administered from August 2017 through November 2017, was used to collect participants' sociodemographic characteristics, self-reported ZIP Code of residence, and perception of which RUCA category best describes the community in which they live. We calculated weighted kappa (ĸ) coefficients (95% confidence interval [CI]) to test for concordance between participants' ZIP Code-derived RUCA category and their selection of RUCA descriptor. Descriptive frequency distributions of participants' demographics are presented. Findings A total of 622 survey participants, residents of New Hampshire (63%) and Vermont (37%), responded to the survey's self-reported rural-urban category. The overall ĸ was 0.33 (95% CI: 0.27-0.38). The highest concordance was found among those living in a small rural area (N = 81, 13%): 62% of this group identified their communities as small rural. Sixty-five percent (300/459) of participants residing in urban or large rural areas reported their community as more rural (small rural or isolated). Sixty-eight percent (111/163) of participants living in small rural or isolated areas identified their community as more urban (large rural or urban). Conclusions Discordance was found between self-report of rural-urban category and ZIP Code-derived RUCA designation. Caution is warranted when attributing rural-urban designation to individuals based on geographic unit, since perceived rurality/urbanicity of their community that relates to health behaviors may not be reflected.
36 citations
TL;DR: Evidence is found that diabetes mortality has declined in the United States over the past 2 decades, but that improvements in mortality vary considerably by place, and that reductions in diabetes mortality are lagging in rural areas, and the rural South in particular, relative to other areas of the country.
Abstract: PURPOSE This brief report examines place-based differences in diabetes mortality in order to understand whether disparities in diabetes mortality have changed across United States Census regions and levels of rurality over time. METHODS We use data from the National Center for Health Statistics from 1999 to 2016 to analyze changes in diabetes mortality over time and across geographical regions of the United States. FINDINGS We find evidence that diabetes mortality has declined in the United States over the past 2 decades, but that improvements in mortality vary considerably by place. Improvements are observed in urban America and in the Northeast and Midwest while diabetes mortality has remained largely unchanged in rural areas, particularly in the rural South. CONCLUSIONS Diabetes is one of the leading causes of death in the United States, but important differences have emerged in the burden of this disease. Reductions in diabetes mortality are lagging in rural areas, and the rural South in particular, relative to other areas of the country. Continued innovations in care and targeted interventions in rural areas are warranted.
35 citations
TL;DR: NPs and PAs face many of the same barriers to providing buprenorphine as physicians have reported, and interventions to address these barriers have the potential to benefit all providers with the waiver to prescribe bupenorphine.
Abstract: Background In 2016, the Comprehensive Addiction Recovery Act permitted nurse practitioners (NPs) and physician assistants (PAs) to obtain a waiver to prescribe buprenorphine to treat opioid use disorder (OUD), with the goal of increasing access to this treatment. This study's purpose was to describe the buprenorphine prescribing practices of NPs and PAs and compare the barriers rural and urban providers face delivering treatment. Methods From the October 2018 Drug Enforcement Administration list of providers with the waiver to prescribe buprenorphine, all rural NPs and PAs (1,057) and a random sample of 500 urban NPs and PAs were surveyed. The questionnaire queried respondents about demographics, prescribing practices, practice characteristics, reimbursement policies, and barriers to prescribing buprenorphine to treat OUD. Results Of the waivered NPs and PAs, 80.3% reported having prescribed buprenorphine and 71.1% said they were currently accepting new patients with OUD. Providers with the 30-patient waiver were treating, on average, 13.2 patients; 37.0% were not treating any patients. The most common barrier, cited by half of providers, was concerns about diversion/medication misuse. More rural providers indicated lack of specialty backup and mental health providers as a barrier than urban providers. Never-prescribers and former-prescribers reported 6 barriers at significantly higher rates than did current prescribers. More rural providers accepted Medicaid and cash reimbursement than urban providers. Conclusions NPs and PAs face many of the same barriers to providing buprenorphine as physicians have reported. Interventions to address these barriers have the potential to benefit all providers with the waiver to prescribe buprenorphine.
34 citations
TL;DR: Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful, and strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults.
Abstract: PURPOSE Analyses compared older drivers from urban, suburban, and rural areas on perceived importance of continuing to drive and potential impact that driving cessation would have on what they want and need to do. METHODS The AAA LongROAD Study is a prospective study of driving behaviors, patterns, and outcomes of older adults. A cohort of 2,990 women and men 65-79 years of age was recruited during 2015-2017 from health systems or primary care practices near 5 study sites in different parts of the United States. Participants were classified as living in urban, surburban, or rural areas and were asked to rate the importance of driving and potential impact of driving cessation. Logistic regression models adjusted for sociodemographic and driving-related characteristics. FINDINGS The percentages of older drivers rating driving as "completely important" were 76.9%, 79.0%, and 83.8% for urban, suburban, and rural drivers, respectively (P = .009). The rural drivers were also most likely to indicate driving cessation would have a high impact on what they want or need to do (P < .001). After adjustment for sociodemographic and driving-related characteristics, there was a 2-fold difference for rural versus urban older drivers in odds that driving cessation would have a high impact on what they need to do (OR = 2.03; 95% CI: 1.60-2.58). CONCLUSIONS Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful. Strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults.
28 citations
TL;DR: The actual distance older breast cancer patients traveled to radiation treatment and the minimum distance necessary to reach radiation care are characterized, and whether any patient demographic or clinical factors are associated with greater travel distance is examined.
Abstract: Purpose The distance patients travel for specialty care is an important barrier to health care access, particularly for those living in rural areas. This study characterizes the actual distance older breast cancer patients traveled to radiation treatment and the minimum distance necessary to reach radiation care, and examines whether any patient demographic or clinical factors are associated with greater travel distance. Methods We used data from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Our cohort included 52,317 women diagnosed with breast cancer between 2004 and 2013. Driving distances were calculated using Google Maps. We used generalized estimating equations to estimate associations between patient demographic and disease variables and travel distance. Findings Patients living in rural areas traveled on average nearly 3 times as far as those from urban areas (40.8 miles vs 15.4 miles), and their nearest facility was more than 4 times farther away (21.9 miles vs 4.8 miles). Older age, being single or widowed, and lower household income were significantly associated with shorter actual travel distance, while increasing rurality was significantly associated with greater actual and minimum travel distance to radiation treatment. Disease severity (stage, grade, etc) was not significantly associated with actual or minimum travel distance. Conclusions In this insured population, travel distance to radiation facilities may pose a significant burden for breast cancer patients, particularly among those living in rural areas. Policymakers and patient advocates should explore service delivery models, reimbursement models, and social supports aimed at reducing the impact of travel to radiation treatment for breast cancer patients.
TL;DR: Patients with COPD in rural areas experience greater morbidity and obstacles to care than those in urban areas, and racial/ethnic minorities and those with low incomes are also at greater risk of forgoing doctor visits due to cost.
Abstract: Purpose The burden of chronic obstructive pulmonary disease (COPD) is high in rural America. Few studies, however, have examined urban/rural differences in health care access, or racial/ethnic and income disparities stratified by urban/rural residence, among persons with COPD. Methods We studied individuals age ≥ 40 years with COPD from the 2018 Behavioral Risk Factor Surveillance System. The primary exposure was "urban" or "rural" county of residence. We examined multiple health and health care access/services outcomes using logistic regressions adjusted for age and sex, and performed analyses stratified by rural/urban county that included additional adjustment for race/ethnicity or income. Findings Our sample included 34,439 individuals. COPD prevalence was 8.6% in rural counties versus 5.4% in urban counties. Rural residents with COPD were poorer, had less education, worse health, and more disability. Of the rural population with COPD, 12.6% were uninsured, versus 10.4% in urban areas (AOR 1.26; 95% CI: 1.00-1.58). Rural residents with COPD were more likely to have not seen a doctor due to cost (AOR 1.18; 95% CI: 1.02-1.36). Differences in other outcomes were mostly nonsignificant. We observed large access disparities by race/ethnicity and income among individuals in both urban and rural counties, with the highest rates of forgone care among minorities in rural counties. Conclusion Patients with COPD in rural areas experience greater morbidity and obstacles to care than those in urban areas. Racial/ethnic minorities and those with low incomes-particularly in rural areas-are also at greater risk of forgoing doctor visits due to cost. Expanded access to health care could address respiratory health inequities.
TL;DR: Findings suggest a rural-urban inequality in perinatal depression risk, which may require improving socioeconomic conditions and reducing associated risk factors among rural women.
Abstract: Objective Rural populations may experience more frequent and intense risk factors for perinatal depression than their urban counterparts. However, research has yet to examine rural versus urban differences in a population-based study in the United States. Therefore, this study examined differences in risk of perinatal depression between women living in rural versus urban areas in the United States. Method Using 2016 data from the Pregnancy Risk Assessment Monitoring System, we examined the association between rural-urban status and the risk of depression during the perinatal time period. The total analytical sample included 17,229 women from 14 states. The association between rural-urban status and risk of perinatal depression was estimated using logistic regression, adjusting for race/ethnicity, maternal age, and state of residence. A second model adjusted for maternal education, health insurance status, and Women, Infants, and Children Special Supplemental Nutrition Program (WIC). Results Odds of perinatal depression risk were higher by 21% among rural versus urban women (OR = 1.21, 95% CI: 1.05-1.41) adjusted for race, ethnicity, and maternal age. This risk difference became smaller and not significant when adding maternal education, health insurance coverage, and WIC participation. Conclusion Findings suggest a rural-urban inequality in perinatal depression risk. Reducing this inequality may require improving socioeconomic conditions and reducing associated risk factors among rural women.
TL;DR: Rural women nationally die of pregnancy-related causes at a greater rate than urban women and established risk factors, including high rates of chronic illness and substance abuse, place rural women at risk for severe maternal morbidity and pregnancy- related mortality.
Abstract: Purpose The Centers for Disease Control and Prevention (CDC) and the American College of Obstetrics and Gynecology have called for researchers to further elucidate medical and social determinants of pregnancy-related death and severe maternal morbidity. This report begins to answer this call in the context of rural Appalachia. Methods This report identifies risk factors exposing women in rural Appalachia to pregnancy-related death and severe maternal morbidity. We also use CDC WONDER data to illustrate rural-urban differences in pregnancy-related death. Findings Rural women nationally die of pregnancy-related causes at a greater rate than urban women. It is unknown how rurality specifically influences pregnancy-related death, but rural women more often embody multiple risk factors associated with negative maternal outcomes. Established risk factors, including high rates of chronic illness and substance abuse, place rural women at risk for severe maternal morbidity and pregnancy-related mortality. These women may also lack the resources to mitigate these risks, including access to high-risk obstetric care. Next steps To address these issues and the concerning lack of data, we propose 4 directions for future study: (1) a determination of the prevalence of pregnancy-related death and severe maternal morbidity in this population; (2) an examination of how rural women utilize existing pre- and perinatal resources; (3) better validation concerning surveillance methods of pregnancy-related death and severe maternal morbidity in rural areas; and (4) an exploratory qualitative study of rural women and health care providers.
TL;DR: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.
Abstract: PURPOSE Opioid use disorder (OUD) during pregnancy is associated with poor maternal and infant outcomes, including neonatal abstinence syndrome (NAS), and both maternal OUD and NAS are increasing disproportionately among rural residents. This study describes the trajectory and characteristics associated with diagnosis of maternal OUD or NAS among rural residents who gave birth at different types of hospitals based on rural/urban location and teaching status. METHODS Hospital discharge data from the all-payer National Inpatient Sample were used to describe maternal OUD and infant NAS among rural residents from 2007-2014. Hospitals were categorized as rural, urban teaching, and urban nonteaching. We estimated incidence trends by hospital categories, followed by multivariable logistic regression analyses to identify correlates of OUD and NAS among rural residents, stratified by hospital category. FINDINGS Incidence of maternal OUD increased in all hospital categories, with higher rates (8.9/1,000 deliveries) among rural residents who gave birth at urban teaching hospitals compared with those who gave birth at rural hospitals (4.3/1,000 deliveries) or urban nonteaching hospitals (3.6/1,000 deliveries; P < .001). A similar pattern was observed for infant NAS. In multivariable models, the association between maternal OUD and infant NAS diagnoses and hospital category differed by rurality (micropolitan vs. noncore.) CONCLUSIONS: There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents. Measured sociodemographic and clinical correlates of maternal OUD and NAS differ by hospital category, indicating variability across hospital locations in patient populations and clinical needs for rural residents with these conditions.
TL;DR: Rural high school students are more likely to smoke cigarettes and use smokeless tobacco than their urban counterparts, although prevalence rates have decreased over time, and use of hookah and e-cigarettes among middle and high schoolStudents has increased over time regardless of place of residence.
Abstract: Purpose Rural adolescents engage in higher smoking and smokeless tobacco use rates than those from urban communities; urban adolescents are more likely to use e-cigarettes. The study investigated whether place of residence (rural vs urban) is associated with tobacco use prevalence and change in prevalence among middle and high school students over time. Methods We analyzed data from the National Youth Tobacco Survey (2011-2016). Multiple logistic regression methods for weighted survey data assessed the relationship of place of residence with current tobacco product use over time, adjusting for demographics. Findings There was no difference in rate of change in use of any tobacco product between rural and urban middle or high school students. Adjusting for age, sex, race/ethnicity, and survey year, both middle and high school rural students were more likely to use cigarettes and smokeless tobacco, whereas urban high school students were more likely to use hookah. Significant polynomial trends were observed for e-cigarette and hookah use patterns, whereas linear changes in use patterns were detected for cigarette and smokeless tobacco use over time. Conclusions Rural high school students are more likely to smoke cigarettes and use smokeless tobacco than their urban counterparts, although prevalence rates have decreased over time. However, use of hookah and e-cigarettes among middle and high school students has increased over time regardless of place of residence. To stem the rapid increase in use of hookah and e-cigarettes, comprehensive tobacco control policies are needed regardless of rural or urban location.
TL;DR: Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts.
Abstract: BACKGROUND Breast reconstruction (BR) is the reconstructive surgical technique that focuses on restoring normal form and function to the breast following oncologic resection. The goal of this study was to determine if BR disparities exist among rural female patients in Kentucky. METHODS A retrospective (2006-2015), population-based cohort study was conducted on breast cancer patients (stages I-III) treated with mastectomy with or without BR. We used 2013 Beale codes to stratify patients according to geographic status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease, and treatment factors was used to predict BR. The likelihood of BR was reported in odds ratios (OR) using a 95% confidence interval (CI). RESULTS Overall, 10,032 patients met study criteria. Of those, 2,159 (21.5%) underwent BR. The rate of BR among urban, near-metro, and rural patients was 31.1%, 20.4%, and 13.4%, respectively (P < .001). Multivariate analysis revealed that women from near metro (OR 0.54, CI: 0.47-0.61; P < .001) and rural areas (OR 0.36, CI: 0.31-0.41; P < .001) were less likely to undergo BR than women from urban areas. CONCLUSION Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts. Efforts should seek to promote equitable access to BR for all patients, including those from rural areas.
TL;DR: Interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.
Abstract: BACKGROUND: The common reality of not following a recommended course of treatment is a major cause of poor health outcomes in patients with heart failure (HF). The purpose of this study was to identify predictors of adherence to HF self‐care recommendations in rural HF patients who received an intervention to promote symptom management and self‐care. METHODS: Data from 349 rural HF patients (42% female, 90% Caucasian) randomized to the intervention arms of the study were used. Adherence was measured using the European Heart Failure Self‐Care Scale questionnaire, a brief measure that asks patients to report their adherence to a variety of recommended HF symptom management behaviors (ie, daily weight monitoring, when to call the physician, medications, diet, and exercise). The following predictors were tested: age, gender, marital status, education level, depression score (measured using PHQ‐9), anxiety score (measured with the Brief Symptom Inventory), and level of perceived control (measured using Control Attitudes Scale‐R). Multivariate linear regression was used to test the model. RESULTS: The model to predict adherence was significant (P < .0001). Of the covariates tested in the regression model, being a male (P = .009), having less anxiety (P = .018), not being depressed (P = .017), and having higher perceived control (P = .003) were predictors of improved self‐care score at 3 months. CONCLUSION: Adherence is a multifaceted and a challenging behavior based on the assumption that the patient agrees with self‐care recommendations. These data suggest interventions designed to promote adherence behaviors should include an assessment of gender, anxiety, depression, and perceived control for optimal outcomes.
TL;DR: The extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents is examined to suggest areas for further research, patient engagement, and education.
Abstract: Background Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents. Methods Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics. Results In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis. Conclusions Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.
TL;DR: While many resources in combatting maternal SUD are being utilized, policy and programmatic responses tailored for mothers with SUD in rural communities might help increase utilization of treatment and reduce barriers to treatment.
Abstract: OBJECTIVE Higher rates of substance use in rural counties compared to urban counties have been well documented Low perceived need for treatment among those with substance use disorder (SUD) has also been documented in the literature However, not much is known about SUD treatment among parenting women in rural counties and the impact of perceived need for treatment in seeking care Little research has also examined barriers to SUD treatment among parenting women in rural communities METHODS Using a large nationally representative dataset, the study utilizes multivariable logistic regression models to estimate the differences in utilizing SUD treatment among parenting women with SUD in rural and urban counties in the United States Role of perceived need for SUD treatment and barriers related to finance, access, and stigma are also examined RESULTS Parenting women in rural counties with SUD who perceive a need for treatment have more than 90% lower odds of receiving treatment compared to those in urban counties In addition, parenting women with SUD in rural counties have more than 50% higher odds of identifying access-related issues such as lack of openings in programs, unavailability of treatment facilities, and lack of transportation as barriers to care compared to parenting women in urban counties CONCLUSION Diagnosis of SUD among parenting women is steadily increasing in rural communities While many resources in combatting maternal SUD are being utilized, policy and programmatic responses tailored for mothers with SUD in rural communities might help increase utilization of treatment and reduce barriers to treatment
TL;DR: US hospitals vary in their preparation to use telehealth to aid in the COVID‐19 battle, among other issues; hospitals’ odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals.
Abstract: BACKGROUND: Telehealth is likely to play a crucial role in treating COVID-19 patients. However, not all US hospitals possess telehealth capabilities. This brief report was designed to explore US hospitals' readiness with respect to telehealth availability. We hope to gain deeper insight into the factors affecting possession of these valuable capabilities, and how this varies between rural and urban areas. METHODS: Based on 2017 data from the American Hospital Association survey, Area Health Resource Files and Medicare cost reports, we used logistic regression models to identify predictors of telehealth and eICU capabilities in US hospitals. RESULTS: We found that larger hospitals (OR(telehealth) = 1.013; P < .01) and system members (OR(telehealth) = 1.55; P < .01) (OR(eICU) = 1.65; P < .01) had higher odds of possessing telehealth and eICU capabilities. We also found evidence suggesting that telehealth and eICU capabilities are concentrated in particular regions; the West North Central region was the most likely to possess capabilities, given that these hospitals had higher odds of possessing telehealth (OR = 1.49; P < .10) and eICU capabilities (OR = 2.15; P < .05). Rural hospitals had higher odds of possessing telehealth capabilities as compared to their urban counterparts, although this relationship was marginally significant (OR = 1.34, P < .10). CONCLUSIONS: US hospitals vary in their preparation to use telehealth to aid in the COVID-19 battle, among other issues. Hospitals' odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals. There is still great potential to expand these capabilities further, especially in areas that have been hard hit by COVID-19.
TL;DR: Rural ovarian cancer patients have greater odds of having stage IV cancer at diagnosis in Midwestern states independent of the distance they lived from their primary care physician and the socioeconomic status of their residential census tract.
Abstract: Purpose We aim to understand if rurality impacts patients' odds of presenting with stage IV ovarian cancer at diagnosis independent of distance to primary care provider and the socioeconomic status of a patient's residential census tract. Methods A cohort of 1,000 women with ovarian cancer in Iowa, Kansas, and Missouri were sampled and analyzed from the cancer registries' statewide population data. The sample contained those with a histologically confirmed primary ovarian cancer diagnosis in 2011-2012. All variables were captured through an extension of standard registry protocol using standardized definitions and abstraction manuals. Chi-square tests and a multivariable logistic regression model were used. Findings At diagnosis, 111 women in our sample had stage IV cancer and 889 had stage I-III. Compared to patients with stage I-III cancer, patients with stage IV disease had a higher average age, more comorbidities, and were more often living in rural areas. Multivariate analysis showed that rural women (vs metropolitan) had a greater odds of having stage IV ovarian cancer at diagnosis (odds ratio = 2.41 and 95% confidence interval = 1.33-4.39). Conclusion Rural ovarian cancer patients have greater odds of having stage IV cancer at diagnosis in Midwestern states independent of the distance they lived from their primary care physician and the socioeconomic status of their residential census tract. Rural women's greater odds of stage IV cancer at diagnosis could affect treatment options and mortality. Further investigation is needed into reasons for these findings.
TL;DR: During 2010-2017, most HIV diagnoses occurred among women residing in nonrural areas, however, women in rural areas had slightly higher levels of late diagnosis and lower levels of viral suppression, which might have resulted from differences in access to testing and treatment services.
Abstract: BACKGROUND Women in rural areas face challenges to HIV diagnosis and care, including limited access to testing and treatment facilities. Recent declines in HIV diagnosis rates among women in the United States are encouraging. However, few studies have addressed how HIV diagnosis and care differ by rurality. METHODS We analyzed National HIV Surveillance System data for women aged ≥13 years with diagnosed HIV infection. We examined diagnoses in the United States during 2010-2017. Then, for women living with diagnosed HIV in 40 jurisdictions with complete laboratory reporting, we assessed viral suppression (viral load <200 copies/mL). Analyses were stratified by rural-urban category: rural (population <50,000), metropolitan (population 50,000-499,000), and metropolitan statistical areas (MSA, population ≥500,000). RESULTS Among 64,004 women who received a diagnosis of HIV infection during 2010-2017, 4.2% resided in a rural area, 15% resided in a metropolitan area, and 80% resided in an MSA. Rural women had the highest percentage of stage 3 infection (acquired immune deficiency syndrome) at diagnosis (rural 30%, metropolitan 27%, MSA 25%). Of 190,735 women living with diagnosed HIV, viral suppression was lower in rural areas (rural 55%, metropolitan 59%, MSA 58%). CONCLUSIONS During 2010-2017, most HIV diagnoses occurred among women residing in nonrural areas. However, women in rural areas had slightly higher levels of late diagnosis and lower levels of viral suppression, which might have resulted from differences in access to testing and treatment services. Interventions are needed to increase HIV testing, care, and viral suppression among women in rural areas.
TL;DR: Higher incidence and increased long-term survival for thyroid cancer were noted in urban areas compared to rural areas, and it is uncertain if rural-urban differences in long- term survival reflect health care disparities, differences in therapy, or other origins.
Abstract: PURPOSE Thyroid cancer incidence is rising, possibly secondary to increased imaging and surveillance. Based on rural access to care disparities, we hypothesized that incidence would be greater in urban compared to rural counties with no significant difference in long-term survival. METHODS An observational study was performed on thyroid cancer patients using Surveillance Epidemiology and End Results data (2000-2012). Age-adjusted incidence rates, incidence rate ratios, and survival rates were calculated across rural-urban designations. FINDINGS Incidence rates were 11.2, 9.8, and 10.1 per 100,000 for urban, rural-adjacent, and rural-nonadjacent counties, respectively. Statistically significantly lower incidence was noted in rural-adjacent and rural-nonadjacent compared to urban areas. Five-year and 10-year survival was significantly lower in rural-nonadjacent counties compared to urban counties. CONCLUSIONS Higher incidence and increased long-term survival for thyroid cancer were noted in urban areas compared to rural areas. It is uncertain if rural-urban differences in long-term survival reflect health care disparities, differences in therapy, or other origins.
TL;DR: This research presents a novel and scalable approach to regenerative medicine that combines traditional and innovative approaches to provide real-time information about the immune system’s response to disease.
Abstract: 1Office of Academic Affiliations, US Department of Veterans Affairs, Washington, District of Columbia 2Northern California Healthcare System, US Department of Veterans Affairs, Sacramento, California 3 Department of Internal Medicine, Division of Gastroenterology/Hepatology, UC Davis School of Medicine, Sacramento, California 4 Department of Family Medicine, The Ohio State University, Columbus, Ohio 5Department of Family Medicine, Ohio University College of Osteopathic Medicine, Athens, Ohio 6Department of Internal Medicine, Division of Rheumatology, Virginia Commonwealth University School of Medicine, Richmond, Virginia 7 Department of Family Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
TL;DR: A 2-by-2 multivariate analysis of variance was conducted to investigate if significant differences and/or interactions existed for internalized homophobia and community connectedness between rural and urban MSM, showing a significant interaction between rurality and doctor's visits.
Abstract: Purpose Men who have sex with men (MSM) face persistent risk of stigma, with past studies showing unequal treatments of MSM in health care settings. Contextual factors, such as internalized homophobia and connectedness to one's community, have shown to serve as a barrier or facilitator (respectively) with regard to MSM's decisions to seek preventative treatment. These studies, however, predominately feature urban populations, with less consideration given to rural MSM. The current study comparatively investigates these contextual factors between rural and urban MSM to detect differences in the frequency of doctor's visits. Methods A 2-by-2 (rural/urban × doctor visit yes/no) multivariate analysis of variance (MANOVA) was conducted to investigate if significant differences and/or interactions existed for internalized homophobia and community connectedness. Findings Results show a significant interaction between rurality and doctor's visits in our sample of predominantly white, self-identified gay men. Higher levels of internalized homophobia and lower levels of community connectedness were seen in rural individuals who had visited a doctor in the past 12 months and in urban individuals who had not seen a doctor in the past 12 months. Conclusions Study findings have implications for future public health research and for health promotion interventions, practices, and policies for MSM in rural areas. Social exclusion reinforces the invisibility of lesbian, gay, bisexual, and transgender (LGBT) populations, particularly in rural areas. Stigma and marginalization of MSM promote structural barriers inhibiting care. Our results give evidentiary support for programs which inform the work of clinicians on mechanisms to create LGBT-inclusive practice settings.
TL;DR: Rural Atlantic Canadians were more likely to report higher levels of total physical activity and lower alcohol consumption, and obesity prevalence was higher in rural Atlantic Canadians, suggesting that novel obesity prevention strategies may be needed for rural populations.
Abstract: Purpose
To describe and compare the sociodemographic and lifestyle characteristics of urban and rural residents in Atlantic Canada.
Methods
Cross‐sectional analyses of baseline data from the Atlantic Partnership for Tomorrow's Health cohort were conducted. Specifically, 17,054 adults (35‐69 years) who provided sociodemographic characteristics, measures of obesity, and a record of chronic disease and health behaviors were included in the analyses. Multiple linear regression and logistic regression models were used to calculate the multivariable‐adjusted beta coefficients (β), odds ratios (OR), and related 95% confidence intervals (CI).
Findings
After adjusting for age, sex, and province, when compared to urban participants, rural residents were significantly more likely to: be classified as very active (OR: 1.19, CI: 1.11‐1.27), be obese (OR: 1.13, 1.05‐1.21), to present with abdominal obesity (OR: 1.08, CI: 1.01‐1.15), and have a higher body fat percentage (β: 0.40, CI: 0.12‐0.68) and fat mass index (β: 0.32, CI: 0.19‐0.46). Rural residents were significantly less likely to be regular or habitual drinkers (OR: 0.83, CI: 0.78‐0.89). Significant differences remained after further adjustment for confounding sociodemographic, lifestyle, and health characteristics. No significant differences in smoking behavior, fruit and vegetable intake, multimorbidity, or waist circumference were found.
Conclusions
As expected, obesity prevalence was higher in rural Atlantic Canadians. In contrast to much of the existing literature, we found that rural participants were more likely to report higher levels of total physical activity and lower alcohol consumption. Findings suggest that novel obesity prevention strategies may be needed for rural populations.
TL;DR: Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation.
Abstract: Purpose To study the relationship between the availability and activation of emergency department-based telemedicine (teleED) and patient disposition in Critical Access Hospitals (CAHs). Methods A non randomized stepped wedge design examined 133,396 ED visits in 15 CAHs that subscribe to a single teleED provider. Data were available for at least 12 months prior to teleED implementation and at least 12 months of post-implementation. Primary analyses were conducted using multinomial logistic regression models with teleED availability (indicator of post-teleED implementation period) and activation (indicator of utilization of teleED service) predicting discharge disposition adjusting for age, sex, and clinical diagnosis. Results Patients for whom teleED was activated were more likely to be transferred [adjusted odds ratio (aOR) = 12.04; 95% confidence interval (CI), 10.97-13.21] and more likely to be admitted to the local hospital (aOR = 3.23; 95% CI, 2.84-3.67) than to be routinely discharged. This pattern was confirmed for patients presenting with chest pain, mental illness, and injury/poisoning. However, in the period following teleED implementation, patients presenting to EDs after telemedicine was available, but not necessarily utilized, were less likely to be admitted to the local hospital (aOR = 0.79; 95% CI, 0.76-0.82) than to be routinely discharged. Conclusions Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation. The relationship between teleED use and disposition may be related to selection in activating teleED for cases more likely to require hospital inpatient care.
TL;DR: It is hypothesized that rural physicians are retiring at higher rates than their urban counterparts in the United States and that this represents a bellwether for workforce challenges at large and that rural urologists are postponing retirement.
Abstract: Author(s): Cohen, Andrew J; Ndoye, Medina; Fergus, Kirkpatrick B; Lindsey, John; Butler, Christi; Patino, German; Anger, Jennifer T; Breyer, Benjamin N | Abstract: ObjectiveTo assess an aging subspecialty workforce and growing population that portends challenges in meeting patient care needs. We hypothesized that rural physicians are retiring at higher rates than their urban counterparts in the United States and that this represents a bellwether for workforce challenges at large.MethodsWe analyzed data from the 2014-2016 American Urological Association Census, a sample-weighted representative survey of urologists, as a case study for subspecialists. We compared urologists who work in rural regions to nonrural regions on available characteristics.ResultsIn 2016, rural urologists accounted for 2.4% of 12,186 practicing urologists in the United States. General urology remained the focus of 90% of rural urologists, compared to 59% of nonrural urologists (P = .03). Alarmingly, 48% of rural physicians were g65 years old in 2016 compared to 29% in 2014, and 33% of rural urologists were solo practitioners compared to 9% of nonrural urologists (P l .01). The planned retirement age for rural physicians increased from 68 in 2014 to 73 in 2016 (P trend = .02). The percentage of rural practice urologists has remained stable since 2014.ConclusionsRural urologists are older and provide more general urological care than their nonrural counterparts. Rural urologists are postponing retirement. Although this might be due to personal desires and financial goals, it may also be due to a relative absence of potential junior partners. Given that almost 50% of rural urologists were older than 65 in 2016, this is not a sustainable solution to an impending shortage of physicians. Greater innovation in telemedicine or alternative care models will soon be needed.
TL;DR: Changes in federal law regarding MOUD had a positive impact on both supply and geographic distribution in Oregon, particularly in frontier areas comprising 10 of 36 counties (27%).
Abstract: PURPOSE We examined the impact on geographic distribution of medications to treat opioid use disorder (MOUD) in Oregon after the Comprehensive Addiction and Recovery Act (CARA) was implemented in February 2017 to include nurse practitioner (NP) prescribers. METHODS We conducted interrupted time series analysis with linear regression on prescriptions dispensed for buprenorphine used for MOUD in the Oregon Prescription Drug Monitoring Database written by physician (MD/DO) and NP prescribers January 1, 2016, to December 31, 2018. We analyzed total prescriptions by prescriber type and pharmacy ZIP Code using STATA 16.1. FINDINGS From January 1, 2016, to December 31, 2018, 420,765 eligible prescriptions were written by waivered MD/DO and/or NP prescribers. Prior to CARA, buprenorphine use was increasing steadily at 140 prescriptions per month (95% CI: 78-201; P < .01). Following CARA, dispensing increased by 88 prescriptions per month (95% CI: 23-152; P = .01). The absolute number increased in rural areas immediately after CARA implementation (368 prescriptions; 95% CI: 124-613; P < .01). NP contribution to total buprenorphine prescribing increased significantly in both urban and rural areas (0.44% per month [95% CI: 0.30%-0.57%; P < .01] and 0.74% per month [95% CI: 0.62%-0.85%; P < .01]). The contribution of NPs had a particularly large impact for very rural (frontier) areas, where NPs provided 36% of all buprenorphine prescriptions by the end of 2018. CONCLUSION Changes in federal law regarding MOUD had a positive impact on both supply and geographic distribution in Oregon, particularly in frontier areas comprising 10 of 36 counties (27%).