Evidence-based Synthesis Program 

Rural vs. Urban

Ambulatory Health Care:

A Systematic Review

Department of Veterans Affairs

Health Services Research & Development Service

May 2011

Investigators:

Principal Investigator: 

Michele Spoont, PhD 

Co-Investigators: 

Nancy Greer, PhD 

Jenny Su, PhD

Research Associates:

Patrick Fitzgerald, MPH

Indulis Rutks, BS

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Minneapolis VA Medical Center

Minneapolis, MN

Timothy J. Wilt, MD, MPH, Director
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

PREFACE

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Spoont M, Greer N, Su J, Fitzgerald P, Rutks I, and Wilt TJ. Rural vs. 

Urban Ambulatory Health Care: A Systematic Review. VA-ESP Project #09-009;2011.

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, 

MN funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Health Services Research and Development. 

The findings and conclusions in this document are those of the author(s) who are 

responsible for its contents; the findings and conclusions do not necessarily represent 

the views of the Department of Veterans Affairs or the United States government. 

Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (e.g., employment, consultancies, honoraria, stock ownership or options, 

expert testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report.
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

TABLE OF CONTENTS

EXECUTIVE SUMMARY

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Future Research............................................................................................................................................. 3

INTRODUCTION

Background.................................................................................................................................................... 5

Definitions of Rurality................................................................................................................................... 6

METHODS

Topic Development........................................................................................................................................ 9

Search Strategy.............................................................................................................................................. 9

Study Selection............................................................................................................................................ 10

Data Abstraction .......................................................................................................................................... 10

Data Synthesis............................................................................................................................................. 10

Rating the Body of Evidence....................................................................................................................... 10

Peer Review................................................................................................................................................. 11

RESULTS

Literature Flow ............................................................................................................................................ 12

Preventive Care/Ambulatory Care Sensitive Conditions............................................................................ 13

Cancer Care ................................................................................................................................................. 16

Diabetes/End Stage Renal Disease.............................................................................................................. 20

Cardiovascular Disease ............................................................................................................................... 23

HIV/AIDS.................................................................................................................................................... 25

Neurologic Conditions................................................................................................................................. 26

Mental Health................................................................................................................................ 28

Processes or Structure of Care ...................................................................................................... 33

Use of Medication......................................................................................................................... 33

Medical Procedures and Diagnostic Tests..................................................................................... 35

Medical Appointments with Providers.......................................................................................... 35

Usual Source of Care .................................................................................................................... 36

Provider Availability and Expertise .............................................................................................. 37

SUMMARY AND DISCUSSION

Conclusions and Recommendations............................................................................................................ 42

Summary of Evidence by Key Question ..................................................................................................... 42

Research Implications and Recommendations............................................................................................ 46
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

REFERENCES ................................................................................................................................................... 49

TABLES

Table 1. Definitions of Urban and Rural................................................................................................... 7

Table 2. Explanation of Confidence Scores............................................................................................ 11

Table 3. Confidence Scores for Preventive Care/Ambulatory Care Sensitive Condition Studies.......... 16

Table 4. Confidence Scores for Cancer Care Studies............................................................................. 20

Table 5. Confidence Scores for Diabetes and End-Stage Renal Disease Studies................................... 23

Table 6. Confidence Scores for Cardiovascular Disease Studies ........................................................... 25

Table 7. Confidence Scores for HIV/AIDS Studies ............................................................................... 26

Table 8. Confidence Scores for Neurologic Conditions Studies ............................................................ 28

Table 9. Confidence Scores for Mental Health Studies.......................................................................... 34

Table 10. Confidence Scores for Processes and Structure of Care Studies.............................................. 40

FIGURES

Figure 1. Analytic Framework ................................................................................................................... 9

Figure 2. Flow Diagram of Included Studies........................................................................................... 12

APPENDIX A. DATA ABSTRACTION FORM.................................................................................. 58

APPENDIX B. PEER REVIEW COMMENTS AND AUTHOR RESPONSES .................... 59

APPENDIX C. EVIDENCE TABLES

Table 1. Preventive Care/Ambulatory Care Sensitive Conditions ......................................................... 65

Table 2. Cancer Screening...................................................................................................................... 67

Table 3. Cancer Care .............................................................................................................................. 69

Table 4. Diabetes/End Stage Renal Disease ........................................................................................... 73

Table 5. Cardiovascular Disease............................................................................................................. 76

Table 6. HIV/AIDS................................................................................................................................. 78

Table 7. Neurologic Conditions.............................................................................................................. 79

Table 8. Mental Health ........................................................................................................................... 81

Table 9. Use of Medication..................................................................................................................... 88

Table 10. Medical Procedures and Diagnostic Tests................................................................................ 90

Table 11. Medical Appointments with Providers ..................................................................................... 91

Table 12. Usual Source of Care ................................................................................................................ 94

Table 13. Provider Availability and Expertise .......................................................................................... 96
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

EVIDENCE REPORT

INTRODUCTION

BACKGROUND 

There are approximately 3 million veterans enrolled in the VA health care system who live in 

rural areas (as defined by VA) -- nearly 40% of the almost 8 million veterans who are current 

users of VA health care.1 Given that only 17% of the US population lives in rural areas, rural 

residents are disproportionately represented among veterans using VA services.2 This trend is 

likely to continue, as more than one-third of OEF/OIF veterans are from rural areas.3

 The Rural 

Veterans Care Act of 2006 was signed into law to improve care for rural veterans. Ensuring that 

the health care needs of rural veterans are met has become a top priority for VA, resulting in 

a considerable expansion of community based outpatient clinics (CBOC’s), inclusion of rural 

health/access as a research priority, and creation of the VA Office of Rural Health (ORH) in 

2006. 

A comparison of rural and urban veterans enrolled in VA health care in 1999 observed that rural 

veterans had lower overall health quality of life (both physical and mental), more comorbidities, 

and lower health quality of life within disease category than urban veterans.4,5 Although more 

recent assessments have shown that rural veterans appear to have comparable or even better 

mental health quality of life than urban veterans, the lower physical health quality of life in rural 

veterans has persisted over time.6,7 While differences in health care use between rural and urban 

veterans have been documented,8 it is unclear to what extent such differences in service use 

contribute to the observed differences in health outcomes. Some of the rural-urban difference in 

physical health quality of life among VA users is likely due to differences in disease prevalence,4

with elevated prevalence rates across numerous conditions among those rural veterans who use 

VA care.9 It remains to be determined, however, whether the observed lower health quality of 

life among rural veterans is due to differences in disease prevalence, disparities in health care 

or differences in other population characteristics. Because this review focuses on health care, 

differences in rural-urban prevalence rates of diseases and other health conditions are beyond 

its scope. This systematic review examines the evidence regarding potential disparities between 

rural and urban areas in health care provision and delivery, and how differences in health care 

may contribute to disparities in health outcomes. 

Our first goal was to determine if a health care disparity exists across the urban-rural spectrum. 

For a disparity to exist, it would have to be demonstrated that health care outcomes of patients 

in rural areas differ from those of patients treated in urban areas for similar conditions. Because 

differences in health care process or delivery do not necessarily lead to disparities, we looked for 

evidence associating differences with poorer health outcomes. In their report, Unequal treatment: 

Confronting racial and ethnic disparities in healthcare, the Institute of Medicine10 defined 

disparity as, “...racial or ethnic differences in the quality of health care that are not due to 

access-related factors or clinical needs, preferences, and appropriateness of intervention”(pg 32). 

They go on to note, however, that inequity in care is often due to access-related factors, and that 

access differences are integrally tied to bias, stereotyping and inherent differences in health care 
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

systems. For the purposes of this review we conceptualized rural-urban disparities as differences 

in health care quality or availability. 

A second goal of the review was to identify areas for intervention should any disparities be 

found. In order to develop a meaningful intervention, specific information regarding differences 

in the structure of health care and the way it is administered (i.e., the process) would be critical. 

Since differences in health outcomes can occur for reasons other than differences in the health 

care systems themselves (e.g., accessibility), our third goal was to examine what, if any, nonhealth care factors (e.g., travel distance to a clinic) affected health outcomes. Because veterans 

who use VA health care actually use more non-VA health care overall,9

 we expanded the focus of 

this review to include comparisons of rural vs. urban health care in non-VA health systems. 

DEFINITIONS OF RURALITY

As noted in a review of the VA rural health literature by Weeks et al. (2008),11 synthesizing the 

literature on rural health is complicated by the methodologic and conceptual issues inherent 

in such a diverse literature. One recurrent problem is the lack of consistency across studies 

regarding the conventions used to define levels of rurality across communities, zip codes 

or counties.11 This inconsistency affects interpretation of the individual studies as well as 

comparability of findings across studies.12,13 It is beyond the scope of this review to address the 

complexities and ramifications of using specific population density classification schemes (for 

a discussion see Berke et al., 200914; Stern et al., 201012; West, 201013). However, given the 

implications of this variation, we note the particular convention used to categorize rurality used 

in each study in the evidence tables for each section. For the convenience of readers who may be 

unfamiliar with these conventions, we provide a table of the most commonly used conventions 

along with a brief description of each (Table 1). 
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lth Care: A Systematic Review Evidence-based Synthesis Program

nd Rural (West et al. 2010;13 Berke et al. 200914) 

f Rural 

nition Designations Descriptions

y Level The Office of Management and Budget (OMB) Metropolitan and Micropolitan statistical areas are a county level classifications defined by the existence of an urban core, the population of the urban core, and the economic and social integration of 

its surrounding territory measured by commuting ties. The OMB strongly cautions against the use of Metropolitan and Micropolitan Statistical Area Standards for defining urban-rural definitions due to the fact that all counties included in Metropolitan 

and Micropolitan Statistical Areas and many other counties contain both urban and rural territory and populations.

Metropolitan Statistical 

Area

•	 Contains an Urbanized Area of 50,000 or more population and adjacent territory that has a high degree 

of social and economic integration with the core as measured by commuting ties

Micropolitan Statistical 

Area

•	 Contains an Urban Core of at least 10,000, but less than 50,000, population and adjacent territory that has 

a high degree of social and economic integration with the core as measured by commuting ties

Non-core based •	 Based on an Urban Center of less than 10,000 people.

y Level The 2003 USDA Rural-Urban Continuum Codes form a classification scheme that distinguishes metropolitan 

counties by size and nonmetropolitan counties by degree of urbanization and proximity to metro areas. This standard divides those of the Office of Management and Budget (OMB) into three metro and six non-metro categories, resulting in a 9-part county coding system. The standards for defining metropolitan areas were modified in 1958, 1971, 1975, 1980, 1990, and 2000. The current scheme was originally developed in 1974. This version allows researchers to specific populations based on population density and metro influence. Due to changes by the OMB’s 

metro area delineation procedures for the 2000 Census, the current 2003 standards are not fully compatible with those of earlier years. 

Metro •	 Counties in metro areas of 1 million population or more

•	 Counties in metro areas of 250,000 to 1 million population•	 Counties in metro areas of fewer than 250,000 population

Non-metro •	 Urban population of 20,000 or more, adjacent to a metro area

•	 Urban population of 20,000 or more, not adjacent to a metro area•	 Urban population of 2,500 to 19,999, adjacent to a metro area•	 Urban population of 2,500 to 19,999, not adjacent to a metro area•	 Completely rural or less than 2,500 urban population, adjacent to a metro area•	 Completely rural or less than 2,500 urban population, not adjacent to a metro area

y Level The VA system of urban/rural classification combines those of the census blocks following census tracts urbanized areas 

and those of county population density. 

Urban •	 Urban nucleus of 50,000 or more people which may or may not contain any individual cities of 50,000 or more, but 

must have a core with a population density of 1,000 persons per square mile and may contain adjoining territory with at least 500 persons per square mile.

Rural •	 Those counties not falling into the extremes of Urban or Highly Rural

Highly Rural •	 Counties with an average population density of 7 residents per square mile
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lth Care: A Systematic Review Evidence-based Synthesis Program

f Rural 

nition Designations Descriptions

Tract Level RUCA is a 33 code system which defines rural areas in terms of census tracts based on population density in an “urban 

area” combined with primary and secondary commuter flow rates. Census tracts can be converted to a ZIP code approximation. Operationalization of this classification system typically involves grouping these codes into larger categories. The most 

common grouping uses a 4 tier system including Urban Areas, Large Rural Towns, Small Rural Towns, and Isolated Rural Towns. Below are the various versions and their data sources over time. Version 1.1 - First publicly released RUCA files. Based on 1998 ZIP code areas and 1990 Census commuting data. Data are not available.Version 1.11 - ZIP code correction made in Oregon file. Version 2.0 - Based on 2004 ZIP code areas and 2000 Census commuting data.*An additional 2.0 version based on 2006 ZIP code areas and 2000 commuting data is also available.

Urban Areas •	 ZIP codes or census tracts that have Metropolitan cores as defined by the OMB

Large Rural Towns •	 ZIP codes or census tracts with Micropolitan cores and substantial commuting patterns to urban clusters

Small Rural Towns •	 ZIP codes or census tracts with primary commuting flows to or within population centers of between 2,500 and 

9,999 residents

Isolated Rural Towns •	 ZIP codes or census tracts in less populated rural areas with no primary commuting flows to Urbanized Areas or 

Urban Clusters

on Density 2000 census criteria All territory, population, and housing units located within an urbanized area (UA) or an urban cluster 

(UC). It delineates UA and UC boundaries to encompass densely settled territory, which consists of: 

•	 core census block groups* or blocks that have a population density of at least 1,000 people per square mile and 

•	 surrounding census blocks that have an overall density of at least 500 people per square mile 

“Rural” therefore consists of all territory, population, and housing units located outside of UAs and UCs. Geographic entities, such as census tracts, counties, metropolitan areas, and the territory outside metropolitan areas, often are “split” between urban and rural territory, and the population and housing units they contain often are partly classified as urban and partly classified as rural. 1990 census criteria All territory, population, and housing units in urbanized areas and in places of 2,500 or more persons outside urbanized areas. More specifically, “urban” consists of territory, persons, and housing units in:

 1. Places of 2,500 or more persons incorporated as cities, villages, boroughs (except in Alaska and New York), and towns 

(except in the six New England states, New York, and Wisconsin), but excluding the rural portions of “extended cities.”

 2. Census designated places of 2,500 or more persons. 3. Other territory, incorporated or unincorporated, included in urbanized areas.

Urbanized Area •	 An urbanized area consists of a central city and surrounding areas whose population is > 50,000. 

They may or may not contain individual cities with 50,000 or more; rather, they must have a core with a population density generally exceeding 1,000 persons per square mile; and may contain adjoining territory with at least 500 persons per square mile (other towns outside of an urbanized area whose population exceeds 2,500). 

Rural Area •	 Rural areas comprise open country and settlements with fewer than 2,500 residents; areas designated 

as rural can have population densities as high as 999 per square mile or as low as 1 person per square mile.

 Density and 

 urban areas

•	 Urban Influence Codes (2003) divide the 3,141 US counties into 12 groups combing both population 

density and proximity to urban areas. 

Metro counties •	 Divided into “large” areas with at least 1 million residents and “small” areas < 1 million residents.

Nonmetro

micropolitan counties

•	 Divided into three groups: adjacent to a large metro area, adjacent to a small metro area, and not 

adjacent to a metro area.

Nonmetro noncore

counties

•	 Divided into seven groups by: 1). their adjacency to metro or micro areas and 2) whether or not they 

have a town/village of at least 2,500 residents.

ormally bounded by visible features, such as streets, streams, and railroads, and by non-visible features, such as the boundary of an incorporated place.
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

METHODS

TOPIC DEVELOPMENT

This project was nominated by HSR&D and the Office of Rural Health. The analytic framework 

and key questions were developed with input from technical expert panel members Brian Bair, 

MD; John Fortney, PhD; Peter Kaboli, MD, MS; Ryan Lilly, MPA; and Alan West, PhD.

The analytic framework is depicted in Figure 1. The final key questions are:

Key Question #1. Do adults with health care needs who live in rural areas have different 

intermediate (e.g., HbA1c, Blood pressure, etc.) or final health care outcomes (i.e., mortality, 

morbidity, QOL) than those living in urban areas?

Key Question #2. Is the structure (e.g., types of available providers) or the process (e.g., 

likelihood of referral) of health care different for adults with health care needs who live in urban 

vs. rural environments?

Key Question #3. If there are differences in the structure or the process of health care in rural vs. 

urban environments, do those differences contribute to variation in overall or intermediate health 

outcomes for adults with health care needs?

Key Question #4. If there are differences in intermediate or final health outcomes for adult 

patients with health care needs, what systems factors other than those due to differences in health 

care structure or process moderate those differences (e.g., travel distance)?

SEARCH STRATEGY

We searched OVID MEDLINE, PsycINFO, and CINAHL from 1990 to June, 2010 using the 

following MEDLINE search terms (or the corresponding terms in PsycINFO and CINAHL): 

hospitals, rural; rural health; rural population; rural health services, and United States. Limits 

to the search included English language, published 1990 or later, population age of 18 years or 

older, and publication types randomized controlled trial, clinical trial, cohort or cross-sectional 

study, meta-analysis, or review. Additionally, we did a hand search of references lists of relevant 

articles and of The Journal of Rural Health using the limits noted above.

Figure 1. Analytic Framework

Adult with Healthcare 

Need

Intermediate

Outcomes:

(e.g., HgbA1c, 

Blood pressure)

KQ2

Structure and/or

Process Differences?

(e.g., Provider Expertise,

Liklihood of Referral)

Non-Patient

Moderating or

Mediating Factors

(e.g., Travel Distance)

Final Health 

Outcomes:

(e.g., Quality of Life,

Patient Satisfaction,

Morbidity, Mortality

KQ1

KQ1

KQ3

KQ4
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

STUDY SELECTION

The principal investigator, co-investigators, and one of the research associates, all with 

experience in critical review of published studies, reviewed abstracts of articles identified in 

the search and selected articles for further review based on pre-defined exclusion criteria. In 

addition to the exclusion criteria used to limit the search, we also excluded articles if they were 

not about health care (e.g., focused on disease prevalence), if they did not include patients from 

rural settings, or if they were not about ambulatory care. Eligible articles provided primary data 

relevant to the key questions.

DATA ABSTRACTION

Data from eligible articles was abstracted by the principal investigator, co-investigators, and 

one of the research associates onto a brief screening form (see Appendix A). The principal 

investigator developed the form and all abstractors completed forms for a common set of six 

articles. Results of the trial abstraction were reviewed with the principal investigator. The 

abstraction form captured data on the study design, sample (including whether the subjects in 

the study were Veterans), definition of rural used in the study, data source including the date of 

datesets used, analyses including covariates, and outcome measures.

DATA SYNTHESIS

Because we wished to examine the body of evidence related to specific areas of health care, the 

studies were reviewed with other studies in that area. We constructed evidence tables showing 

the study characteristics and results for all included studies. We critically analyzed studies to 

compare their characteristics, methods, and findings. We compiled a summary of findings for 

each clinical topic, and drew conclusions based on a qualitative synthesis of the findings.

RATING THE BODY OF EVIDENCE

Due to the qualitative nature of the synthesis, standard methods for rating the body of evidence 

do not apply and there are no validated rating systems to compare the quality of observational 

studies. Based on the work of others,15,16,17 we developed a rating system that we used as a 

heuristic in our efforts to compare studies that used different methodologies and to facilitate 

a synthesis of the evidence base in each content area. Although these ratings are essentially 

qualitative in nature, they provide the reader with information regarding our evaluations of the 

studies and, consequently, the overall evidence base. For each study, we evaluated the internal 

and the external validity, and then assigned an overall Confidence Score based on these ratings. 

The principal investigator and one of the co-investigators rated all articles after independently 

rating a set of 20 articles and reviewing the results. In Table 2 we detail the scales used and the 

kinds of elements that were considered within each rating category.
11

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Table 2. Explanation of Confidence Scores

Internal Validity Rated G(Good), F(Fair), P(Poor). In order to receive a “G” for internal validity would 

need to have “G” ratings for all subsumed elements.

Sampling Method/Bias Low response rates without correction; convenience sampling; 

Predictors/Confounders Omission of socioeconomic/insurance factors or other factors usually associated with 

service use (e.g., age).

Outcomes Unreliable or not validated measures; use of proxy variables (e.g., self-reported service use)

Statistical Methods Omission of bivariate or multivariate statistics; Ignored data clustering

External Validity Rated G(Good), F(Fair), P(Poor). In order to receive a “G” for external validity would 

need to have “G” ratings for all subsumed elements.

Use of proxy variables or 

aggregate measures

Use of county level predictors or outcomes in lieu of individual ones; Dichotomized 

urban rural without further gradations if urban/rural were a covariate in their model.

Representativeness of 

sample 

Small samples; samples limited to one demographic group; no correction for biased 

sampling;

Study design appropriate 

for the research question?

Dichotomized urban rural without further gradations if area of residence was the focus 

of the study; poorly conceptualized study; data insufficient to answer primary research 

question.

Overall Confidence 

Score

Rated as follows:

High Quality = further research unlikely to change confidence in effects. Both internal 

and external rated as “G”

Moderate Quality= further research likely to have an important impact on confidence 

and may change the estimate of effect.

Low Quality= further research is very likely to have an important impact and will likely 

change the estimate of effect.

Very Low Quality= any estimate of effect is uncertain.

Note: “H” Overall Confidence Score would require “Good” ratings for both Internal and 

External Validity.

PEER REVIEW

A draft version of this report was sent to nine peer reviewers. Their comments and our responses 

are presented in Appendix B.
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

RESULTS

LITERATURE FLOW

The literature flow is presented in Figure 2. The combined search library contained 1,381 citations, of which we reviewed 333 articles at the full-text level. We excluded 165 of the 333 articles and added 24 references through hand-searching reference lists of relevant articles and The 

Journal of Rural Health. Of 192 possible studies, we excluded 93 because they were not related 

to ambulatory care, described an intervention, or provided background information. Three studies were added based on comments received during peer-review resulting in 102 articles reporting data pertaining to one of the key questions. The included articles were categorized under the 

following ambulatory care services: preventive care/ambulatory care sensitive conditions, cancer 

care, diabetes/end stage renal disease, cardiovascular disease, HIV/AIDS, neurologic conditions, 

and mental health. We also identified and included articles focused on use of medication, medical 

procedures and tests, and provider and service utilization more generally.

Figure 2. Flow Diagram of Included Studies

Search results (MEDLINE, 

PsycINFO, CINAHL)

(n=1,381)

Abstract Review

Potentially eligible studies for 

full text review (n=333)

Articles abstracted (n=192)

Included studies (n=102)

Studies added after peer

review (n=3)

Studies added:

a. hand searching (n=5)

b. Journal of Rural Health 

(n=19)

Non-United States population = 6

Population <18 years old = 3

Not publication type criteria = 66

Not Healthcare outcomes, 

structure/process/harms = 80

Non-Rural Health = 10

TOTAL = 165

Non-United States population = 50

Population <18 years old = 97

Not publication type criteria = 312

Not Healthcare outcomes, 

structure/process/harms 506

Non-Rural Health = 83

TOTAL = 1,048

Not related to key questions = 93

(includes non-ambulatory care, 

intervention studies, background papers)
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

PREVENTIVE CARE/AMBULATORY CARE SENSITIVE CONDITIONS 

(Table 3 and Appendix C, Tables 1 and 2)

There were two studies looking at immunization rates,18,19 nine looking at cancer screening 

rates,18-26 one examining prenatal care,27 and three examining hospital rates for ambulatory care 

sensitive conditions.28-30

Immunization rates were examined in only two studies, both using data more than 10 years 

old. Among respondents to the 1994 US National Health Interview Survey, the rate of flu shot 

receipt among 4,051 people over 65 yr was examined.19 No differences were observed between 

older rural and urban residents in the receipt of flu vaccine in adjusted analyses. Similarly, 

national data of 130,452 respondents from the 1997 Behavioral Risk Factor Surveillance System 

(BRFSS) and the 1999 Area Resource File found no rural-urban differences in the rates of either 

flu or pneumonia vaccines among women age 65 years and older.18

Only one study examined prenatal care.27 This study used the 2003 Oregon Pregnancy Risk 

Assessment Monitoring System to examine the odds of receiving prenatal care after the first 

trimester in RUCA defined urban, large rural and small rural areas among 1,508 women. Women 

were surveyed post childbirth about when during their pregnancy they initiated prenatal care 

(if at all). No differences were found between residence categories in the odds of late initiation 

(after first trimester) of prenatal care. However, given methodologic problems with the study, our 

confidence in this finding is moderately low. 

Ambulatory care sensitive conditions (ACSC) are those conditions in which inadequate 

outpatient treatment leads to increases in hospitalization.30 Conditions that are considered to be 

ambulatory care sensitive include congestive heart failure (CHF), hypertension, angina, chronic 

obstructive pulmonary disease, as well as other conditions in which hospitalization can usually 

be avoided, such as bacterial pneumonia, cellulitis, diabetes, gastroenteritis, asthma, and urinary 

tract infections. A study of the prevalence of ACSC hospital admissions in New York State 

from 1991-1993 found that the rates increased as population density decreased within each of 

the demographic groupings (New York City area, upstate urban-suburban areas, more remote 

rural). They did not compare across areas. Of note, the percentage of blacks was positively 

associated with the rate of ACSC admissions in the two more populous groupings.30 In a much 

better designed study, Laditka (2009) examined ACSC admissions in 8 states during 2002.28

They reported a step-wise increase in the rate ratios of admissions for patients 18-64 years across 

levels of rurality adjusted for demographics and availability of health care services. Although 

further adjustment for death rates from chronic diseases (e.g., heart disease) did not change the 

association appreciably, adjustment for percentage of population that was uninsured reduced 

the association across all levels of population density, suggesting that insurance-related access 

contributed to the variation across the spectrum of population density. However, since rates in 

the most rural areas remain elevated relative to urban rates even after adjusting for insurance 

(RR=1.28, 95%CI=1.12-1.47) the contribution of insurance possession to the population density 

effect is only partial. For patients 65 years or older, the step-wise increase in ACSC admissions 

was retained when all adjustments were made except for those related to death rates and 

physician supply (which was not significantly associated with ACSC admissions) (RR=1.46, 

95%CI=1.39-1.52 most rural:urban).
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Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

A study of secondary and tertiary prevention among 787 older adults with ACSCs (specifically, 

arthritis, hypertension, coronary heart disease, diabetes mellitus, peptic ulcer disease, and chronic 

obstructive pulmonary disease [COPD]), was conducted in Iowa in 1995.29 No differences 

were found between rural and urban residents in condition-specific prevention scores, but 

methodologic limitations of this study resulted in a low Confidence Score, suggesting that these 

results are likely to change with new information. Although rural residents with these chronic 

conditions saw fewer specialists than urban residents (7% vs. 12%, p<0.05), and were somewhat 

less likely to report a need for medical advice in the previous year (50% vs. 58%, p<0.05), they 

also had better continuity of care than urban residents (100% vs. 83% of time seeing physician 

they saw most, p<0.001).

The rate of colorectal cancer (CRC) screening was assessed in two national studies, and one 

regional study. All three studies found a rural disadvantage in screening rates. National data of 

130,452 respondents from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and the 

1999 Area Resource File examined CRC screens (fecal occult blood test or proctosigmoidoscopy). 

Residents from rural areas adjacent or non-adjacent to urban areas were less likely to get CRC 

screening (ORs=0.83 and 0.82, respectively).18 Similar results were reported using the 1998-1999 

datasets of the BRFSS of 23,565 men and 37,847 women over age 50 years.22 In rural areas, 16.2% 

of residents had a fecal occult blood test vs. 22% in large urban areas. Examining sigmoidoscopy/

colonoscopy rates yielded a similar finding, with 28.2% of rural residents receiving these screens 

vs. 35.2% of those who live in large urban areas. Although attenuated, these differences remained 

after adjustments. A case-control study of CRC screening in North Carolina using a nurse led 

patient interview found fewer rural residents reported CRC screening in the previous 5 years.24

When differences in screening rates were held constant, a rural disparity in the incidence of CRC 

was eliminated, suggesting a difference in health care access. 

There were five studies examining breast and cervical cancer screening rates in national samples. 

The 1994 US National Health Interview Survey was used to assess, cervical and breast cancer 

screening (i.e., mammography) among 8,970 age 18 years and older, and among 2,729 women 

age 50 years and older respectively.19 No differences were observed between rural and urban 

women in the receipt of cervical cancer screens. Differences were found between urban and rural 

women in mammography (68% of urban vs. 61 percent of rural; p =0.01). These differences 

were no longer apparent after adjustment for education, household income and health insurance 

status. Among the 12,637 patients 65 yr and older and/or disabled who participated in the 1993 

Medicare Current Beneficiary Survey, screening rates were lower among women from smaller 

non-urban counties relative to large urban counties for breast (28.6% vs. 34.4%) and cervical 

(28.4% vs. 23.1%) cancers in bivariate analyses.26 As with the 1994 National Health Interview 

study, these differences disappeared after adjusting for income, Medicaid status, physician 

availability, age, race, education and functional status.

All three studies using the BRFSS datasets found rural-urban differences in breast and/or 

cervical screening rates. In a study using the 1997 BRFSS database,18 women from rural areas 

were significantly less likely to get cervical cancer screening (ORs=0.86 and 0.88), while only 

those from rural areas adjacent to metropolitan areas were less likely to get mammograms 

(OR=0.82). Factors found to be predictive of screenings included insurance status, availability 

of primary care providers, and income. A study using the 1998-1999 BRFSS database examined 
15

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

mammography and clinical breast exams among 108,326 women over 40 years old, and cervical 

cancer screens among 131,813 women over the age of 18 years.21 Among rural women over 40 

years old, 66.7% had mammograms and 73% had clinical breast exams. The rates among urban 

women were 75.4% for mammography and 78.2% for clinical breast exams. Similar differences 

for cervical cancer screening rates were found, with 81.3% of rural women and 84.5% of the 

most urban women getting screens. These differences were attenuated with adjustment, but 

remained significant. Of note, rural-urban differences were greater among black and Hispanic 

women. Finally, a study examining cervical screening rates using 2002 BRFSS, found that the 

odds of receiving a Pap test among 91,492 rural women depended on the number of available 

primary care providers.23 Urban women who lived in counties with fewer providers (i.e., fewer 

than 300 primary providers per 100,000 women) were more likely to get a Pap test than rural or 

suburban women from counties with similar provider availability (OR=1.13, 95%CI=1-1.28). In 

counties in which there were moderate numbers of providers (i.e., 300-500 per 100,000 women), 

only those in suburban counties were disadvantaged (OR=0.72, 95%CI=0.55-0.94). The odds 

of mammogram receipt were greater for urban (OR=1.21, 95%CI=1.11-1.32) and suburban 

(OR=1.28, 95%CI=1.17-1.4) women than rural women independent of provider availability.

In both regional studies in which breast and cervical cancer screening rates were assessed 

there was a rural disadvantage, though significance remained after adjustment in only one of 

the studies. Using state BRFSS data from 1996-1997, non-disabled rural women in Iowa were 

found to have had lower rates of screening for breast (X2

=5.73, p<0.0001) and cervical (X2=6.0, 

p<0.0001) cancer than their urban counterparts.25 For example, of those from the most rural 

regions (population density of fewer than 20 people per square mile), only 37.3% received 

a mammogram and only 61.3% were screened for cervical cancer. In contrast, in the most 

densely populated areas (100 or more per square mile), 56.4% and 73.7% received screenings 

for breast and cervical cancers respectively. Similarly, a smaller study using 1,922 respondents 

from the Tennessee BRFSS for 2001 and 2003 found more urban than rural women received 

a mammogram in the previous two years (78.3%, 95%CI=75.9-80.7 vs. 71.3%, 95%CI=67.4-

75.2).20 After adjusting for demographics, insurance status and having a health care provider, 

however, rural residence status was no longer significant.

Summary

Immunization rates appear to be comparable in rural vs. urban areas; however, given that there 

were only two studies and that both relied on data 10 years old, our confidence in this finding 

while moderate, remains provisional. 

The one study of prenatal care suggested no rural-urban difference; however, given the 

study design, the regional nature of the sample and the absence of confirmatory findings, our 

confidence in the evidence base is low.

All studies examining cancer screening rates found rural-urban differences. The primary 

difference among the studies was that in some of them, the rural-urban difference disappeared 

once access factors (e.g., income, availability of physicians, insurance status) were controlled, 

while in others the differences remained significant albeit of a smaller magnitude. This suggests 

that rural-urban differences in cancer screening rates are at least partially due to differences in 

health care access. 
16

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Of note, screening rates are not uniformly lower across rural areas. For example, a study looking 

at rates of mammography in randomly selected Rural Health Clinics nationally found triple 

the rate of screening in the Middle third of the country compared to that in the Western third of 

the country (OR=3.75, 95%CI=1.43-9.87).31 Studies using national databases, therefore, may 

overlook actual rural-urban differences by pooling across regions. 

Hospitalizations associated with ACSCs are, at best, indirect measures of health care quality 

and/or access. Of the two studies examining hospitalization rates for ACSCs, we had 

greater confidence in the study that sampled from eight states and in which a higher rate of 

hospitalization for these conditions was found in rural areas. That the presence of federally 

qualified Rural Health Clinics or Community Health Centers have been found in other studies to 

diminish the rates of ACSC hospital admissions,32 suggests that such admissions may be related 

to the availability of health care resources. Still, given the limited evidence base, this can only be 

viewed as provisional.

Table 3. Confidence Scores for Preventive Care/Ambulatory Care Sensitive Condition Studies

Study

Casey

200118

Zhang

200019

Kinney

200624

Epstein

200927

Laditka

200928

Schreiber

199730

Saag 199829

18

Coughlin

200221

Coughlin

200422

Coughlin

200823

Stearns

200026

Brown

200920

Schootman

199925

Internal Validity G G G F G F F G G G G G G

Sampling Method/Bias G G G F G G F G G G G G G

Predictors/Confounders G G G G G F G G G G G G G

Outcomes G G G F/P G G F G G G G G G

Statistical Methods G G G G G F G G G G G G G

External Validity G F G F F F F G G G F F F

Use of proxy variables or 

aggregate measures G G G G F F F G G G G G F

Sample Representativeness 

(size, composition) G F G F G G G G G G F G G

Design appropriate for the 

research question G G F G G F G G G G G F F

Overall Confidence Score H M M M/L M L L H H H M M M

CANCER CARE (Table 4 and Appendix C, Table 3)

Comparisons of rural and urban health care for cancer have focused on variation in staging, 

mortality, and quality of care. There were 12 studies comparing urban and rural cancer care. 

Three studies examined mortality.25,33,34 Nine studies examined cancer stage at the time of 

diagnosis,24,25,33,35-40 three studies examined the relationship between screening and disease 

progression,25,35,37 and five looked at treatment quality.33-35,41,42

Of the three studies of mortality, two were of regional samples and the one national study used 

a sample of people 65 years and older. Using the Iowa Surveillance, Epidemiology, and End 
17

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Results (SEER) database for 1991-1995 and the BFRSS database for 1996-1997, mortality among 

breast and cervical cancer patients was examined.25 No differences in age adjusted mortality rates 

for cervical and breast cancer were found between rural and urban women. Similarly, using the 

national SEER database and the Medicare Claims database from 1995 and 1999, patients over 

65 years with lung cancer were identified and service utilization, stage of illness at presentation 

and mortality rates were compared across four levels of rurality (N=26,073).33 As in the Iowa 

study, no differences were seen in overall survival between rural and urban areas either before or 

after adjustments. Factors that were predictive of mortality were patient demographics, receipt 

of radiation for those with stage II and IV disease, and the number of subspecialists per 10,000 

residents 65 years and older. Both the odds of radiation receipt and the supply of subspecialists 

were lower in rural areas (radiation 47.0% urban vs. 43.2% rural, trend only; subspecialists: urban 

10.6 ±7.6 per 10,000 residents vs. most rural 1.2 ± 3.3 per 10,000, p<0.01). 

Mortality was also evaluated in a cohort of patients with lymphoma diagnoses who were 

registered in the Nebraska Medical Center Oncology Database.34 Overall survival rates were 

lower for those rural residents who were treated by community providers as compared to 

either urban residents or rural residents treated by university affiliated providers (5 year 

survival rate 51% vs. 59-66%; p<0.001), suggesting that community providers in rural areas 

had less expertise. However, because of the nature of the sample used, this finding may not be 

generalizeable. 

Four studies examined differences in rates of diagnostic staging at the time of initial cancer 

presentation.33,35,37,38 Three studies found differences between rural and urban areas in the odds 

of having an incident cancer staged, whereas one national study of lung cancer patients 65 years 

and older did not find differential odds between rural and urban areas.33 A comparison of 1,105 

urban residents and 1,463 rural residents from 18 rural communities surrounding Lake Superior 

with incident cancer between 1992-1997,35 found that rural cancer patients were less likely to 

have breast (60% vs. 83%), prostate (41% v. 60%) or non-small cell lung cancers (82% vs. 

90%) staged at the time of initial diagnosis than urban residents. No differences were found in 

rate of staging for prostate or small cell lung cancers. Examination of 9,685 new cancer cases 

recorded in the Mississippi State Department of Health Central Cancer Registry in 1996 found 

that rural residents had significantly lower odds of having their lung, colorectal, breast or prostate 

cancers staged at the time of diagnosis (OR=0.83)37. This rural disadvantage was notably more 

pronounced for women (OR=0.75) and for African Americans (OR=0.73). Controlling for race 

and gender, rural white males were less likely to have their prostate cancer staged than were 

urban white males (OR=0.70). Finally, a national study of lung and colorectal cancer (CRC) 

patients found decreased odds of cancer staging at the time of diagnosis among rural residents.38

In a study of 129,811 colorectal cancer patients and 161,479 lung cancer patients registered in 

the SEER database between 2000-2003, rural patients were less likely to have had their cancer 

staged for both lung (14% vs. 9%) and colorectal (9% vs. 6%) cancers.38 Taken together, the data 

suggest differences between rural and urban residents in the odds of having unstaged disease. 

Moreover, the lower rate of incident cancer staging at the time of presentation may vary by race, 

geographic location, type of cancer and age of the patient.

Studies that examined stage of disease progression at the time of diagnosis used this outcome so 

as to infer differences in screening rates and/or treatment access not captured in most national 
18

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

and state databases. For example, examination of the rate of in situ vs. invasive breast and 

cervical cancers recorded in the Iowa SEER database between 1991-1995 showed that women 

who were from more urban areas had higher age-adjusted rates of in situ breast cancer (47.7 

vs. 37.3 per 100,000) and lower rates of invasive cervical cancer (7.3 vs. 9.3 per 100,000), 

both of which were interpreted as indicating underutilization of screening in rural areas.25

Similarly, among 2,568 cancer patients in the Lake Superior area study who were staged at 

the time of diagnosis, rural residents with breast, colorectal, and non-small cell lung cancers 

were more likely to present at later stages of disease progression than urban residents with 

those conditions.35 Staging differences were not noted for prostate or small cell lung cancers, 

however. The Mississippi study also found that rural residents were more likely to present with 

regional or distant metastatic disease (vs. local) compared to urban residents when cancer types 

were considered collectively (Χ2

=8.4, df=2, p<0.05).37 Comparisons within cancer types in the 

Mississippi study found that differences between rural and urban residents in the risk for more 

advanced disease was significant only for lung cancer (X2=12.3, p<0.005).37

In contrast to these findings, several studies reported no rural-urban differences or reported an 

urban disadvantage, and only one of them received a low confidence score.36 For example, the 

national study of Medicare beneficiaries 65 years and older by Shugarman (2008),33 found no 

differences between urban and rural areas in the stage of lung cancer at the time of diagnosis, 

nor did a case-control study of CRC in North Carolina.24 A large national study of colorectal 

(n=129,811) and lung (n=161,479) cancers using the SEER database compared the odds of 

late stage disease presentation between the RUCC-defined highly urban and most rural areas 

(population less than 20,000).38 Relative to the rural areas, urban residence was associated with 

a small but significantly increased likelihood of stage IV disease for both colorectal (17.9% 

rural vs. 18.5% urban) and lung (41.2% rural vs. 42.9% urban) cancers after controlling for race, 

age, median county income and gender. A large study using a multi-level modeling approach 

to examine the odds of late stage initial presentations of breast, colorectal, lung, and prostate 

cancers among over 140,000 patients in the Illinois State Cancer Registry who developed cancer 

between 1998-2002 also found that urban residents were more likely to present with later stage 

disease for all four cancer types.39

In the Illinois study,39 disparities between urban and rural areas for prostate cancer were 

eliminated when the model included the patient factors of race and age. For colorectal cancer, the 

urban disadvantage partially disappeared in the model including patient age and race (B= -0.156, 

p<0.05 for the most rural) and almost completely disappeared in the model including income 

and access (B= -0.085, p>0.05 for the most rural). This suggests that distance from a healthcare 

provider, being young and black were risk factors for later stage of presentation for this illness. 

Only residence in large towns was associated with lower odds for later stage disease presentation 

(B= -0.198, p<0.05). For breast cancer, those who were in the most rural areas were equally 

likely as those in metropolitan Chicago to present with late stage disease (B= - 0.032, p >0.05) 

and, similar to colorectal cancer, the greatest advantage was for residents of large towns (B= 

-0.167, p<0.05). Rural areas were comparable to urban areas once age and race were included 

in the model. Only lung cancer showed a clear urban disadvantage in each model, the greatest 

advantage being for those residents who were diagnosed in large towns (B= -0.431, p<0.05), a 

finding similar to that for breast and colorectal cancers.
19

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

The advantage for large rural towns in the Illinois study was also found in a well designed study 

of cancer patients in Nebraska. Examination of the stage of cancer at the time of diagnosis 

among 5,521 incident colorectal cancers in Nebraska between 1998-2003 found that residents 

from micropolitan communities (i.e., counties with an urban cluster of 10,000 to 49,999 people) 

were more likely to present with CRC at earlier stages of disease than residents from more rural 

or more urban areas in both adjusted and unadjusted analyses (OR=1.22, 95%CI=1.05, 1.42).40

There were very few studies examining the quality of cancer care and those that did suggest that 

there may be lower quality care in rural areas. Elliott (2004) reported that rural treatment of cancer 

was found to be of lower quality in the Great Lakes region across cancer types in terms of initial 

management, clinical trial participation and post-treatment surveillance; however, scores derived 

to measure these variables were not independently validated.35 In a study of almost 7,000 women 

treated for breast cancer from 1991-1996 in the national SEER database, younger women with 

newly diagnosed ductal carcinoma in situ had reduced odds of therapeutic radiation receipt if they 

lived in a rural area (OR=0.38).42 While radiation receipt among younger women was not related 

to availability of therapeutic radiation in the patient’s county, for older women more distant access 

to a therapeutic radiation site was associated with reduced odds of radiation receipt (OR=0.48). A 

similar finding was observed in a national study of Medicare beneficiaries over 65 years, where 

fewer of those living in rural areas received radiation (most urban 46.8% vs most rural 43.2%).33

Two studies observed differences in the availability of cutting edge treatments, but since both 

studies were rated with fairly low Confidence Scores the findings should only be viewed as 

suggestive and worthy of further study. A study of 461 women with estrogen sensitive breast 

cancers listed in the North Carolina Central Cancer Registry and who were also Medicaid 

enrollees between 2000-2004 examined the odds of ever receiving a prescription for an 

aromatase inhibitor (vs. Tamoxifen only). Rural residents were less likely than urban patients to 

have received a prescription for an aromatase inhibitor (OR=0.54).41 The quality of lymphoma 

treatment was found to be lagging in rural areas, but only if the provider was not university 

affiliated.34 While this suggests that rural community based treatment for lymphoma is of lower 

quality, our confidence in the generalizability of these findings is relatively low.

Summary

The evidence for differences in cancer-related health outcomes related to place of residence is 

relatively weak for most outcomes. Many of the studies used data that were at least 10 years old. 

Given the rapidly evolving nature of oncologic care, this is a significant limitation.

There were no consistent rural-urban differences in mortality or in the stage of illness at the time 

of initial presentation. Greater consistency was noted in the odds of unstaged disease, with rural 

residents less likely to have their cancer staged at the time of initial presentation. Interpretation 

of this finding is complicated by two factors, however. First, studies categorized patients by 

residence rather than by point of care and rural patients are more likely to pursue treatment for 

conditions such as cancer in urban areas.43 Rural providers may not pursue diagnostic procedures 

necessary to stage cancer if the patient intends to pursue treatment elsewhere. Second, the 

evidence base may be subject to a reporting bias since the odds of cancer staging were never the 

primary focus of the studies reviewed and studies that did not find a difference may not have 

reported a null finding.
20

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

It must be noted that patients in rural areas are not homogeneous, and barriers impeding 

screening of and treatment for cancer vary within both urban and rural populations. Depending 

on the compositions of the rural and urban samples being compared, age differences, income 

factors and racial/ethnic disparities may underlie some rural-urban differences when they 

emerge. For example, the large percentage of low income blacks in Chicago relative to the more 

rural areas in Illinois likely contributed to urban disadvantage in the odds of later stage of cancer 

at initial presentation. Similarly, older breast cancer patients may be more affected by distance to 

care than younger patients.

Finally, studies looking at rural-urban differences in quality of care were few and methodologically 

problematic given either a lack of association with specific treatment guidelines or that treatment 

guidelines changed during the course of the study (e.g., McLaughlin, 2009).41

Table 4. Confidence Scores for Cancer Care Studies

Study

Shugarman

200833

Loberiza

200934

Elliott

200435

Paquette

200738

Higginbotham

200137

Chirumbole

200936

Schootman

199925

Kinney

200624

Sankaranarayanan

200940

McLafferty

200939

Schootman

200142

McLaughlin

200941

Internal Validity G F F F F F G G G G/F F F

Sampling Method/Bias G F G G G G G G G G G G

Predictors/Confounders G F G F F F G G G G/F F G

Outcomes (clarity of 

measurement) G G F G G F G G G G G F

Statistical Methods G G G G F F G G G G G G

External Validity F F F F F F F G G/F F F F

Use of proxy variables or 

aggregate measures G G G/F G G F G G G F F G

Representativeness of 

sample F F/P G F G G G G G G G F/P

Study design appropriate 

for the research question? G G F G F F F F G/F G G G

Overall Confidence 

Score M M/L M/L M M L M M H/M M M M/L

DIABETES/END STAGE RENAL DISEASE (Table 5 and Appendix C, 

Table 4)

Only three studies (all cross-sectional) examined potential differences in health outcomes 

between urban and rural residents for diabetes or kidney disease.44-46 One moderate to high 

quality study relied on patient self-report to assess complications of diabetes in a national 

sample,45 while a low quality examined the incidence of diabetes-related end-stage renal 

disease.46 The third study, of high quality, examined mortality rates between urban and rural 

patients receiving dialysis.44 There were six studies (also all cross-sectional) examining 
21

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

differences in measures of care for diabetes (e.g., concordance with American Diabetes 

Association [ADA] guidelines). Two were of low quality, two were of moderate quality, and 

two were of moderate to high quality. The smallest study compared two sites,47 two national 

studies reported no difference between rural and urban areas,48,49 and another large national 

study reported a mixed effect of residence category in that some outcome measures were 

more favorable for those in rural areas whereas others were more favorable for those in urban 

areas.45 A fifth study in Washington State found better quality of care measures in large towns 

than in either urban or more rural areas.50 The sixth study of adherence to ADA guideline 

recommendations was a national study that found rural disparities, but only in some parts of the 

country, and rural advantage in others.51

In a study by Morden et al. (2010),49 quality indicators of eye exams, foot exams, LDL levels, 

blood pressure and hemoglobin A1c (HbA1c) levels were assessed among 11,688 veterans with 

diabetes in 2005. No differences were found in quality indicators between highly rural and urban 

RUCA categories. Koopman (2006), using the National Health and Nutrition Examination Survey 

from 1988-1994 and rural or urban classification based on metropolitan statistical areas, found 

that urban Hispanics had higher odds of their diabetes not being detected relative to urban whites 

(3.7% vs. 2.3%), rural whites (2.8%), and rural Hispanics (2.7%; p<0.05).45 Urban Hispanics were 

also more likely than the other groups to report a lack of usual source of health care (11.4% vs. 

1.8% urban whites, 6.5% rural whites, and 5.1% rural Hispanics; p<0.01). In multivariate analyses, 

urban vs. rural primary residence was not associated with the odds of diabetes being detected once 

demographic and health care utilization were controlled. This further supports the association 

between non-detection of diabetes and limited contact with health care providers. In addition, rural 

Hispanics more frequently had uncontrolled BP relative to urban Hispanics (OR=1.5, 95%CI=0.94-

3.45) or either group of whites (p<0.01), but they were not significantly different from either group 

of whites in multivariate analyses controlling for demographic, access and some health factors. 

There were no group differences in glycemic or control or lipid levels. 

A rural disadvantage was reported in a very small study in Alabama comparing patients in one 

“rural” family practice clinic (n=78) and one “urban” internal medicine clinic (n=109) with 

respect to HbA1c levels, eye exams, foot exams, lipid profiles, and microalbuminuria tests.47

Urban and rural were not defined, and given the local nature of the study and the methodologic 

issues, our confidence in this finding is very low. 

A much larger and better designed study comparing compliance with ADA guidelines for HbA1c 

levels, eye exams, and foot exams in two national databases reported that rural residents with 

diabetes received both more and less guideline care depending on the outcome and database 

used.45 Although the directions of effects were the same in both databases, they were only 

significantly different in the larger database. Slightly more rural residents, defined as those living 

in non-metropolitan statistical areas, received a quarterly HbA1c level (OR=1.16), but this 

difference was no longer significant after adjustments (i.e., race, region of the country, insurance 

coverage, and having a personal physician). Differences that remained significant even after 

adjustment were decreased odds among rural diabetics of having a dilated eye exam (OR=0.88) 

or foot exam (OR=0.85) or receiving diabetes education (OR=0.83). Inconsistent evidence for 

rural-urban differences in diabetes care was reported in a study of older Medicare patients in 

Washington State.50 Urban residents with diabetes were equally as likely as rural residents to 
22

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

get eye exams, but they were more likely than rural residents (defined based on RUCA with 4 

rural subgroups) to get an HbA1c check (55.6% vs. 52.2%) and a cholesterol screen (66.6% vs. 

63.2%). After adjustments, residents living in large remote rural towns were the most likely to 

have had the tests. Importantly, rural residents were only less likely to get the assessments if they 

had not seen an endocrinologist in the prior year.50 That is, specialty consultation, much more 

common among urban residents, was a primary determinant as to whether patients received the 

guideline assessments. 

Some of the inconsistency across studies may be due to differences between rural and urban 

areas in the rate of adherence to guideline recommended tests across geographic regions of 

the country. For example, in an examination of the geographic distribution of diabetic patients 

receiving a composite measure of guideline tests (i.e., lipid levels, HbA1c levels, and eye 

exams), Weingarten et al. (2006), found that rural residents (categorized as rural or semi-rural) 

were actually more likely to receive the tests than urban residents depending on in which region 

of the country they lived.51 Because the study relied on aggregate measures, however, this finding 

should be considered only tentative. 

One of the many deleterious consequences of poorly controlled diabetes is end-stage renal 

disease (ESRD). Ward (2009) compared the rural and urban zip codes of 18,377 diabetic patients 

in California for the odds of ESRD attributable to diabetes.46 There was only a trend for a 

decreased likelihood of ESRD among rural patients (beta=-0.035, p<0.06). However, because 

the model was adjusted for factors associated with access and poor illness control (i.e., insurance 

status and number of hospitalizations due to hyperglycemic complications), it may be that one 

of these factors underlies the differences associated with rural vs. urban residence. That patients 

from health professional shortage areas were actually less likely to have ESRD, may reflect this 

problem with their model. Because bivariate results were not reported for this parameter, we 

could not assess potential problems with the statistical model used and rated our confidence in 

the finding as low.

In an analysis of treatment for 552,279 patients with ESRD who initiated dialysis between 

1995-2002, the impact of rural vs. urban residence varied by race and ethnicity.44 There were no 

significant differences between urban and rural areas in types of treatment other than that rural 

areas (including large rural, small rural, and remote) were more likely to use peritoneal dialysis. 

When target hematocrit levels were the outcome, there were no significant differences between 

urban and rural areas. Target urea reduction ratios were slightly more likely to be reached by 

rural than urban sites (small rural 92.9% vs. 91.2% urban). Mortality and transplant rates showed 

a more complex picture, however. Relative to urban Hispanic patients, rural Hispanic patients 

had elevated mortality rates both before (OR=1.25, 95%CI=1.14-1.36) and after adjustment 

(OR=1.11, 95%CI=1.01-1.22). Rural white non-Hispanics and blacks had lower mortality 

than urban white non-Hispanics and blacks, respectively, but only after adjustment. Transplant 

rates were lowest among black patients regardless of where they lived, with residents of small 

rural areas more disadvantaged than residents of urban areas (OR=0.89, 95%CI=0.82-0.96). In 

contrast, rural Native Americans living in remote areas were actually more likely than Native 

Americans living in urban areas to get a transplant (OR=1.27, 95%CI=1.01-1.59). A similar rural 

advantage was evident for non-Hispanic whites (OR=1.11, 95%CI=1.06-1.16). 
23

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Summary

There were no consistent differences between rural and urban areas in diabetes treatment quality 

measures, and two of the largest, moderate to high quality studies found no differences. Whether 

rural-urban differences in diabetes care varies across regions of the country requires further 

exploration.51 For all patients, having access to a physician, and possibly an endocrinologist, may 

increase the odds of both illness detection and adherence to treatment guidelines. The increased 

use of Rural Health Clinics in underserved areas has greatly improved treatment access and, 

consequently, adherence to treatment guidelines.52

There was also little evidence for a disparity between rural and urban patients with diabetes in 

terms of diabetes complications or the prevalence of ESRD. Once a patient had ESRD, racial 

differences clearly affected outcomes, and this variation across race/ethnicity groups interacted 

with rural vs. urban residential categories. For example, a high quality study reported that 

blacks with ESRD had lower transplant rates regardless of where they lived, but were more 

disadvantaged in rural areas.44 In contrast, rural Native Americans were actually more likely than 

their urban counterparts to receive a transplant.44

Table 5. Confidence Scores for Diabetes and End-Stage Renal Disease Studies

Study

Andrus 

200447

Weingarten 200641

Krisha 

201045

Rosenblatt 

200150

Morden 

201049

Koopman 

200648

Ward 

200946

O’Hare 

200644

Internal Validity F F G F G F F G

Sampling Method/Bias F F G F G G F G

Predictors/Confounders P P G F G G F G

Outcomes G G G F G G F G

Statistical Methods P G G F G F P G

External Validity F/P F F F F F F G

Use of proxy variables or 

aggregate measures F F G G G G F G

Representativeness of sample 

(size, composition) P P F F G F F G

Is the study design appropriate for 

the research question? F F F G F G F G

Overall Confidence Score VL L H/M M H/M M L H

CARDIOVASCULAR DISEASE (Table 6 and Appendix C, Table 5)

Only five studies examined outpatient management of cardiovascular disease, and two of these 

were smaller regional studies. The largest study, and the only one for which we had at least a 

moderate to high Confidence Score, was done by Morden et al., (2010) on 23,780 veterans with 

hypertension, about one-third of whom also had a mental disorder.49 No differences in blood 

pressure (BP) control were found across three RUCA categories. 
24

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

A Colorado study compared quality of care for hypertension among 780 rural and urban patients 

with diabetes from 26 primary care sites.53 The study relied on provider post-appointment 

surveys. They found that rural patients had lower systolic and diastolic BP, but that urban 

providers were more likely to take action than rural providers if the patient’s BP were poorly 

controlled (39.1% vs. 27.5%, p<0.02). However, of the factors that predicted whether action was 

taken at a given medical visit, the number of prescribed medications and whether the patient’s 

BP was at or near goal were the only significant predictors, possibly reflecting differences 

in subsample characteristics. Of note, number of prescribed medications was significantly 

associated with rural residence (e.g., 39% of rural residents were taking 8 or more medications, 

whereas only 28% of urban residents took as many; p<0.025).

The remaining studies were given fairly low Confidence Scores, and so shall be reviewed only 

briefly. In a study by King (2006), rural site of health care was associated with better BP control 

in a chart review study looking at 300 people from three separate practices in South Carolina 

(OR=0.3, 95%CI=0.16-0.55).54 We rated this study as having lower quality because of the small 

non-random sample, lack of control of within site clustering, and use of chart indications of 

adherence. A second regional study, comparing one urban with one rural site in New Mexico 

examined differences in treatment via chart review of 200 patients, 100 with cardiovascular 

disease and 100 without.55 They found that patients treated in the urban, university associated 

center were much more likely to receive beta-blockers or calcium channel blockers, antiplatelet 

therapy, and statins, and that urban patients were better at attaining BP goals (53% vs. 37%, 

p=0.02). LDL goals, on the other hand, were comparable in rural and urban areas (51% vs. 57%, 

ns). Confidence in this study’s findings were considered to be low due to the sampling method, 

statistical approach, and variable outcome measures. 

Finally, a series of case reports examined change in medication regimens in 32 elderly cardiac 

patients post-discharge.56 Urban cardiac patients reported greater fluctuations in medication 

regimen, as suggested by the number of changes in the types of drug used after discharge 

compared to rural cardiac patients; however, the urban cardiac patients had worse outcomes than 

the rural patients despite comparable levels of cardiac disease.

Summary

Three of the five studies reviewed were quite small, and only one study had a higher Confidence 

Score. That study, conducted on veterans, found no differences between rural and urban patients 

in control of hypertension. The Colorado study found different degrees of blood pressure 

control between urban and rural residents, but no differences in quality of care. However, that 

study consisted of patients with diabetes and had some significant flaws that compromised 

the reliability of the findings. The remaining studies were not of sufficient quality to draw 

conclusions beyond the clinics from which their samples were drawn. 
25

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Table 6. Confidence Scores for Cardiovascular Disease Studies

Study

Morden

201049

King

200654

Colleran

200755

Hicks

201053

Dellasega

199956

Internal Validity G P F F P

Sampling Method/Bias G P G F P

Predictors/Confounders G G F F F

Outcomes G P G G F

Statistical Methods G F F/P G P

External Validity F P F F P

Use of proxy variables or aggregate 

measures

G P F G F

Representativeness of sample G P P F P

Study design appropriate for the research 

question? F F G F P

Overall Confidence Score H/M VL L M VL

HIV/AIDS (Table 7 and Appendix C, Table 6)

There were four papers that reported rural-urban differences in HIV/AIDS patients.57-60

In a study of 308 women from Georgia diagnosed with AIDS by 1990, non-metropolitan 

residence was associated with a shorter median survival time (296 days vs. 400 days for urban 

residence) and a lower odds of surviving 90 days (0.84 urban vs. 0.69 non-metropolitan).57 Our 

confidence in the study is very low, however, given significant methodologic problems and the 

use of data that covered cases diagnosed over 20 years ago. 

The frequency of visits per year did not differ between urban and rural residents in either 

adjusted or unadjusted analyses of a large observational cohort study of HIV patients in 

North Carolina.59 However, all patients received care at the University of North Carolina 

HIV Outpatient Clinic, suggesting that distance to clinic was not a significant barrier to care. 

Relatedly, a national study using the HIV Cost and Services Utilization Study (HCSUS) from 

1996 found that nearly three-quarters of rural HIV patients receive their HIV-related care in 

urban areas.60 Only older age was associated with receiving HIV-related care in a rural setting. 

In contrast to the North Carolina study, nearly one-third who received their care in urban settings 

reported that the distance deterred them from needed clinic appointments; however, actual 

number of clinic appointments was not assessed. Using the same dataset, Cohn (2001) found 

that rural HIV-related care was more likely to be of lower quality than urban care. Specifically, 

they found that 73% of urban residents received highly active antiretroviral therapy (HAART) 

vs. only 57% of rural residents (p<0.001).58 After adjusting for CD4 counts and the covariates 

(see table), urban patients had a three-fold higher odds of receiving HAART than rural patients. 

Moreover, whereas 75% of urban patient received prophylactic medication for pneumocystis 

carinii pneumonia, only 60% of rural residents did (p<0.007). Although not directly related to 

treatment variables, these differences may be due to the fact that 38% of rural patients received 
26

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

care from providers with little experience treating HIV patients compared to only 3% of urban 

residents.

Summary

The very sparse data on the treatment of HIV/AIDS suggests that rural residents might not 

receive care comparable to that received by HIV infected residents living in urban areas if they 

receive care locally rather than travel to specialty HIV clinics in urban areas. However, no firm 

conclusions can be drawn from this minimal evidence base. A more recent assessment of the 

quality of HIV care is warranted given that diffusion of knowledge regarding treatment standards 

for HIV/AIDS may have occurred in the intervening period. 

Table 7. Confidence Scores for HIV/AIDS Studies

Study

Whyte

199257

Napravnik

200659

Schur

200260

Cohn

200158

Internal Validity F G/F F G

Sampling Method/Bias G F G/F G

Predictors/Confounders P G G G

Outcomes G G F G

Statistical Methods F G G G

External Validity P F F G/F

Use of proxy variables or aggregate measures F F F G

Representativeness of sample P F F G

Study design appropriate for the 

research question? P G F F

Overall Confidence Score VL M M H/M

NEUROLOGIC CONDITIONS (Table 8 and Appendix C, Table 7)

There were only three studies that examined urban/rural differences in health care for patients 

with multiple sclerosis (MS), and all three of them were from the same research group and 

were based on the same dataset. The studies were based on a survey of national MS Society 

members, with sampling stratified to achieve 500 MS patients in each of three population density 

categories: urban, within 50 miles of urban area, and more than 50 miles. Their overall response 

rate was a low 31%, and several aspects of the methodology resulted in our giving all three 

studies low Confidence Scores.61-63 In bivariate analyses, more MS patients in rural areas had a 

primary progressive form of MS, but fewer reported that they were being treated with disease 

modifying medications (urban 64%, adjacent rural 57%, remote rural 55%).61 More MS patients 

in urban areas saw a neurologist in the previous year (urban 75.4%, adjacent rural 71%, remote 

rural 66.5%) and more patients in remote and adjacent rural areas indicated that they had wanted 

to have seen a neurologist in the previous year but did not do so (urban 9.4%, adjacent rural 

18.9%, remote rural 26.9%).62 Finally, the primary reason reported for not seeking treatment was 
27

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

a lack of availability of mental health providers (urban 5%, adjacent rural 33%, and 13% remote 

rural).63

There were only two studies that focused on services for those who incurred a traumatic brain 

injury (TBI).64,65

A survey of 292 residents with TBI 12-18 months previously, in the Iowa Central Registry for 

Brain and Spinal Cord Injuries in 1998, examined self-rated health and dependence on others.64

There were no differences between rural vs. urban areas in the association between perceived 

need for care and actual receipt of services; however, the authors did not examine the odds of 

service receipt in a multivariate model, and we rated this study with a low Confidence Score. 

Two studies examined the availability of health professionals who provide the interdisciplinary 

care needed by those who had TBIs. A survey of health providers in Missouri in 1999 found 

that although nearly one-third of state residents live in rural areas, much lower percentages 

of all provider types related to the treatment of patients with TBIs (e.g., physiatrists, other 

physicians, rehab therapists, mental health providers) worked in rural areas.65 A similar pattern 

was found in a nationwide study of numbers of rehabilitation therapists (physical therapists, 

occupational therapists, and speech-language pathologists) in counties or “county sets” in most 

of the contiguous United States between 1980-2000.66 Fewer rehabilitation therapists per 100,000 

residents were found in primary care health professional shortage areas. Although the number 

of all three types of rehabilitation therapists increased in both urban and rural county sets during 

the 20 year time period, the difference in the ratio of therapists per 100,000 residents remained 

significantly different between urban and rural areas (urban: rural rates per 100,000 for physical 

therapists 50.9: 35.5, occupational therapists 24.7: 15.3, and speech pathologists 35.0: 29.5).

Summary

Findings from the three studies of rural treatment for MS, all based on the same dataset, were 

inconclusive given several methodologic problems with the research design, measures and 

analyses. 

There was only one study that looked at outcomes for patients with a history of TBI in rural vs. 

urban settings of Iowa, but we had little confidence in the findings of that study. Two studies 

examining the availability of rehabilitation specialists found a paucity of such providers in many 

rural areas relative to urban areas. Significantly more research should be done on the course of 

recovery of rural TBI patients after their acute treatment, and to ascertain what types of services 

they receive by commuting to urban areas, what services are precluded by limited provider 

availability and/or travel distance, and what the impact of provider availability is on health 

outcomes.
28

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Table 8. Confidence Scores for Neurologic Conditions Studies

Study

Buchanan

2006a61

Buchanan

2006b62

Buchanan

2006c63

Schootman

199964

Johnstone

200265

Wilson

200966

Internal Validity F F/P F/P F G G

Sampling Method/Bias P P P G G G

Predictors/Confounders G G G F G G

Outcomes F F F F G G

Statistical Methods P P P F G G

External Validity F/P F/P F/P F G/F G/F

Use of proxy variables or aggregate measures F F F F F F

Representativeness of sample P P P F G G

Study design appropriate for the 

research question? F P P F G G

Overall Confidence Score L/VL VL VL L H/M H/M

MENTAL HEALTH (Table 9 and Appendix C, Table 8)

There were three studies that compared suicide rates and medication use between rural and urban 

areas,67-69 two studies that examined the odds of hospitalization,70,71 five papers that addressed 

MH service access among rural residents with severe mental illness,72-76 three studies that 

examined rural-urban differences in treatment of mood disorders,69,77,78 one study examining 

PTSD,79 five studies that examined receipt of alcohol/drug treatment,80-84 and four papers that 

examined whether subgroups of rural residents were less likely to get mental health treatment.85-88

A large national study of suicide completers found an association between suicide and 

antidepressant prescription rates.67 In rural areas, the suicide rates were higher than in urban 

areas (17.14 per 100,000 in the most rural vs. 11.51 per 100,000 in the most urban). Within these 

rural areas, there were fewer prescriptions for antidepressants and, of those that were written, 

a higher proportion of them were for the older tricyclic antidepressants (ratios of tricyclics vs. 

newer antidepressants were 1:1 in rural vs. 1:2 in urban). Only prescriptions for non-tricyclic 

antidepressants were associated with reduced suicide rates. A second study examining suicide 

rates among 41 county clusters in California from 1993-2001, found similar elevations in suicide 

rates among rural counties, but no association between suicide rates and the availability of either 

health care providers or physicians.68 Although suggestive, these studies use only aggregate 

measures and limited control for confounders, resulting in lower Confidence Scores. One study 

that followed 470 depressed people in Arkansas found no difference in the odds or quality of 

depression treatment between rural and urban residents, but did find an elevated rate of suicide 

attempts among those in rural areas.69

Both studies that examined hospitalization rates per county for major mental illnesses used the 

2000 Health Care Cost and Utilization Project database for 14 states.70,71 Both studies reported 

similar findings – that rural areas had lower hospitalization rates. Specifically, hospitalization 
29

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

rates for schizophrenia were greatest in the most urban areas relative to all others (p<0.05).71

Similarly, hospitalizations for depression were lower in rural vs. more urban areas (e.g., 49% 

lower in the most rural counties, p<0.05).70 No relationship was found between provider 

availability and hospitalization rates for schizophrenia, but positive relationships were found 

between availability of physicians and hospitals and hospitalization rates for depression 

(p<0.05); however, there was no relationship between hospitalization rates and availability of 

psychiatrists.71 Both studies examined environmental predictors of hospitalization rates and 

found that factors associated with urban living (e.g., housing stress) were predictive of higher 

rates, where as rural factors (e.g., farm-based economies) appeared to be protective. Because 

the base rates of mental illness in the counties studied were not known a priori and because both 

studies relied on aggregate measures, it cannot be determined from these studies whether urban 

environmental factors are conducive to the development or exacerbation of mental illness (or 

highly rural areas protective), or whether mentally ill people are more likely to migrate to urban 

areas. Consequently, our Confidence Scores are lower for these studies.

There were five articles that addressed accessibility of MH services for rural residents with 

severe mental illness, one of which was an examination of the VA’s mental health intensive 

case management program (MHICM). Three of these focused on whether rural residents with 

serious mental illness had difficulty accessing needed services, one examined whether travel time 

affected the number of mental health treatment appointments, whereas the fifth examined access 

within the context of continuity of care. 

Rost et al. (1998) screened 11,078 adults in Arkansas for mental illness and compared ruralurban differences in a very small subsample with bipolar disorder (29 rural and 24 urban 

residents) on service utilization and outcomes.46 Rural residents were much more likely to be 

seen only in a general medical setting (OR=22.1, 95%CI=2.5-198.3), to have needed acute 

medical or mental health care (OR=5.8, 95%CI=0.8-40.7), and to have experienced a manic 

episode in the year following the baseline assessment (OR=4.0, 95%CI=0.8-20.5). Although the 

screened sample was large, the resulting small number of those with bipolar disorder resulted 

in a low Confidence Score rating. The same study produced a larger number of patients with 

major depression, but only n=106 were included in a study examining the relationship between 

travel time to a preferred provider, number of depression-related appointments, and the odds of 

receiving guideline concordant depression treatment.74 Distance from a preferred provider was 

significantly associated with a reduced number of visits in adjusted analyses (p<0.05). Increased 

travel time, in turn, was associated with reduced odds of guideline concordant treatment 

(OR=0.292, CI= 0.087-0.987).

A study of 258 patients with schizophrenia seen in public mental health settings (primarily VA) 

in Arkansas between 1992-1999, found that rural residence was associated with an increased risk 

of an irregular vs. regular pattern of mental health service use in adjusted analyses (OR=1.99, 

95%CI=1.07-3.71).73 For all patients, comorbid substance abuse increased the odds of infrequent 

or irregular mental health service use. However, among rural residents, the negative impact of 

comorbid substance abuse was significant only if the patient did not have contact with their 

family at least once per week (OR=41.94 for infrequent service use vs. regular MH use among 

those with minimal family contact). This suggests that the role of family in managing patients 

with severe mental illness may differ in rural vs. urban areas. 
30

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

The VA study of the amount and types of care received by 5,221 patients with serious mental 

illness enrolled in a MHICM program reported that patients in rural areas received fewer types of 

services than urban patients.75 Although the difference in patient contact between rural and urban 

residents differed only slightly (though significantly), rural residents were less likely to receive 

several types of recovery-related services, such as psychotherapy (83% urban vs. 67% isolated 

rural), substance abuse treatment (35% urban vs. 29% rural town and 12% isolated rural), and 

rehab services (48% urban vs. 42% rural towns and 27% isolated rural) despite comparable 

symptomatology. Moreover, rural residents were more likely to be seen by only one person on 

the treatment team than urban patients. Whether this affected recovery is unclear, as all symptom 

measures were assessed at the time of program enrollment.

The fourth study focused on the ease of care transition from inpatient to outpatient services for 

4,930 patients with serious mental illness who were discharged from Virginia state hospitals in 

1992.72 Specifically, they found that rural residents had significantly better continuity of care than 

urban patients in that the community mental health centers associated with outpatient treatment 

for rural residents were much more likely to have copies of the discharge records (89% rural vs. 

76% urban), to have contacted the patient during the hospitalization (58% rural vs. 49% urban), 

to have made contact with the patient after discharge (82% rural vs. 78% urban), and to have 

seen the patient for an appointment (79% rural vs. 76% urban). Despite some limitations in rural 

mental health services for those with serious mental illness, the smaller size of rural community 

mental health clinics likely contributed to the post-discharge continuity. Of note, there were no 

differences in a composite of these continuity measures between black and white patients in 

rural areas, but in urban areas, blacks were clearly disadvantaged. That is, race disparities existed 

mostly in urban areas. 

There were two other studies that used the same dataset that examined rural-urban differences 

in treatment of bipolar disorder referenced above, and these subsequent studies focused on 

Arkansans who screened positive for major depression. Examining quality of care and outcomes 

for the 434 who met criteria for major depression, Rost (1999) reported that there were no ruralurban differences in the odds of outpatient treatment of depression, type of care, odds of care 

meeting clinical guidelines for acute stage treatment, or adherence to treatment.77 Urban residents 

were more likely to have been high users of specialty mental health care, with 22% making 

23 or more visits during the follow-up year compared to 4% of rural residents (p=0.04). Rural 

residents, were significantly more likely to be hospitalized for physical problems (OR=3.05, 

95%CI=1.23-7.53). In the second paper, the odds of these elevated admissions were really 

significant only during the first 6 months after baseline, with rural residents having much higher 

odds of hospitalization for physical (6.1% vs. 0.3%, p<0.01) and mental health (9.8% vs. 1.1%, 

p<0.05) problems.69

Rural vs. urban hospitalization rates for depressed patients was also examined in a secondary 

analysis of two separate depression treatment studies, involving 1,455 patients from 11 states.78

As in the Arkansas study, it was found that the odds for hospitalization in a six month follow-up 

period were greater among rural residents for physical health problems (OR=1.8, 95%CI=1.2-

2.8). At 18 months, rural residents had more hospitalizations for mental health problems 

(OR=2.3, 95%CI=1.0-5.4). Although there were no differences in the rate of outpatient specialty 

care between urban and rural residents, only about one-third of all patients in the sample 
31

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

indicated that they took antidepressants for at least two of the previous six months. Because of 

the sampling and other methodologic problems inherent in this study, however, our Confidence 

Score was low. 

 Only one very small study examined service use among patients diagnosed with PTSD.79 No 

significant differences were found in the number of specialty PTSD clinic appointments between 

48 urban and 52 rural veterans. The absence of a finding is inconclusive, however, given the 

inadequate power to detect possible differences and the limited number of confounders included 

in the analyses. 

There were five studies that examined receipt of alcohol/drug treatment. Two studies of moderate 

to moderately high quality found no rural-urban differences in treatment utilization,80,81 and three 

of moderate to low quality found greater treatment utilization among residents living in urban 

areas.82-84

In a Florida study of 2,222 out-of-treatment injection drug users and crack smokers, the rate 

of drug treatment receipt in the previous 24 months was twice as high for drug users in the 

urban Miami area than for drug users in the rural Immokalee area (16.3% vs. 4.4%, p<0.001).82

Moreover, those in the urban Miami area who received any treatment were in treatment for twice 

as long as those treated in the more rural Immokalee area (28.3 weeks vs. 12.1 weeks, p<0.001). 

Importantly, however, there was a much lower rate in the Immokalee area of unsuccessful 

attempts at getting treatment (4.9% vs. 10.8%, p<0.001), suggesting that the lower rate of 

treatment receipt among the rural drug users was at least partially due to differences in treatment 

seeking. Given the sampling issues, however, the generalizability of this study is limited.

Comparable treatment rates were reported in a lower quality study by Robertson and 

Donnermeyer (1997),83 who assessed rates of treatment for drug abuse in the 1991 National 

Household Survey on Drug Abuse. Among the 3,629 subjects included in their study, only 10.8% 

of the nonmetropolitan-rural respondents received drug treatment and, among those who used 

illegal drugs in the past 12 months, the rate dropped to 5.6% (vs. 6.6% of the remaining survey 

respondents). Finally, in a study examining continuity of care for 4,621 veterans discharged from 

inpatient alcohol treatment programs, rural residence increased the odds of attending an aftercare 

appointment.84 However, distance to treatment was a significantly greater treatment barrier for 

rural residents than for urban residents. 84

To better define which rural residents were less likely to utilize mental health care, there were 

four papers using national samples that examined whether subgroups of rural residents were 

particularly unlikely or disadvantaged. Using data from two panels of the MEPS between 

1996-1998, Petterson (2003) observed that rural residents who received mental health care had 

fewer visits per calendar year than urban residents (p<0.01), had higher rates of hospitalization 

(p<0.04), and were more likely to only see a physician for their treatment (p<0.02).85 Rural 

residents had fewer mental health visits even after adjustment for demographic factors (p<0.01). 

After adjustments were made for income, insurance and physical health status in addition to 

demographic variables, the differences between rural and urban residents in mental health care 

use were only a trend (p<0.1), suggesting that differences in access accounted for much of the 

observed disparity for rural residents. Importantly, Petterson (2003) noted that urban residents 

who reported only “fair mental health” were nearly twice as likely as similarly rated rural 
32

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

residents to have sought mental health care (38% vs. 24%, p<0.01) suggesting that rural and 

urban residents may also differ in perceived need for care. 85

In a separate study, Petterson (2009) used four panels from the same database (representing 

1996-2000) to examine whether rural-urban differences observed in the 2003 study were similar 

across racial/ethnic groups.86 They observed a rural disadvantage for receipt of any mental health 

treatment among whites, with 9.4% in urban areas having received mental health care but only 

7.3% of those in the most rural areas. Both blacks and Hispanics were less likely to receive any 

mental health care or specialty mental health care regardless of whether they lived in a rural 

or urban area. However, whereas the difference between blacks and non-Hispanic whites was 

significant independent of residence urbanicity, the disparity between blacks and whites was 

greater in urban areas than in rural areas (urban OR=0.41, 95%CI=0.35-0.49; rural OR=0.58, 

95%CI=0.35-0.94). The same pattern was seen when only specialty mental health care was 

considered -- the difference between blacks and whites was significantly different in urban areas, 

but not in the most rural areas (urban OR=0.43, 95%CI=0.36-0.53; rural OR=0.62, 95%CI=0.28-

1.39). Differences between whites and Hispanics follow a similar pattern except that specialty 

mental health care differed only in urban areas, whereas the receipt of “any mental health care” 

differed in urban and larger rural areas but not in the most rural areas. 

Another study using the same dataset (MEPS from 1996-2000) focused on gender differences 

in mental health care use between rural and urban residents.87 Women from any geographic area 

were significantly more likely to have had any mental health treatment or specialty mental health 

treatment than men (10% vs. 5.8% and 6.3% vs. 3.8%; p<0.01). They found that both men and 

women in rural areas were less likely to receive specialty mental health services relative to their 

urban counterparts even after adjustment for demographics, insurance and usual source of care 

(women urban-rural OR=1.52, men urban-rural OR=1.94; p<0.05). 

In examining mental health treatment across disorders, the National Comorbidity StudyReplication study conducted between 2001-2003,88 found that urban residents were much more 

likely to have received mental health services within the previous 12 months than rural residents 

(urban vs. rural OR=2.1, 95%CI=1.7-2.7), and more likely to have received specialty mental 

health treatment (urban vs. rural OR=2.2, 95%CI=1.2-4.1). However, treatment adequacy from 

mental health specialists (but not general medical providers) when it did occur, was found to 

be lower in urban areas among those who received any mental health treatment (urban vs. rural 

OR=0.4, 95%CI=0.2-0.8).

Summary

Many studies of mental health services in rural vs. urban areas focused on specific regions, which 

may not be generalizable to other parts of the country. Most studies examined differences in service 

provision and only a few associated any differences that were found with patient outcomes. This 

limited the conclusions that could be drawn regarding the adequacy of rural vs. urban health care. 

In those few studies that assessed patient outcomes, no consistent evidence for a rural disadvantage 

was found. Moreover, while rural residents were found to receive fewer MH services than urban 

residents in several studies, the clinical impact of this difference was not assessed. 

Two studies that focused on the relationship between suicide and mental health care parameters 

used aggregate (i.e., county) measures for both variables. Although the elevated suicide rates 
33

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

could suggest differences in health care access and/or quality, it is unclear whether the observed 

association between reduced county mental health care parameters (e.g., new generation 

antidepressant use) and suicide rate would remain if the individual (vs. the county) were the unit 

of analysis. One prospective study found elevated suicide rates among depressed rural residents 

in Arkansas, but the small numbers made it impossible to determine if this were related to 

differences in mental health care.

Of note, two studies found greater racial disparities in mental health treatment receipt in urban 

areas. This could reflect a selectively improved access for whites in urban areas or a greater 

difficulty with access for minorities. Moreover, it also underscores the importance of examining 

race-rurality interactions, since ignoring such interactions could result in both race and/or rural 

disparities being attenuated.

PROCESSES OR STRUCTURE OF CARE (Appendix C, Tables 9-13)

There were a number of studies that compared various aspects of health care structure or 

processes between urban and rural health care settings without focusing on either a particular 

medical or mental health condition or, in most cases, without reference to health outcomes. We 

review these studies here as they relate to Key Question #2.

Use of Medication (Appendix C, Table 9)

There were a number of studies that examined the use of prescription medications without 

associating medication use with health outcomes. The studies on medication use examined 

prevalence and/or intensity of medication use,56,89-94 expenditures for prescription drugs,92,93,95

likelihood of having a usual pharmacy,94 and degree of change in postdischarge medication 

regimen.56 All of the study samples consisted of outpatients over 65 years old. Three studies92,93,95 

used national samples and the rest used samples from a single state. Two of the studies92,95 that 

had used a national sample had relatively small sample sizes (N<1,100). The sample sizes for 

the single-state studies varied widely, ranging from 3256 to 18,641.91 One study was of moderate 

quality, three were of low to moderate quality, and four were of low quality.

Of the seven studies that examined prevalence and/or intensity of medication use, all but 

one were rated with moderate to low Confidence Scores. Among these studies, five reported 

significant rural-urban differences on the number of medications used; however, the direction of 

effects was inconsistent. Comparing the number of medications prescribed for cardiac patients 

discharged from a tertiary hospital, Dellasega et al. (1999) found a greater number of drugs 

prescribed over time for urban patients than for rural patients (e.g., 5.9 vs. 4.2 for urban and 

rural, respectively, at four weeks post-discharge), even after controlling for severity of illness 

at time of discharge.56 Similarly, Hanlon et al. (1996) found greater use of prescription drugs 

among urban elderly residents than their rural counterparts (OR=1.40, 95% 95%CI 1.18-2.04).90

Mueller and Schur (2004), on the other hand, found greater number of prescriptions filled by 

elderly rural Medicare beneficiaries compared to elderly urban beneficiaries (for those with drug 

coverage, medians of 23 and 20.8, p<0.01, for rural and urban, respectively; for those without 

drug coverage, medians of 18.1 and 16.0, p<0.05, for rural and urban, respectively).93 Notably, 

rural residents were somewhat less likely to have coverage for prescription drugs (59.4% rural 

vs. 75.4% urban, p<0.01).
34

lth Care: A Systematic Review Evidence-based Synthesis Program

r Mental Health Studies

200568

Farrell

199672

Fischer

200873

Mohamed

200975

Rost & Owen

199876

Rost

199977

Fortney

199974

Fortney 

200770

Fortney

 200971

Rost & Zhang

199869

Rost

200778

Elhai

200479

Booth

200080

Grant

199681

Metsch

199982

Fortney

199584

Robertson

199783

Petterson

200385

Petterson 

200986

Hauenstein

200687

Wang

200588

F F F F F G G G/F G/F G F F G G/F F G F G/F G/F G/F G

G G G G G G G G G G F G G G F G G G G G G

F P F G G G G F F G G P G G/F G G F G G G G

G G F F F G F G G G F G G G G G F F F F G

F F G F G G G G G G G/F F G G F G F G G G G

P F F F F F F F F F F P G/F F F F F F F F F

P G F G G F G F F F F G F F/P G F F F F F G

G G F G P G/F F/P G G G/F F F/P G G P G G/F G G G F

F F G F F G F F F G F/P P G G/F F F F/P G G G G

L M M M L M M/L M/L M/L M L VL H/M M M/L M L M M M H/M
35

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

In a study of non-cognitively impaired residents 65 years and older in western Texas, Xu et al. 

(2003) found no difference in the odds of prescription drug use between individuals living in urban 

counties and those living in rural counties (i.e., counties outside of MSA or with a population less 

than 50,000); however, those living in frontier counties (i.e., counties with fewer than 7 people per 

square mile) had lower odds (OR=0.59, p<0.01) of prescription medication receipt.94

In contrast to these findings from lower quality studies, a large study of 18,641 Pennsylvania 

residents by Lago et al, (1993) did not find a rural-urban difference in medical claims for the 

number of prescriptions.91 Other studies using national samples similarly found no rural-urban 

difference in drug expenditures between rural and urban residents.92.93 Some support was found 

for a race by population density interaction for medication use in a study of 4,163 residents 

in North Carolina.89 Specifically, urban whites were more likely to take greater number of 

prescription drugs than rural whites (β=0.21, SE=0.10, p<0.05), but there was no association 

between rurality and intensity of prescription drug use among blacks (β=0.12, SE=0.08, ns). A 

secondary analysis of data from a national survey of 996 elderly participants also failed to find 

rural-urban differences in the percentage of family income spent on drugs after controlling for 

income, insurance, and health status.95

The odds of having a usual pharmacy were lower for frontier county residents compared to urban 

residents in West Texas (OR=0.64, p<0.01), but rural residents were more likely to report that 

their pharmacies provided medication delivery services.94

Medical Procedures and Diagnostic Tests (Appendix C, Table 10)

Two studies, both of which received low Confidence Scores, looked at use of medical procedures 

or diagnostic tests. Miller (1995) examined use of medical procedures and services provided by 

physicians among rural and urban Medicare beneficiaries.96 The use of most services, including 

office visits and consultations, imaging services, and diagnostic testing, were found to be lower in 

rural areas compared to urban areas. Focusing on racial disparities in service utilization, Escarce 

et al. (1993) compared use of 32 medical procedures between white and black patients living in 

urban and rural areas.97 The results showed an interaction of rurality and race on 8 (or 57%) of 14 

outpatient medical procedures, with racial disparities being greater in rural than in urban areas. 

Medical Appointments with Providers (Appendix C, Table 11)

Findings were mixed across 10 studies (1 of high quality, 5 of moderate quality, 2 of low to 

moderate quality, and 2 of low quality) examining frequency of ambulatory care visits. While four 

studies found no differences in visit frequency between rural and urban,29,98-100 four studies found 

that number of appointments tended to increase as population density increased.8,101-103 Based on 

data from the 1984 National Health Interview Survey on people 65 yr and older, it was found that 

those who lived in non-metropolitan areas were 35% less likely than non-inner city metropolitan 

residents to visit a physician. Using a more recent cohort of that database (1992) and focusing 

on the 112,246 residents under 65 yr, Mueller and colleagues (1998) found that rural residents 

as a group were less likely to have seen a physician in the previous 12 months.103 Minority status 

and living in the Southern part of the US were independent predictors of not seeing a physician 

in the previous 12 months; however, the strongest predictor was a lack of insurance (OR=0.42, 

95%CI=0.40-0.44). In a national study of any health care use in the past 12 months among 50,993 

respondents to the National Health Interview Surveys from 1999-2000, 78% of urban residents and 
36

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

79% of rural residents reported using at least some health care.

100 Similar findings were reported 

by a second national study using the Medical Expenditures Panel Survey from 1996 which found 

no difference across rural or urban areas in the odds of having at least one ambulatory visit in 

the past year.102 However, rural residents reported fewer visits on average than residents of large 

metropolitan (4.9 visits vs. 6.1 visits, p<0.02). For individuals with at least one visit, the number of 

visits ranged from 6.5 for rural residents to 8.3 for large metropolitan residents (p<0.001). 

Weeks et al. (2005) examined the number of primary, specialty, and mental health visits from 

1997-1999 among rural vs. urban veterans 65 years and older living in New England.8

 Rural 

veterans had fewer visits in all three treatment sectors. A study comparing 25,092 veterans at 108 

community-based outpatient clinics (CBOCs) with 26,936 veterans at 72 VA medical centers 

(VAMCs) found more primary care visits (difference=0.10 visits) but fewer specialty care visits 

(difference=-1.42) per year among CBOC patients compared to VAMC patients.104 The same 

pattern of results was found an earlier study that used smaller samples of CBOCs and VAMCs.105

Usual Source of Care (Appendix C, Table 12)

We identified seven cross-sectional studies (two of moderate quality, three of low to moderate 

quality, and two of low quality) that addressed issues related to having a usual source of care (i.e., 

a specific clinic from which they receive care). Four of the studies included nationwide samples of 

patients with sample sizes ranging from 3,871 to 50,993.48,100,102,106 Three of the studies were regional, 

specifically west Texas107,108 and North Carolina.98 Sample sizes in these studies ranged from 2,097 

to 4,162. One of the studies included only active duty, uniformed service members.106 Three studies 

included only patients age 65 and older,98,107,108 and one study included only patients 18 to 64 years of 

age.100 There was one study that compared only individuals of Hispanic or non-Hispanic white race/

ethnicity.107 Overall, we found that similar percentages of rural and urban residents report having a 

usual source of care. The percentages of rural and urban residents who reported having had a health 

care visit in the past year similarly did not differ by geographic location.

Six studies specifically looked at whether individuals had a usual source of care. In a large 

nationwide survey of individuals ages 18-64 years, 82% of urban respondents and 83% of rural 

respondents reported having a usual source of care.100 Although there was no difference in the 

odds of having a usual source of care between respondents from urban and rural areas, race/

ethnicity differences were found (e.g., 68% of Hispanics vs. 85% of whites reported a usual 

source of care) and these disparities were comparable in urban and rural areas.100 Koopman 

(2006), using the National Health and Nutrition Examination Survey from 1988-1994, also found 

that Urban Hispanics were more likely than either urban or rural whites or rural Hispanics to 

report a lack of usual source of health care (11.4% vs. 1.8% urban whites, 6.5% rural whites, and 

5.1% rural Hispanics; p<0.01).48

 In another national study with a similar patient population, the percentages of patients who 

reported having a usual source of care were 87% in the most rural counties, 89% in counties 

adjacent to a large metropolitan areas, 78% in large metropolitan counties, and 78% in smaller 

metropolitan counties.102 In the adjusted model, patients in the most rural areas and those in rural 

areas adjacent to large metropolitan areas were more likely to have a usual source of care than 

residents in large metropolitan areas. Other factors significantly associated with having a usual 

source of care included worse health and higher income. 
37

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Two regional studies of patients over 64 years old found that between 94% and 96% reported 

having a usual source of care with no difference between urban and rural residents98,108 In the 

adjusted model, having insurance other than Medicare/Medicaid was associated with increased 

odds of having a usual source of care while Hispanic ethnicity was associated with decreased 

odds.108 Both studies also looked at whether the respondent had a personal provider. No 

differences were found between rural and urban areas in the odds of having a personal provider 

(87%).108 Hispanic ethnicity and lower income were associated with decreased odds.108 The 

second study reported a rural advantage for continuity of care with a primary care provider (88% 

rural vs. 82% urban; p<0.05).98 A third study, comparing Hispanic and non-Hispanic whites in 

rural or frontier counties of west Texas reported that the likelihood of having a personal provider 

was not associated with degree of rurality; however, non-Hispanic whites were significantly 

more likely to report that they consulted their personal doctor or nurse.107

Three studies reported results related to ability to obtain care.98,106,107 A nationwide survey of over 

3,800 Department of Defense beneficiaries found that health plans and health care, ability to get 

care quickly, and doctor communication were rated significantly higher by residents in areas 

adjacent to metropolitan areas or in non-adjacent areas. Getting needed care and customer services 

were rated higher by residents of metropolitan areas.106 A study of Hispanic and non-Hispanic 

whites in rural and frontier areas of west Texas found lower percentages of Hispanics reporting that 

they see a specialist when needed, that they are able to obtain transportation to the doctors’ office, 

and that they see a doctor or nurse as soon as they want for both illness/injury and routine care. In 

an adjusted analysis, Hispanic ethnicity was no longer associated with decreased ability to obtain 

care but remained significantly associated with decreased ability to see a doctor or nurse when 

they wanted to. Residence in a frontier or rural county was not related to ability to obtain care or to 

obtain care without a long wait.98 Finally, in a study of 4,162 residents of urban or rural counties in 

North Carolina, 6% of the urban respondents and 10% of the rural respondents (a non-significant 

difference) reported that they put off care due to transportation difficulties while14% of urban and 

25% of rural respondents put off care due to the cost (p<0.05).98

Provider Availability and Expertise (Appendix C, Table 13)

We identified 12 cross-sectional studies related to provider availability and expertise. Four 

studies were national studies.28,66,109,110 One study was conducted in eight states in southeastern 

United States.111 One study included clinicians from California and Washington.112 The remaining 

studies were conducted in Wisconsin,113 Texas,114 Florida,115,116 Washington,117 or Georgia.118

Three studies enrolled patients,110,111,113 seven studies enrolled providers,28,109,112,115-118 and two 

studies presented data by county.66,114 Two of the studies were of high quality, five were of low to 

moderate quality, and five were of low quality. Overall, the evidence suggests that more remote 

locations are underserved by health care providers. People who live in these areas are more likely 

to see a family practice physician, a physician assistant, or a nurse practitioner. In one state, 

services are being decreased or eliminated by both rural and urban physicians. There is limited 

nationwide data on this topic. 

Nationwide, the availability of primary care physicians per 10,000 residents decreases in an 

almost linear fashion from an urban high of 17.8 (SD=16.1) to a low of 7.2 (SD=7.8) in rural 

areas adjacent to a micropolitan area.28 The ratio was slightly higher in remote rural regions with 

a ratio of 9.2 (SD=8.9),28 but the variability across remote regions can be highly problematic. 
38

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

For example, the distribution of physicians and physician assistants was examined in rural and 

remote counties of Texas using the Texas Medical Board Web site and from US Census Data.114

Seventeen of 254 Texas counties had no licensed doctors or physician assistants. Statewide, 

there was one physician assistant for every 13.6 physicians. In the 60 frontier counties, however, 

the ratio was one physician assistant for every 2.3 physicians. Frontier counties, then, have 

not only a diminished availability of medical providers, but more of the providers that they do 

have are physician extenders. Patient perceptions of physician availability were consistent with 

the epidemiologic assessments. Biola et al. (2009) surveyed 4,879 patients living in 150 rural 

counties in the southeastern United States, and examined agreement with the statement “I feel 

there are enough doctors in my community.”111 As would be expected, patients who lived in areas 

with more physicians relative to the county population were more likely to respond that there 

were enough physicians. Of interest, the perception that there were an insufficient number of 

physicians was greater not only among patients who live in areas with fewer physicians relative 

to county residents, but also among those who traveled more than 30 minutes for care, those 

who lived in a more impoverished county or who had problems with the cost of care, and among 

those who lacked confidence in their physician’s level of expertise. 

As noted previously, differences in provider availability were not only found for primary health 

care providers. A nationwide study of numbers of rehabilitation therapists (physical therapists, 

occupational therapists, and speech-language pathologists) between 1980-2000, found that 

although the disparity in therapist availability between rural and urban areas had improved 

over the 20 year period, that the ratio of therapists per 100,000 residents remained significantly 

different between urban and rural areas (urban:rural rates per 100,000 for physical therapists 

50.9:35.5, occupational therapists 24.7:15.3, and speech pathologists 35.0:29.5).66

In addition to limitations in provider availability, rural residents often have different types of 

providers available to them. A nationwide study of over 34,000 patients from non-metropolitan 

areas had greater adjusted odds of receiving services from family physicians, nurse practitioners, 

or physician assistants and lower adjusted odds of receiving services from general internists or 

non-surgical specialists.110 Similarly, in the Wisconsin Longitudinal Study,113 primary provider 

type was determined among survey respondents who indicated they had a usual source of 

care and compared across metropolitan, micropolitan, or nonmetropolitan (i.e., rural) areas.113

Overall, 4.5% of respondents reported that a physician assistant or nurse practitioner was their 

primary care provider and, in adjusted analyses, these provider types were more common among 

nonmetropolitan residents. Also consistent with findings was a study of over 28,000 clinicians 

practicing in California and over 5,600 clinicians practicing in Washington State.112 Of physician 

assistants practicing in California, 22% were in rural areas. A similar pattern was observed in 

Washington. Family physicians, nurse practitioners, and physician assistants were more likely 

to practice in a rural area (relative to obstetrics/gynecology). Physician extenders in rural areas 

often work longer hours, see more patients and provide care to more patients without insurance 

than their urban counterparts.118 Differences were found not only in the prevalence of physician 

extenders, but also in the type of physicians practicing in rural areas. For example, in a study of 

over 4,000 providers in Washington State,117 family physicians were most likely to provide care 

in a rural area; psychiatrists, cardiologist, and gastroenterologists were least likely. Although 

the diagnostic scope of practice was similar for rural and urban physicians, rural obstetriciangynecologists were more likely to care for diagnoses outside of their specialty and rural general 
39

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

surgeons were more likely to care for gastrointestinal disorders (vs. cardiac conditions for urban 

surgeons). Not surprisingly, procedure rates were higher for rural physicians.

Of concern is the fact that often the qualifications of physician extenders in rural areas may not 

be comparable to those practicing in urban settings. A survey of nurse practitioners, certified 

nurse midwives, and physician assistants in Georgia found that of 554 nurse practitioners 

who responded, 31% were working in a rural environment.118 Rural nurse practitioners were 

less likely to have had a bachelor’s degree and fewer had specialty credentials. This may be 

particularly concerning given that they were more likely to provide care in solo and clinic 

practice settings. Of 73 certified nurse midwives, 29% worked in a rural setting. Rural certified 

nurse midwives also had fewer specialty credentials, worked more hours per week, and saw 

more patients per hour. Of the 18% of 452 physician assistants practicing in rural settings, fewer 

had at least a bachelor’s degree compared to those practicing in urban settings. Although there 

is limited data comparing the quality of care between rural primary care providers who are 

physician extenders and those who are physicians, patients in the Wisconsin Longitudinal Study 

whose usual source of care was a physician assistant or nurse practitioner were more likely to 

report lower satisfaction with access to care (beta=−0.22, 95%CI=−0.35-−0.09), and were less 

likely to have received a complete health exam (OR=0.74, 95%CI = 0.55-0.99) or a mammogram 

(OR=0.65, 95%CI=0.45-0.93).113. However, a national Web survey of physician assistants in 

2008 (response rate 49%), found that rural physician assistants were better at diagnosing and 

treating dermatologic conditions than their urban counterparts (p<0.03).109 This was interpreted 

as being most likely due to the larger number of dermatologic cases seen by rural practitioners 

(78% rural see most dermatologic cases vs. 62% of urban physician assistants). Importantly, the 

referral rate for specialty treatment did not differ by rural-urban practice settings. 

Two studies, both conducted in Florida, reported that physicians in both urban and rural area 

were curtailing the services that they offered, largely in response to malpractice costs.115,116

Overall, 60% of 308 respondents from both rural and urban areas reported that “delivery of 

patient services in their practice had been decreased or eliminated in the last year.”116 Of the 539 

respondents to a survey of rural physicians, 55% reported they decreased or eliminated patient 

services in the past year. Among the services decreased were mental health services (reported 

decreased by 35%), vaccine administration (29%), office-based surgeries (40%), Pap smears 

(24%), x-rays (24%), endoscopies (43%), and electrocardiograms (11%). Additionally, there was 

a significantly greater reduction or elimination of services, overall, by physicians who saw higher 

numbers of Medicare patients.115

Summary

There is limited availability of any health care providers in highly rural areas, and specialists in 

particular. There was some weak evidence that physician extenders in rural areas may not have 

comparable credentials to their urban counterparts. Rural residents were more likely to have 

family medicine physicians as their primary care doctors, as well as primary providers who were 

physician extenders. Having fewer health care choices seemed to increase the odds of remaining 

with the same provider over time, thereby improving continuity of care. There is weak evidence 

that in some parts of the country, health care providers in highly rural areas may not have 

comparable credentials as their counterparts in urban area. It is unclear to what extent this might 

generalize to other areas. 
40

lth Care: A Systematic Review Evidence-based Synthesis Program

r Processes or Structure of Care Studies

Dellasaga 

199956

Fillenbaum 

199389

Hanlon 

199690

Lago

199391

Lillard 

199992

Mueller 

200493

Xu 

200394

Rogowski 

199795

Miller 

199596

Escarce

 199397

Blazer 

199598

McConell 

199399

Saag

199829

Himes

1993101

Larson

 2003102

Mueller 

1998103

Weeks

 2005

8

Maciejewski 

2007104

Fortney

 2002105

F G G F F F F F F F F F F F F F F G F

F G G F F G F F F F F F F G G G G G G

F G G F F F G F F F G F G F G G F G F

F G F G F G F F F F F F F F F G G G G

F G G G F F G F F F G F G F F F F G F

P F F F F F P F F P F F F G G F F G F

F G G G F G F F F F G G G G G F G G G

P F F F F G F F F F F F F G G G G G G

P G G G F P P F F P F F P G G F F G F

L M/L M/L M L M/L L L L L M/L L L M M M M H M
41

lth Care: A Systematic Review Evidence-based Synthesis Program

Meza

 2006106

Glover

2004100

Borders

2004107

Rohrer

2004108

Koopman 

200648

Wilson

200966

Ferrer

2007110

Biola

2009111

Grumbach 

2003112

Everett

2009113

Jones

2008114

Gunderson 

2006115

Manachemi 

2006116

Baldwin 

1999117

Strickland 

1998118

Laditka

200928

Brown

2009109

P G F F F G F F F F G F F G F G PP G F F G G F P F F G F F G F G P

F G G G G N/A F G F F N/A N/A N/A N/A N/A N/A F

F G F F G G G P F G G F F G G G P

F G G G F G F G G G N/A G G G G G F

F F F F F G/F F P F F G F F F F G P

G G G G G F G F G G G G G G G G F

P G F P F G F F F F G F F F F G F

F F F P G G F P P F G F F F F G P

L M M/L L M H/M M/L L L M/L H L L M/L M/L H L

r Processes or Structure of Care Studies
42

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

SUMMARY AND DISCUSSION

Conclusions and Recommendations

In this section, we will summarize the results as they relate to the key questions and provide a 

series of recommendations for future research on rural health issues. 

 As evidenced by our review, there were several conditions for which there was a paucity of 

evidence regarding their prevention, diagnosis or treatment in rural health care settings (e.g., 

sexually transmitted diseases, rheumatoid arthritis, COPD, chronic pain, hepatitis C, anxiety 

disorders, substance use disorders, post-treatment cancer surveillance, traumatic brain injury). 

Studies tended to be conducted in areas in which either the information was readily available in a 

national database, a performance measure or guideline existed for which there was evidence and 

which served to operationalize quality care (e.g., via claims data), or a local health care problem 

existed that the authors were seeking to quantify. Given the data sources, study designs were 

predominantly cross-sectional or retrospective cohort designs, and only one of the studies we 

reviewed used a prospective design. Few studies associated health care differences with health 

outcomes. Given these limitations, the strength of the evidence was at best weak to moderate 

for most areas even when a significant finding was consistently present. This complicated 

interpretability. Most of our conclusions, therefore, are at best suggestive. 

Another significant conceptual problem with the use of extant data sources and the crosssectional study designs used was that potential reasons for rural-urban differences were often 

treated as confounders and adjusted for in statistical models. There are many correlates of rural 

residency that may affect health care utilization or access (e.g., lower rates of college graduates, 

types of health insurance, higher rates of poverty in highly rural areas, etc.).119 Statistically 

adjusting for these contextual characteristics only to then find no difference between rural 

and urban residents in health outcomes does not mean that rural residents or, in some cases, 

urban residents are not disadvantaged.120 Similar points have been made in discussions of race 

disparities,121 with recommendations made to “unpack” the factors underlying the differences, 

which we feel are also applicable in this area. 

Because our evidence base relied on peer reviewed articles, we did not include national reports 

examining potential differences in rural vs. urban health care. However, because these reports 

serve to inform policy makers, at the end of this section we compare findings from the 2010 

National Healthcare Disparities Report122 and the 2010 VHA Facility Quality and Safety 

Report123 with the results of this systematic review.

SUMMARY OF EVIDENCE BY KEY QUESTION

Key Question #1. Do adults with health care needs who live in rural areas have 

different intermediate (e.g., HbA1c, Blood pressure, etc.) or final health care outcomes (i.e., mortality, morbidity, QOL) than those living in urban areas?

Most of the evidence regarding potential differences in health care outcomes between rural and 

urban patients is weak either by the quality of the study designs and/or the paucity of studies 
43

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

evaluating whether any differences exist. Below we list the findings for which there is some 

evidence of a health care disparity. 

• There is some weak evidence that increasing rurality is associated with a greater frequency 

of hospitalization for ACSC’s. 

• No evidence for differences in cancer mortality.

• There is some evidence of greater rates of DCIS and lower rates of invasive cervical 

cancer in urban areas where screening rates are higher. 

• There was no evidence for a disparity between rural and urban patients with diabetes in terms 

of diabetes complications or the prevalence of ESRD. However, there was some evidence 

that race by rurality interactions may exist in diabetes care and in the treatment of ESRD. 

• Although very limited, the available information suggests that outpatient control of 

hypertension, at least among veterans, does not differ between those residing in rural vs. 

urban areas. 

There was weak evidence for higher hospitalization rates for rural residents treated for 

depression in Arkansas.

Key Question #2. Is the structure (e.g., types of available providers) or the process (e.g., likelihood of referral) of health care different for adults with health care 

needs who live in urban vs. rural environments?

Use of Medication

No consistent differences were found in receipt of or adherence to medication. To the extent that 

a few studies reported any differences, urban residents tended to receive more medications. 

Medical Procedures and Diagnostic Tests

The use of most services, including office visits and consultations, imaging services, and 

diagnostic testing, were found to be lower in rural areas compared to urban areas. More 

consistent evidence was found specifically for lower screening rates for breast and cervical 

cancer in many rural areas. Differences in screening rates for colorectal cancer are not 

consistently found. However, all but one study found a greater frequency of unstaged cancer at 

the time of diagnosis in rural areas compared to urban areas. 

Medical Appointments with Providers

Rural residents were less likely to see a medical provider than urban residents. Specifically, rural 

residents were less likely to see specialists, and low availability of specialists had deleterious 

impact on some health outcomes (e.g., cancer mortality). However, studies did not generally 

account for the fact that rural residents often receive specialty health care in urban clinics and 

how this might affect health outcomes. More consistent was the lower rate of mental health care 

service receipt among residents in rural areas. 
44

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

Usual Source of Care

There was no consistent evidence that rural residents were less likely to have a usual source of 

care. In fact, there was more consistent evidence that rural residents had better continuity of care. 

Having fewer health care choices seems to increase the odds of remaining with the same provider 

over time. 

Provider Availability and Expertise

There was consistent evidence that highly rural areas had a paucity of health care providers. 

There was some evidence that providers in some highly rural areas were more likely to be 

physician extenders (e.g., physician assistants, nurse practitioners). There was some weak 

evidence that physician extenders in some rural areas may not have comparable credentials to 

their urban counterparts. More consistent evidence was found indicating that rural residents were 

more likely to have primary care providers whose training was in family medicine rather than 

general internal medicine or OB/GYN. There was also consistent evidence that rural residents 

had less access to specialty medical services unless they traveled to urban health care centers. 

Fewer non-physician rehabilitation specialists are available in rural areas. 

There was weak evidence provided by one study that suggested that limitations in provider 

knowledge might impact clinical practice viz. colorectal cancer screening.

The two studies examining the availability of rehabilitation specialists both found a paucity 

of such providers in many rural areas relative to urban areas. One of the studies compared 

availability over several years, increasing confidence in this finding. Similarly, there is a fairly 

consistent finding of fewer mental health specialists in rural areas.

Quality of Care

There were also no consistent differences between rural and urban areas in treatment quality 

measures for diabetes, although one study found evidence for regional variation in rural 

disparities. This was not assessed in other studies. Similarly, the two larger studies of treatment 

of hypertension did not find any quality differences between rural and urban settings. 

Although the studies are few, there is some evidence suggesting that care for some conditions 

(e.g., HIV/AIDS) may be lower in rural areas. Two of three studies examining quality of cancer 

treatment indicated lower quality of care in rural areas. The third, however, found that rurality 

was less of a contributor to quality care differences than was provider characteristics.

Key Question #3. If there are differences in the structure or the process of health 

care in rural vs. urban environments, do those differences contribute to variation 

in overall or intermediate health outcomes for adults with health care needs?

Although there were many studies that documented differences in health care structure or process 

between urban and rural health care settings, as we noted above few associated those differences 

with variation in health outcomes. The list of findings below is generally based on single studies 

of variable quality. Results can only be considered suggestive. 
45

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

• Lower rates of mammography and cervical cancer screening in rural areas was associated 

with lower rates of ductal carcinoma in situ (vs. more invasive breast cancer) and higher 

rates of invasive cervical cancer in rural areas. 

• Improving access by the creation of Rural Health Clinics in underserved areas was 

associated with improved adherence to treatment guidelines for diabetes.52

• Limited numbers of providers in rural areas may foster better continuity of care. 

• Limitations in provider availability may be associated with increased odds of 

hospitalization among older rural residents for ACSCs.

Two studies that were published after our sampling frame demonstrate comparable rates of 

pharmacotherapy for rural and urban residents with depression and rural vs. urban veterans with 

depression or anxiety disorders.124,125 Both studies found that the odds of having psychotherapy 

appointments, however, were lower among those who lived in rural settings, and that this 

difference was mediated by provider availability.

Key Question #4. If there are differences in intermediate or final health outcomes 

for adult patients with health care needs, what systems factors other than those 

due to differences in health care structure or process moderate those differences 

(e.g., travel distance)?

Insurance

• Lack of insurance was associated with increased odds of ACSC associated admissions, 

but this was not limited to rural residents; however, within rural areas those who had 

supplemental HMO plans had fewer admissions compared to older residence with a feefor-service insurance plan. Of note, one study found that Medicare HMO enrollees had to 

travel further for acute care services than Medicare fee-for-service patients, and were less 

likely to receive services within their county.126

Travel Distance

• There was limited evidence that having a greater distance to treatment decreased odds of 

receipt of radiotherapy for older women with breast cancer, aftercare for veterans treated 

in inpatient alcohol treatment programs, and frequency of mental health appointments. 

• The presence of Rural Health Clinics in underserved areas improved treatment access and 

adherence to treatment guidelines for patients with diabetes. 

Patient Attitude

• There is some weak evidence that urban residents may have a lower threshold for seeking 

mental health care than do rural residents, and that this may be related to differential use 

of mental health services. 

Race Disparities

• For many conditions covered in this review, race disparities were greater in urban than 

in rural areas. This was observed in admissions for ACSC-related conditions, stage 
46

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

at presentation for colorectal and prostate cancers, detection of diabetes, secondary 

prevention for diabetes-related conditions, post-hospitalization continuity of care for 

mental illness, and, among Native Americans, the odds of receiving a kidney transplant. 

• Race disparities were greater in rural areas for mortality rates among Hispanics for ESRD 

and for rates of organ transplants for blacks. 

The 2010 National Healthcare Disparities Report (NHDR) compared health outcomes between 

noncore areas (defined as rural counties without metropolitan or micropolitan areas) with large 

fringe metropolitan areas (defined as suburban counties of metropolitan areas with one million 

or more residents).122 Most of their findings relating to adult ambulatory healthcare, found 

results comparable to this review. Specifically, the NHDR also found evidence for increased 

hospitalizations for ACSC’s, elevated suicide rates, reduced rates of CRC screens and lower 

insurance rates among rural residents. Differences in the NHDR and this review were only noted 

for lung and CRC related mortality rates and the odds of flu vaccination (they found disparities, 

we found the evidence to be inconsistent for cancer care). Importantly, it must be noted that the 

studies covered by this review most often compared rural areas with urban areas, not suburban 

areas. Given that we found urban disparities in some healthcare areas (notably cancer care), 

this might account for the differential findings. Finally, the NHDR reported differences in a 

few areas for which no articles were included in this review -- advice for exercise among obese 

patients and the five year odds of cholesterol screening -- both of which demonstrated a rural 

disadvantage. 

The 2010 VHA Facility Quality and Safety Report compared US census defined urban areas with 

non-urban areas (called rural, but which would include suburban counties).123 Only bivariate 

findings are included in the report. Comparable to this evidence synthesis, no differences were 

noted for guideline concordant follow-up care for patients with diabetes, control of hypertension, 

or immunization rates for influenza. Also assessed in that report, but not covered by this evidence 

synthesis, were patient satisfaction, counseling for tobacco cessation and mental health screens, 

none of which demonstrated consistent differences between rural and urban areas nationally. 

Despite the similarities, it is difficult to conclude that no differences between highly rural and 

urban (or suburban) areas exist because of the way VA categorizes urban vs. rural.

RESEARCH IMPLICATIONS AND RECOMMENDATIONS

As has been shown by others, the definition of rural that is used in a study has a significant 

impact on the findings and, consequently, the policy implications.11,12,14 Yet, there is little 

consistency across studies either in terms of what convention is used to define rural or how a 

chosen convention is actually employed in the study. Consequently, we make the following 

recommendations for researchers regarding definitions of “rural” and other methodologic issues 

based on our observations and the work of others.11,12,14

1. Specify the convention that was used to define “rural” in the study and how it was specifically 

operationalized. Many studies use rural–urban commuting area codes (RUCA) as their starting 

point, but then combine the categories in unique ways. The convention used by VA may 

minimize rural-urban disparities for some healthcare services. A more graded convention (e.g., 

RUCA, RUCC or UIC) would allow for better identification of areas in need of intervention. 
47

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

2. Provide a rationale for why the convention used in the study was chosen and the potential 

impact of that choice on the research question (e.g., Is a monotonic relationship between 

levels of population density and the outcome variable expected?).

a. Consider using a statistical method for deciding between conventions if more than one 

option is available.12

3. If the study questions do not call for a clear choice in the convention to be used, consider 

using more than one convention and reporting the results for both definitions.

4. Provide a rationale for the unit of analysis viz. the research question. For example, does the 

unit of analysis reflect the functioning of local health care systems or markets (e.g., county 

vs. zip code as unit of analysis) or is the focus individual health outcomes? 

a. Associations between health care parameters and specific health outcomes found when 

using aggregate units (e.g., counties or zip codes) may not hold at the individual level 

(i.e., a modifiable areal unit problem). This limitation was generally not acknowledged. 

As noted by Rost et al.,127 many of the important questions concerning rural-urban disparities in 

health care cannot be answered by simply demonstrating differences in health care systems. A 

more useful set of questions focus on clarifying what health outcomes, if any, show a disparity, 

for whom does the disparity exist, and why is there a disparity. Accordingly, we make the 

following recommendations.

1. Because many factors are correlated with rurality, adjusting for all available covariates 

may lead to false conclusions regarding the association of rurality and study outcomes, and 

provide insufficient information for the development of healthcare policy. For most research 

questions, a more contextual analytic approach should be used.

a. For example, first reporting bivariate associations (missing from many papers) and then 

examining which, if any, of the available covariates significant in multivariable models 

contributed to the observed differences in the bivariate analyses. Alternatively, other 

statistical models, such as multilevel models, might be useful. 

b. These associations must also be considered when selecting instrumental variables or 

developing propensity models for risk adjustment.

2. Most rural residents receive their primary health care locally. However, a significant 

proportion of rural residents will travel to more urban areas for medical conditions that 

require specialist treatment or for which they have less confidence in the expertise of their 

usual provider111 Few studies acknowledged this trend, and those that did generally omitted 

data from those individuals who received their care in urban settings. Studies should address 

this selection bias and seek to understand its implications for their study findings and for the 

health care systems involved. 

3. In several studies, interactions were found between race (and/or income) and residential 

population density. Such interactions may have significant implications for interventions 

designed to address a rural health disparity, and should be tested in the research model if 
48

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

appropriate. Interactions between race and rurality should be further explored as they could 

reflect any of the following (see Stern, 201012 for a discussion):

a. Living in a rural or urban area affects health care (or access to health care) for a minority 

group differently than it does for whites.

b. The association is due to the distribution of minority members of the patient group in 

question.

c. A third factor is associated with both race and rurality (e.g., poverty)

d. There is an association between race and some aspect of the healthcare system (e.g., 

proportion of providers who are minorities). 

4. Studies that describe differences in healthcare systems but do not associate such differences 

with health outcomes are of limited value. Areas with limited healthcare resources may 

engage in successful service substitution and areas with an abundance of health care 

resources may engage in overutilization.

5. Only one of the studies we reviewed that compared rural with urban health care used a 

prospective design. This limits the confidence with which factors associated with a rural 

disparity can be considered as potentially causal. 

6. Studies focused on providing descriptions of barriers to care are only helpful insofar as the 

barriers are associated with actual limitations in the use of needed healthcare services. All 

consumers have barriers to care, but not all barriers limit health care seeking. 

7. Large national databases often involve statistical corrections to adjust for any potential 

sampling bias. Using such databases improves a study’s external validity; however, the 

findings from such secondary analyses are often limited by what measures are available in 

the database.

8. Studies that relied on self-report measures rarely assessed or corrected for sampling bias, and 

many did not include sampling bias as a possible study limitation. Similarly, studies sampling 

from multiple sites often did not address potential clustering effects in their analyses. 

9. Studies that sample nationally should consider examining whether there is regional variation 

in observed rural-urban disparities. Regional variation in rural-urban disparities has been 

demonstrated in studies involving veterans4

 and non-veterans.31,51 Pooling across regions may 

attenuate disparities. Moreover, health care systems operate locally and identifying areas 

where problems are greatest would help policy makers target areas that have the most need. 

There are large gaps in the evidence base across clinical conditions, and minimal empirical work 

conducted on several areas of particular interest to the VA (e.g., TBI, PTSD, Hepatitis C). Filling 

in the evidence base will allow VA policy planners to make informed decisions about resource 

allocation.
49

Rural vs. Urban Ambulatory Health Care: A Systematic Review Evidence-based Synthesis Program

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