58

lth Care: A Systematic Review Evidence-based Synthesis Program

66

TA ABSTRACTION FORM 

Check if Background paper 

First Author Year Inclusion Eligibility? Y N If "No", what #?

Cross-sectional Case-control RCT NonRCT Review/Meta-analysis

sites/ 

onal? 

Sample

size Inclusion/Exclusion Criteria Vet? 

Rural/

urban? Rural definition used 

Y N Y N 

Survey

ote response rate) 

Health care 

Records 

Primary vs.

secondary National database (define) 

Date(s) of 

dataset 

1o 2o

Adjusted Covariates/Independent Variables 

Appropriate Stats? Y N N/A 

Adjusted for sampling 

bias? Y N N/A 

Adjusted for non-response 

bias? Y N N/A 

Adjusted for clustering? Y N N/A 

Findings: Include outcome measures and, if appropriate, magnitude of effect. 

2 3 4 4a
59

lth Care: A Systematic Review Evidence-based Synthesis Program

R REVIEW COMMENTS AND AUTHOR RESPONSES

REVIEWER COMMENT RESPONSE

 and methods for this review clearly described? 

Thank you.

portant to highlight that this review is comparing the care of rural 

nd that data for rural vs. urban veterans are even more sparse and 

rural veterans face the same disparities in care as rural non-veter

We agree, and have clarified this in the text. 

 methods make sense and are useful for researchers, providers, 

f this kind is needed. It is not clear why only ambulatory care articles 

ction when some of the topics were relevant beyond only ambula

n of inconsistencies and other problems related to definitions of 

ban” is viewed conceptually were very important. More detailed 

o be done to address this (e.g., how will consensus be reached) 

nformation is needed about the study selection, data abstractions, 

e body of evidence. It would be hard to replicate this review with the 

We focused on ambulatory care. Including hospital care would have made the review unwieldy and too diffusely focused. That being said, some traditionally non-ambulatory care topics were included because they were indirect indicators of ambulatory care access and/or quality (e.g., hospitalizations for ambulatory care sensitive conditions). We have further clarified our methodology in the text. 

ld be expanded. It is difficult to assess the quality or thoroughness 

s, as the description of the process is minimal. Data abstractions 

ed in critical analysis of the literature,” but there is no description of 

ns of the abstractors. There is a bit more description of the evalu

were reviewed, but no mention of who did these ratings or of any 

ables in which you present your ratings of the quality of the studies 

he text. For example, in a table, you give two studies low confidence 

no indication that there may be problems with those studies. As one 

would know that you have doubts about the quality of these studies 

the table at the end of the section. Few readers will do this. Within 

want to segregate the good studies form the bad ones so the reader 

st on. 

These are both excellent points and we have made relevant revisions in the text. 

bias in our synthesis of the evidence? 
60

lth Care: A Systematic Review Evidence-based Synthesis Program

REVIEWER COMMENT RESPONSE

ctive review that highlights the lack of good information and the in

ons. Thank you.

on of bias, sources of bias could be better protected against 

thods used for review would be strengthened by blinding reviewers 

-rater reliability could be tested by more than one reviewer review

ar what preparation the reviewers had and how the reviewers were 

urpose. The term “trained reviewer” is used several times without 

at means. There is variation in that term.

We have elaborated on the methodology in the text to address the issues raised. The first and second authors rated all papers after jointly rating 20 to achieve consensus in our ratings. Since there is no evidence based rating system for nonrandomized trials, we had to develop our own. In the text, we acknowledged that the ratings were qualitative in nature and that their primary value was to explicate to the readers the bases of our evaluations. 

is pretty inconclusive.

d published evidence. One problem, however, is that the synthesis 

oducts within agencies (i.e., white papers, special studies). In the 

ducted internal analysis of clinical quality and patient satisfaction 

differences between patients residing in rural and urban areas.

The task was to develop a synthesis of the existing published peer-reviewed evidence base. We did, however, examine studies conducted by OQP and AHRQ, and have commented on the findings of those reports in our discussion. 

unpublished studies that we may have overlooked?

 was on published, peer-reviewed literature but reports issued by 

 undergone internal review should perhaps be considered particu

parities. The AHRQ National Health Disparities Report, as well as 

port Cards for 2008-2010 are worth consulting. The VHA report 

 performance measurement system (including process and satisfac

esidence.

As noted above, we have now examined studies conducted by OQP and AHRQ, and have commented on the findings of those reports in our discussion.

nd the scope beyond the three data sources used and include more 

e). Inclusion of relevant dissertation research would be helpful. 

are included (since there is publication bias) would strengthen the 

While we agree that information from well controlled studies that did not make it to publication because of negative 

findings would be informative, the systematic nature of the evidence based synthesis report precludes the use of nonpeer reviewed literature.

alth, including telephone management. When we began the literature review for this report, a 

separate report was being developed to cover the telehealth literature. 
61

lth Care: A Systematic Review Evidence-based Synthesis Program

REVIEWER COMMENT RESPONSE

rational products within agencies. Some of these results are avail

as Data.gov and on VA Websites. See comments above. 

Thank you.

rmance measures, programs, quality improvement measures, 

erences that will be directly affected by this report? If so, 

Thank you – we will share the responses to this question with the people responsible for dissemination of the report.

 review to inform our own measurement systems and reports, and 

 use of risk adjustment procedures that may “adjust away” the 

working closely with the Office of Rural Health to create more robust 

ties and believe the partnership will be strengthened by this report.

ngs presented at annual HSR&D national meetings and b) pro

Rural Health

ated widely and used as the basis for creating an agenda for sys

 knowledge and practice. VA’s various centers (e.g., VERCs and 

port to help focus their efforts and assure that their work is appli

ghly rural areas.

significantly impact and direct future directions in rural health re

mplementation and quality improvement efforts.

mendations on how this report can be revised to more directly 

tion needs.

dies that you do not believe contribute. It becomes hard to pick up 

gs when everything is presented. Several of the studies were of dif

rural differences in health care in my opinion. I also think that more 

ng the studies that you believe really are valid and generalizable 

ty rating column to your evidence tables. It is hard to go back and 

ummary tables in the text when possible.

We have clarified study quality within the text and have added the final Confidence Score rating to our evidence tables to assist readers. 

pecific recommendations to policy makers, such as which definition 

cific advice on how to adjust for patient mix so as not to submerge 

.

It is our belief that the convention to be used in studies for the categorization of population density cannot be determined by this review and likely will vary depending on the type of study being conducted. Similarly, case mix adjustment depends on the focus of the study (e.g., whether or not to adjust for travel distance) will vary depending on the focus of the study. 
62

lth Care: A Systematic Review Evidence-based Synthesis Program

REVIEWER COMMENT RESPONSE

 tables (similar to the ones presenting the strength of evidence) with 

hich studies found significant rural-urban differences in the main 

d allow the reader to get a quick visual on how many and what pro

ces in diabetes outcomes, for example.

We have added ‘+’ and ‘-’ indicators to our tables to assist readers. 

 seems out of place in a summary section. Perhaps it would fit bet

When we began this report, a separate systematic review was to be conducted on telehealth interventions. For this reason, we chose to NOT evaluate telehealth studies and to focus instead on other types of interventions. However, since that review was not conducted, we agree with reviewers that examining only non-telehealth interventions makes 

little sense and so we have excluded that section from the final report. 

 lots of information. I liked the way the authors categorized their 

ons and by disease categories within those. Some specific com

– saying standard search terms isn’t enough

 definition in the intro when you say 40% of veterans are rural

 long, the review really does lack the whole piece on telehealth that 

pensate for in-person ambulatory access deficits. At least need to 

ght be helpful to segregate VA and non-VA studies within each cat

n VA studies to denote them. Even saying they looked at “veterans” 

ooking at VA services, or even VA users.

dn’t see a section on that to be able to give feedback on. I assume 

de telehealth. This may call for a separate literature review to in

ot rely on “rural” “urban” terms to get at the articles they want.

spective (or even longitudinal but non-interventional) studies is re

re HSR&D should make the point (to ORH) that improving care and 

ust about observing and recording what’s out there, but about plan

vely evaluating their effect on rural veteran’s health and access.

We have clarified our methods and the reasons why a review of telehealth interventions were not included. The section on interventions was removed for the reasons noted above.There were an insufficient number of studies conducted within VA to separate them. However, we specifically note VA studies when they were reviewed.

ts per above comments. Because of the complexity of the issues, 

nd thoughtful “risk adjusted” analysis

Implications for risk adjustment have since been emphasized in the report. 

re was reported for rural residents although there was no evidence 

ve a usual source of care seems incongruous

The distinction has now been clarified in the text. 

r rates of invasive cancer related to lower rates of screening” – 

s really link these two?

Yes, for cervical and breast cancers as we note.
63

lth Care: A Systematic Review Evidence-based Synthesis Program

REVIEWER COMMENT RESPONSE

 and race (and/or income) should be considered.” – You might com

(at least evaluating outcomes) is extremely prone to confounding 

settings when ill/needing more health care or, people who chose 

r health care choices than those choosing an urban setting 

This was noted in the discussion. 

owever, whether the observed lower health quality of life among 

ces in disease prevalence, disparities in health care or both.” Or, dif

ocals to live in. it is more complex than this in my opinion

We agree, and further clarified this in the text.

strategy figure, do you think there would be any value in adding 

telling what category the papers fell into?

We feel this might increase confusion. 

on of disparity does not include variation due to differences in 

 agree with this statement. I thought the IOM focused on all differ

t due to differences in need and preference. I would just drop this 

The specific reference was clarified in the text. 

ance of the evidence to veterans. Perhaps each summary could 

hat no VA study exists.

We specifically indicated which studies focused on veterans. Since many veterans use non-VA care and many of those who use VA split their care between VA and community providers, all studies are potentially relevant to veterans. 

dies were missed from the Journal of Rural Health that I think are 

LL, Kunik ME, Fortney JC. Use of Psychotherapy by Rural and Ur

Health, 26(3): 225-233, 2010. 

Dong F. The Association between Rural Residence and the Use, 

n Care, Journal of Rural Health,26(3): 205-213, 2010.

These studies were published after our March 2010 pull date. However, given their relevance we note their findings in the discussion. 

ity in rural versus urban: Rost, K., M. Zhang, et al. (1998). “Rural

 treatment and suicidality.” Medical Care 36(7): 1098-1107. This study, which was already included in the review, was added to the section covering suicidality.

at rurality is related to hospitalization rates for depression and 

 Zhang l, Xu S, Dong F, Rost K. Community-Level Risk Factors for 

ministration and Policy in Mental Health and Mental Health Ser

, 2007

unity-Level Correlates of Hospitalizations for Persons with Schizo

60(6): 772-778, 2009.

We included these per your recommendation; however, the methods used were only suggestive regarding reasons for differential hospitalization rates in rural vs. urban areas.

 were found to receive fewer MH services than urban residents in 

act of this difference was unclear.” - See this article: Fortney J. Rost 

Geographic Accessibility on the Intensity and Quality of Depression 

884-893, 1999.

We have now included this article in our review. 
64

lth Care: A Systematic Review Evidence-based Synthesis Program

REVIEWER COMMENT RESPONSE

 This study is actually the better study, as it is quasi-experimental:

en J, and Burgess J. Does Improving Geographic Access to VA Pri

ents’ Patterns of Utilization and Costs? Inquiry, 42(1):29-42, 2005

The relationship between CBOC placement and rurality is not uniform, which is why we did not include this interesting article in our review. 

ually lots and lots of travel distance articles which you didn’t find be

ural vs urban studies. You might need to either drop this or expand 

We agree that our search terms did not allow us to comment sufficiently on this topic. 

that urban residents have a lower threshold for seeking mental 

nts” - I don’t really believe this. Severity at intake is not different 

ts.

We are aware of no studies that actually asses provider availability and patient treatment attitudes and needs in urban and rural residents and then associate those differences with use of mental health services. 

Weeks, Wallace, 2008; Berke, 2009; Stern, 2010) the definition of 

 a significant impact on the findings and, consequently, the policy 

erate that rural is a proxy for many different things (travel time, 

and that the rural vs urban literature does not determine what un

findings. 

We have clarified this in the report. 

elated with rurality, adjusting for all available covariates may lead to 

association of rurality and study outcomes, and provide insufficient  of healthcare policy. For most research questions, a more contex

e used.” – Good observation! Might want to include this point in the 

Thank you for this recommendation. We have now done so. 

bers (and indicate statistical significance, if appropriate) instead of 

increased rates etc. or give the page number where the specific 

ent

We have tried to improve the clarity of findings in the report. 

nd a greater frequency of unstaged cancer at the time of diagnosis 

n areas.” - I think it would be good to mention the outcomes (pres

this finding affects mortality

No information about the implications of unstaged disease for outcomes were made in the papers reviewed. The odds of unstaged disease was not a primary focus of the studies, but was an incidental finding.

 operate locally and identifying areas where problems are greatest 

 areas that have the most need.” - Rurality may very well be differ

ry i.e. rural Alaska is different than rural Mississippi etc.

We think these differences have received very little attention. 
65

lth Care: A Systematic Review Evidence-based Synthesis Program

ENCE TABLES

ventive Care/Ambulatory Care Sensitive Conditions 

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ndents

ents whose 

uld not 

ata using 

rmation 

rd (FIPS) 

National data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and the 1999 Area Resource File

Urban = Metropolitan Statistical Area (MSA) Rural adjacent: nonmetropolitan county physically adjacent to metropolitan Rural nonadjacentcounty

Age, gender, education, Income, race/ethnicity, insurance coverage, primary care physicians/1000 population, census region

High Influenza vaccination in the 

past year for women ≥ 65 years old (-)Pneumonia vaccination for women ≥ 65 years old (-)

random 

men who 

child 60-

lection date 

2003 Oregon Pregnancy Risk Assessment Monitoring System Oregon Birth Certificate databaseResponse: 65.8%

Rural-Urban Commuting Area Codes: urban, large rural, or small/isolated rural

Age, marital status, education, Hispanic ethnicity, intended or unintended pregnancy, household income, questionnaire language 

Low/Moderate

Late initiation of prenatal care (-)Barriers to prenatal care initiation (-)

with ≥ 

of children 

 counties 

yses of 

Kentucky, 

k, North 

rolina, and 

Hospital discharge data for 2002 from State Inpatient Databases (SIDS); Area Resource File (2002); U.S. Census Bureau; U.S. Census Bureau’s Small Area Health Insurance Estimates 

2003 Urban Influence Codes (U.S. Department of Agriculture) with 7 levels from large metro to most rural

Hospital bed supply, hospitals with EDs, health maintenance organization penetration, presence of community health center or rural health center, race, education, population density, unemployment, state fixed effects 

Moderate Hospitalizations for ambulatory 

care sensitive conditions – ages 18 to 64 (+); R>UHospitalization for ambulatory care sensitive conditions – ages 65 and older (+); R>U

welling 

ears), ≥ 1 of 

ons, resi

most rural 

 counties

Population based phone survey evaluating six common chronic indicator conditions (arthritis, hypertension, cardiac disease, diabetes mellitus, peptic ulcer disease, and chronic obstructive pulmonary disease)Response: 57%

U.S. Department of Agriculture continuum codes. Urban: metro areas with > 250,000 residentsRural: <2,500 residents in a single incorporated place and not adjacent to metro areas

Age, gender, education beyond high school, living on a farm, alcohol use, smoking in the past, medical advice needed in the past year, supplemental private insurance, medication coverage, Medicaid, VA clinic in the past year, Distance from physician, congregate meals, Use of Meals on Wheels, Homemaker service

Low Continuity of care (seeing 

same physician) (+); R>UAppointments with specialists (+); R>UPerceived need for medical advice (+); R<U
66

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

es with 

New York State Department of Public Health; U.S. Census Bureau 1990

Six point urbanrural scale based on population, size of largest city/town, % of workforce that commutes outside the county; grouped to New York City area, upstate New York urbansuburban, and more remote rural 

% of population in poverty, population density (population per square mile, % blacks, number of primary care physicians per 1,000 population), location of ZIP code (within 8 miles of hospital, within a health professional shortage area [HPSA])

Low Ambulatory Care Sensitive 

Conditions (ACSC) admissions:a) increased as population density decreased within each of the 3 defined regions (+) b) increased as percentage of black residents increased (+) except in the most rural group (-)c) increased as number of primary care physicians per 1000 increased (+)

 women 

1994 National Health Interview Survey (NHIS) Overall response: 79.5% 

U.S. Office of Management and Budget’s (MSAs and non-MSAs)

Census region, education, household income, insurance status, overall health status

Moderate Flu shots received in previous 

year (-)

n

al; F=Frontier; S=Suburban; (+)=difference statistically significant; (-)=difference not statistically significant
67

lth Care: A Systematic Review Evidence-based Synthesis Program

cer Screening

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

620 rural)

anic whites 

ack, age 

ening mam

mmography

Behavioral Risk Factor Surveillance System (BRFSS) 2001 and 2003

Rural-Urban Continuum Codes (RUCCs) – collapsed to 2 levels: rural or urban

Age, race/ethnicity, marital status, education, employment, health status, smoker, health insurance, personal health care provider

Moderate Screening mammography 

utilization (-)

ndents

ents whose 

uld not be 

using county 

 Processing 

des; Califor

ograms and 

ad modified 

estions)

National data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and the 1999 Area Resource File

Urban = Metropolitan Statistical Area (MSA) Rural adjacent = nonmetropolitan county physically adjacent to metropolitan Rural nonadjacentcounty

Age, gender, education, income, race/ethnicity, insurance coverage, primary care physicians/1000 population, census region

High Colon cancer screening for 

women and men age ≥50 (+); U>all RCervical cancer screening for women age > 18 (+); U>all RMammogram for women age ≥50 (+); U>non-adjacent R

mears), 

aphy)

county of 

n with 

tus, ≥18 

ysterectomy

men with 

phy screen

ng Alaska, 

 Columbia

Behavioral Risk Factor Surveillance System (BRFSS) 2002Area Resource Files (ARF) 2004Census 2002

US Department of Agriculture (USDA) RUCC collapsed to 3 levels: rural, suburban, metropolitan

Individual-level covariates (e.g., age, race, marital status, education, income, employment, health insurance, health status) and contextual covariates (e.g., residence, number of health centers per population, number of physicians per population)

High Pap test in counties with <300 

primary care providers per 100,000 women (+); U>R, U>SPap test in counties with 300-500 physicians per 100,000 women (+); U>SMammogram (+); U>R, S>R

d 37,847 

rs

Behavioral Risk Factor Surveillance System (BRFSS) 1998-1999

USDA RUCC collapsed to 3 levels: rural, suburban, metropolitan

Race/ethnicity, age, gender, education, health insurance, visit to physician in past year, health profile, shortage area

High Fecal occult blood test in past 

year (+); U>R, S>RSigmoidoscopy or colonoscopy in past 5 years (+); U>R

n, age ≥ 40 

y and clini

tion)

, age ≥ 18 

of hyster

g)

Behavioral Risk Factor Surveillance System (BRFSS) 1998-1999

USDA Beale Codes collapsed to 3 levels: metropolitan, suburban, rural

Age, gender, race, education, number of people in household, health status, visit to physician in past year, marital status

High Mammogram in past 2 years 

(+); U>R, U>S, S>RPap test in past 3 years (+); U>R
68

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 952 con

ace, age, 

ges 50-80 

confirmed 

inoma of 

Interviews (face-to-face) 1996-2000Response: 72% (cases), 62% (controls)

U.S. Census Bureau 1990 standardsUrban: Metropolitan Statistical Area (1 city with ≥50,000 or total metro area of ≥100,000)Rural: non-metropolitan

Age, race, gender, education, poverty index, recent colorectal cancer screening

Moderate Colon cancer screening (NR); 

U>R#

#Unadjusted analysis

breast or 

diagnosed 

utionalized, 

Behavioral Risk Factor Surveillance System (BRFSS) 1996-97Surveillance, Epidemiology, and End Results (SEER) 1991-95Response: 39%

Based on number of residents per square mile; 5 levels <20, 20-29, 30-39, 40-99, or 100 or more res/mi2; urban=more 

than 100 res/mi2

Breast cancer screening model: income, having health insuranceCervical cancer screening model: education, age, income, having health insurance

Moderate Breast cancer screening (+); 

U>RCervical cancer screening (+); U>R 

 enrollee 

g in house

Medicare Current Beneficiary Survey (MCBS) 1993

1993 Urban Influence Codes (UIC); 9 categories collapsed to 5 for this study

Age, gender, race, Medicaid status, income, education, living arrangement, health status, functional status, provider supply

Moderate Mammogram in last year (-) 

(except rural county with city of >10,000 < urban)Pap test in last year (-)

ears), 2,729 

,051 (flu 

d all three 

 3 years 

rs, mam

ears for 

flu shot in 

e ≥65 yrs 

U.S. National Health Interview Survey (NHIS) 1994Response: 80% 

Metropolitan Statistical Areas (MSA); urban county is within MSA; rural is all other non-metropolitan counties

Education, household income, health insurance status, Census region

Moderate Pap smear (-)

Mammogram (-) 

n

al; F=Frontier; S=Suburban; (+)=difference statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
69

lth Care: A Systematic Review Evidence-based Synthesis Program

cer Care

 (Sample 

xclusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

pancreatic), 

l or pancre

Pennsylvania Department of Health, Bureau of Health Statistics Research 2000-05US Census Bureau 2000American Medical Association Physician-Related Data Resources

US Census Bureau; grouped 67 counties into 22 Workforce Investment Areas (WIA); rurality variable was % of a WIA population that was rural

Age, gender, insurance status, education, poverty status, race, number of physicians per 100,000, ratio of oncology physicians to primary care physicians

Low Later stage at diagnosis:

Pancreatic (+); U>RColorectal (-)

r 57% rural)

cally 

cancers of 

m, lung, or 

rs, resided 

re physi

ral study 

e English, 

eeks of 

on (Minne

chigan)

Health Care Records 1992-97 U.S. Census 

Bureau 

Age, oncology consultation Low/

Moderate

Proportion of cases staged at diagnosis:(+); U>R for breast, non-small cell lung, and prostate cancer(-); colorectal and small cell lung cancerStage at diagnosis:

(+); R>U for breast, colorectal, and non-small cell lung cancer(-); small cell lung or prostate cancerInitial management score:(+); R<U for all cancersClinical trial participation:(+); R<U for colorectal and prostate cancerSurveillance testing score:(+); R<U lower breast and colorectal cancer (-); for lung and prostate cancer 

ases

cancer 

cer site)

Mississippi State Department of Health Central Cancer Registry and Division of Vital Statistics 1996

Census data: county with more than 50% rural designated as rural

Age Moderate Cancer incidence (-)

Cancer mortality (-)

Cancer staged at diagnosis :(+); U>R, all sites(+); U>R; women(+); U>R; African Americans (except lung cancer)Advanced stage at diagnosis (+); R>U all sites and lung cancer
70

lth Care: A Systematic Review Evidence-based Synthesis Program

 (Sample 

xclusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 952 con

ace, age, 

ges 50-80 

confirmed 

inoma of 

Interviews (face-to-face) 1996-2000Response: 72% (cases), 62% (controls)

U.S. Census Bureau, 1990Urban: Metropolitan Statistical Area (1 city with ≥50,000 or total metro area of ≥100,000)Rural: non-metropolitan

Age, race, gender, education, poverty index, sampling probabilities

Moderate Colon cancer stage at diagnosis (-)

a complete 

data, resi

oma 

raska Lym

p (Nebras

 states)

University of Nebraska Medical Center Oncology Database 1982-2006

Rural-Urban Commuting Area code; collapsed to 2 categoriesProviders classified as universityor communitybased

Median household income, distance traveled, year of treatment

Low/Moderate

Risk of death (-); risk greater for rural community treated patients than urban or rural university treated patients; in high-risk subgroup risk higher for all groups relative to urban university treated Advanced treatment (-); use was higher in Universitytreated compared to community treated regardless of residenceDeath from primary lymphoma (+); R>U

olorectal, 

ncer; 

Illinois State Cancer Registry 1998-2002Surveillance, Epidemiology, and End Results (SEER) staging data

Rural-Urban Commuting Areas: modified to create Chicago city, Chicago suburb, other metropolitan, large town, and rural

Multiple models1) unadjusted2) age, race3) socioeconomic and access variables based on zip code

Moderate Risk of late stage diagnosis:

Model 1 (+); city > all other regions for all 4 cancers (except lung cancer in suburb)Model 2 (+); city > all other regions for colorectal, breast (except city similar to most rural), and lung (except city similar to suburb) cancers; city > suburb (only) for prostate cancerModel 3 (+); city >other metro and large town for breast, city > large town for colorectal, and city >all regions except suburb for lung cancers
71

lth Care: A Systematic Review Evidence-based Synthesis Program

 (Sample 

xclusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

us Medic

wly started 

itor or 

e receptor

ge I-III 

ed adjuvant 

rapy during 

yrs, white or 

Linked North Carolina Central Cancer Registry-Medicaid Claims data 2000-04

US Census Bureau and US Department of Health and Human Services- urban or rural

Tumor size, type of surgery, race, type of provider and practice setting, admitted to hospital, admitted to nursing facility, receiving home health care, age

Low/Moderate

Treatment with aromatase inhibitors (+); U>R

ectal), 

 (≥20 yrs) in 

th primary 

ancer 

Surveillance, Epidemiology, and End Results (SEER) database (National Cancer Institute), 2000-03

Rural-Urban Continuum Codes (RUCCs) – 9 levels collapsed to:rural (levels 7 and 9) or urban (levels 1 to 3)

Age, race, language isolation, gender, marital status, income

Moderate Unstaged cancer rates:

Colorectal (+); R>ULung (+); R>U#

Stage IV at presentation:Colorectal (+); U>RLung (+); U>R#Unadjusted analysis

colorectal 

s, no miss

Nebraska Cancer Registry 1998-2003 Surveillance, Epidemiology, and End Results (SEER) staging data

Office of Management and Budget (OMB) 2003 definitions: urban metropolitan, micropolitan nonmetropolitan, rural nonmetropolitan

Age, gender, race/ethnicity, marital status, education, income, insurance, anatomic site

Moderate/High

Early stage at diagnosis (+); Micropolitan>R (metropolitan no different from rural)

breast or 

diagnosed 

utionalized, 

Behavioral Risk Factor Surveillance System (BRFSS) 1996-97Surveillance, Epidemiology, and End Results (SEER) 1991-95Response: 39%

Based on number of residents per square mile; 5 levels <20, 20-29, 30-39, 40-99, or 100 or more res/mi2; urban=more 

than 100 res/mi2

Age Moderate In situ breast cancer rate (NR); 

R<UInvasive cervical carcinoma (NR); R>UBreast or cervical cancer mortality (-)

] rural)

all ages, 

mary mi

med DCIS 

 with breast 

s and 5 

Surveillance, Epidemiology, and End Results (SEER) programArea Resource File (ARF)

Metropolitan Statistical Area SEER registry, year of diag- nosis Moderate Receipt of radiation therapy: Age <65 yrs (+); R<U

Age 65+ (-)
72

lth Care: A Systematic Review Evidence-based Synthesis Program

 (Sample 

xclusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 urban, 

9% small 

 rural)

usly en

neficiaries, 

osed can

r 1995-99

 in man

ge renal 

 Medicare 

wide 

SEER data linked to Medicare claimsArea Resource File 

Rural-urban commuting area (RUCA codes) – 30 codes collapsed to 4 categories: urban, large rural city, small rural town, isolated small rural town

Gender, race/ethnicity, age at diagnosis, median ZIP code income, comorbidities, number of subspecialists, number of hospitals, residing in health professional shortage area, residing in census tract with >15% non-fluent English speakers

Moderate Mortality (-)

Unstaged at diagnosis (-)Stage at diagnosis (-)Number of subspecialists (+); R<UReceipt of radiation therapy (trend); R<U

n

al; F=Frontier; S=Suburban; (+)=difference statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
73

lth Care: A Systematic Review Evidence-based Synthesis Program

betes/End Stage Renal Disease (ESRD)

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

abetes, two 

eir clinic in 

 (Rural = 

Medical records of patients seen in clinics between January and August 2001Data collection took place AugSept 2001 in Rural clinic; and Feb-March 2002 in urban clinic

Not defined other than rural family practice clinic was a “physician-owned private family practice clinic with one physician provider” and urban internal medicine clinic included five physicians specializing in internal medicine and one physician specializing in endocrinology

None Very Low Preventive care consistent 

with American Diabetes Association guidelines (NR); R<U#

Blood pressure, lipid, and HbA1c goals met (NR); R<U#

#Unadjusted analysis

n, ≥20 

onalized, 

ANES III: 

xamination, 

 files

participate 

the survey

Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994

Urban: MSARural: Non-MSA

Gender, age, BMI, perceived health status, income, insurance status, education, usual place of care, # times seeing physician in past year, duration of diabetes

Moderate Undiagnosed diabetes (-)

Uncontrolled BP (+); RHispanics>UHispanicsGlycemic control (-)Cholesterol control (-)

51)

)

nd older

Behavioral Risk Factor Surveillance System (BRFSS) 2001-2002; Medical Expenditure Panel Survey (MEPS) 2001-2002.

Urban: MSARural: Non-MSA

Age, BMI, insurance coverage, gender, race/ethnicity, education, region of country, income, personal physician

Moderate/High

Prevalence of diabetes (+); R>UCompliance with diabetes care guidelines for eye exam, foot exam, diabetes education 

(+); R<U based on BRFSS (-); based on MEPS (eye and foot exam only)Compliance with guidelines for 

HbA1c test (-)
74

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 with 

2005 national Veterans Health Administration cardiometabolic quality of care random sample chart review SMITREC: VA Serious Mental Illness Treatment and Evaluation Center

RUCA categoriesRUCA 1: urbanRUCA 2: large rural city/townRUCA 3: small/isolated rural town

Mental disorder diagnosis, RUCA (1-3), age, gender, race (black/non-black), marital status, substance abuse diagnosis, Charlson comorbidity index score, # VA outpatient visits, # visits to a VA community-based outpatient clinic, VA cost share category

Moderate/High

LDL, foot exams, eye exams, renal testing, HbA1c, blood pressure (-)

,363 dialy

dialysis 

d 12/31/02 

ays without 

U.S. Renal Data System2000 U.S. CensusCMS Dialysis Facilities Compare database

Rural-Urban Commuting Area Codes (RUCA):Urban areaLarge Rural AreaSmall Rural AreaRemote, Small Rural Area

Age, gender, comorbid conditions at start of dialysis, dialysis modality at 90 days; ZIP code per capita income and % >25 yrs with high school diplomaStratified for race/ethnicity

High Survival (+); all R white 

non-Hispanic > U white nonHispanic; remote small R white Hispanic < U white Hispanic; small R and remote small R black > U blackTime to kidney transplant (+); all R white non-Hispanic > U white non-Hispanic; large R and small R black < U black; remote small R Native American > U Native American

r-service 

us cover

years, alive 

94, 2+ phy

or diabetes 

edical care 

Medicare Part B claims data 1994

RUCA subset:UrbanAdjacent Large RuralRemote Large RuralAdjacent SmallRemote Small

Sociodemographic factors, comorbidities, provider specialty

Moderate Glycated hemoglobin test (+); 

Adjacent large R<all other locations(+); Large remote > all others

681 ZIP 

 by ZIP)

 years, 

d-stage re

) attributed 

somal domi

ey disease 

o 6/30/04, 

U.S. Renal Data System*, 2000 U.S. Census, California Office of Statewide Health Planning and Development*, U.S. Dept of Health and Human Services Health Resources**1/1/01 to 6/30/04

U.S.D.A RuralUrban Commuting Area Codes; 10 levels collapsed to rural (codes 9, 10) or urban (codes 1-8)

Socioeconomic status (income, proportion with income <200% of poverty level, house value, rent, education, % college graduates), insurance status, hospitalization for hypoglycemic events, rural location

Low Annual incidence of ESRD 

attributed to diabetes (-)Annual incidence of ESRD attributed to autosomal dominant polycystic kidney disease (-)
75

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ervice 

ries with 

75, enrolled 

 with ≥23 

us Part 

atient or 

2 outpatient 

nal diabe

asurement 

CMS National Diabetes Database (Part of Medicare Health Care Quality Improvement Program) 1999-2001Participants identified from Part A and Part B claims data

County codes from the Federal Information Processing Standards; based on urban-rural continuum codes – 9 codes collapsed to 3: Urban, Semi-rural (adjacent to metropolitan area), Rural (not adjacent)

Race (white/non-white), ethnicity (Hispanic/nonHispanic), states (Census divisions)

Low Indicator rate* 

A. in 10 top performing states (many in northern and eastern regions of US): 1 of 10 SR<U, 3 of 10 SR>U; 2 of 10 R<U, 2 of 10 R>U B. in 10 lowest performing states (many in south): 9 of 10 SR<U, 1 of 10 SR>U; 7 of 10 R<U, 1 of 10 R>U*Indicator rate = Annual HbA1c measurement; Biennial lipid profile; Biennial eye exam

n

l; (+)=difference statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
76

lth Care: A Systematic Review Evidence-based Synthesis Program

diovascular Disease 

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

s old, seen 

he study 

emic medi

ommunity 

us year

Medical record review; randomly selected charts to include 50 patients with cardiovascular disease (CVD) (25 Hispanic, 25 non-Hispanic white) and 50 without CVD from each site

Not defined other than “urban academic medical center”, “rural community clinic”

Age, gender, hypertension, diabetes, dyslipidemia, smoking status

Low Standard medications for 

treatment of CVD (+); U>R#

Cholesterol lowering medications (+); U>R#Attainment of blood pressure goal (+); U>R#Attainment of LDL goal (-)#

#Unadjusted analysis

rom tertiary 

 31 coun

primary 

l or surgical 

ognitively 

rged to 

Patient medical records; phone survey post-discharge to 20 weeksSurvey Response: 32/50 completed all five surveys (60%) 

Pennsylvania Dept of Aging Rural Services Task Force seven designations:Philadelphia, Allegheny, urban, suburban, semi-urban, semi-rural, and rural (based on population density and proximity to major metropolitan area)

Age, gender, marital status, education, number of hospitalizations, severity of illness

Very Low Number of medications at discharge and during follow-up 

(+); U>R with more fluctuations in medications in urban patientsNumber of cardiac medications at discharge and during follow-up (+); U>RGeneral Health SF-36 scale (NR); R improved over time, U decreased over time

completed 

 encounter, 

with type 2 

orado (13 

Provider questionnaire, June 2003-May 2004Response: not stated

Rural: community of fewer than 25,000 residents at least 32 km (20 mi) from a major metropolitan center

Age, gender, race, ethnicity, BP (near goal or uncontrolled), practice level, communication problems, income level, number of prescription medications

Moderate Provider taking action if BP 

was poorly controlled (-)Number of medications (+); R>U

t, diag

 (100 from 

an, and a 

Medical record review; consecutive sample Not defined other than “urban university family practice 

center”, “suburban residency practice”, “rural private practice” clinics

Age, race, gender, number of medications, number of visits in past 12 months, comorbidities

Very Low Blood pressure control (+); 

R>U
77

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 with hyper

tely 1/3 with 

D])

2005 national Veterans Health Administration cardiometabolic quality of care random sample chart review SMITREC: VA Serious Mental Illness Treatment and Evaluation Center

RUCA categoriesRUCA 1: urbanRUCA 2: large rural city/townRUCA 3: small/isolated rural town

Mental disorder diagnosis, RUCA (1-3), age, gender, race (black/non-black), marital status, substance abuse diagnosis, Charlson comorbidity index score, # VA outpatient visits, # visits to a VA community-based outpatient clinic, VA cost share category 

Moderate/High

Blood pressure control (-)

n

 statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
78

lth Care: A Systematic Review Evidence-based Synthesis Program

AIDS

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

al)

ted adults 

from Janu

996

States

HIV Cost and Services Utilization Study (HCSUS) 1996; rural component

Urban: MSA or New England county metropolitan areasRural: non-MSAOffice of Budget and Management, 1992

Age, gender, race, ethnicity, risk group behavior, education, insurance, household income, region of care, CD4 count, HIV provider type

Moderate/High

Appointments with providers caring for more HIV-infected patients (+); urban care > rural care#

Use of pneumocystis carinii pneumonia medication (+); urban care > rural care#Use of highly-active antiretroviral therapy (HAART) (+); urban care > rural care

s, attended 

ent at a 

lina HIV 

2000 and 

d States 

th Carolina)

Patient medical records from the University of North Carolina HIV outpatient clinic

Rural: MSA with < 50,000 inhabitants 

Age, gender, race/ethnicity, insurance status, distance to clinic, clinical AIDS diagnosis, CD4 cell count, time since entry into HIV care

Moderate Average number of clinic visits 

per year (-)#

nts

cted adults, 

 sampled 

n early 

s seen by 

mergency 

rs 

States

HIV Cost and Services Utilization Study (HCSUS) 1996American Medical Association MasterFile of physicians

Urban: MSARural: non-MSAOffice of Budget and Management, 1992

Age, gender, race/ethnicity, risk group, clinical stage, annual income, insurance status, CD4 count

Moderate 73.6% of rural residents 

received HIV care in urban setting#

Older patients more likely to receive care in rural area (+)#

s

esidents of 

nd older at 

hose cases 

2/31/90

Centers for Disease Control and Prevention (1983-1990)Office of Vital Statistics (Georgia), March 1991

Metro Atl: residents of 8 counties of metropolitan Atlanta Other Areas: residents of remaining counties

Race, mean age, mode of infection

Very Low Median survival time (+); 

Metro>Other#

Probability of surviving 90 days (+); Metro>Other#

n

 statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
79

lth Care: A Systematic Review Evidence-based Synthesis Program

rologic Conditions

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

of the Na

rosis (MS) 

Phone interview, Oct 2004 – Jan 2005Response: 31% 

Urban: Metropolitan Statistical Area (MSA)Adjacent Rural Area: <50 miles from MSAMore Remote Rural Area: >50 miles from MSA

None Very Low Saw neurologist in past year 

(+); U>MRR#

Wanted to see neurologist but did not (+); MRR>U, AR>U#Majority of MS care from primary care physician (+); MRR>U#

of the 

clerosis 

Phone interview, Oct 2004 – Jan 2005Response: 31%

Urban: Metropolitan Statistical Area (MSA)Adjacent Rural Area: <50 miles from MSAMore Remote Rural Area: >50 miles from MSA

None Low/

Very Low

Taking disease-modifying medications (+); U>MRR#

Discontinued disease-modifying medications because of other medical side effects(+); AR>U#Discontinued disease-modifying medications because of out-of-pocket expense (+); AR>U#

of the 

clerosis 

Phone interview, Oct 2004 – Jan 2005Response: 31%

Urban: Metropolitan Statistical Area (MSA)Adjacent Rural Area: <50 miles from MSAMore Remote Rural Area: >50 miles from MSA

None Very Low Need for mental health care 

in past 12 months (+); AR<U, MRR<U#

No insurance coverage for mental health care (+); AR>U, MRR>U#No providers in area or too far to visit (+); AR>U#

 or county 

ngle state 

rged to 

 >50,000)

unties or 

Alaska, 

es with 

definitions 

2000

Numbers of rehabilitation therapists (physical [PT] or occupational [OT] therapists, speech-language pathologists [SLP]) from 1980 and 1990 ARF and 2000 EEOHealth Professional Shortage Area Data

US Office of Management and Budget (OMB) – metropolitan (metro): central county with ≥1 urbanized area and outlying counties economically tied to core county 

None Moderate/

High

PTs, OTs, or SLPs per 100,000 residents (NR); U>R#

PTs, OTs, or SLPs per 100,000 residents (NR); Non-shortage area > partial or total shortage area#
80

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

f provid

eople with 

ry

U.S. Census Bureau, 2000; Office of Social and Economic Data Analysis, 2000; Rural Policy Research Institute, 2000; Missouri State Board of Registration for the Healing Arts, 1999; American Board of Professional Psychology; Missouri Brain Injury Association, 2000

Office of Management and Budget (OMB) designations of Metropolitan and Non-metropolitan(MSA or non-MSA)

None Moderate/

High

Physicians (NR); U>R#

Physiatrists (NR); U>R#Nurses (NR); U=R#Rehabilitation Therapists (NR) U>R#Mental Health (NR); U>R#

ge 18+ 

ained July

Survey sent to persons identified through the Iowa Central Registry for Brain and Spinal Cord Injuries, January, 1998Response: 57.4% (292 is subset – those 18 years and older)

Population density (residents/square mile) – 5 levels<20, 20-29, 30-39, 40-99, 100+

Injury severity, age, gender, type of respondent (injured person vs. proxy), inability to see a doctor because of cost

Low Functional dependence (+); 

most urban > non-urbanPerceived need for services (-)

n

emote Rural; AR=Adjacent Rural; (+)=difference statistically significant; (-)=difference not statistically significant; (NR)=significance not reported
81

lth Care: A Systematic Review Evidence-based Synthesis Program

tal Health

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

scharged 

iatric 

 community 

ers (CMHC, 

in 1992

Questionnaire (completed by CMHC staff), 1992Inpatient DatabaseQuestionnaire completion rate: 97% (94% linked to database)

State mental health authority definition - rural is <120 people/sq mi

None Moderate Continuity of care (+); R>U 

as indicated by a. CMHC had record of discharge, b. CMHC contacted patient during hospitalization, c. patient and CMHC had contact after discharge, d. CMHC provided face-to-face services, and e. composite score#

#Unadjusted analysis

% rural; 

67, schizo

alth service 

vailable for 

Interviews with patients (consumers) and family, friends, or providers who knew patient well (informants) 1992-99

Office of Management and Budget – Urban: Metropolitan Statistical Area (MSA)Rural: non-MSA

Insight into illness, cognitive functioning, age, gender, ethnicity

Moderate Irregular vs. regular outpatient 

mental health service use (+); R>UComorbid substance abuse effect on mental health service use (+); less effect on patients with family support at least weekly

 (4,373 

nt in mental 

se manage

gram

Clinical process assessments by MHICM staff after veteran’s 1st 6 months in MHICM program, FY2000-FY2005

VA Outpatient Encounter File

Rural-Urban Commuting Codes – 4-groups: urban (U), large rural city (LR), small rural town (SR), or isolated rural (R) community 

None Moderate Patient contact (+); R<U#

Receipt of services (+); all R<UPsychotherapy, substance abuse treatment, crisis intervention, medication management, screening or care for medical problems, rehabilitation, vocational support, housing support #

#Unadjusted analysis

month 

screened 

sion (tele

ed, manic, 

lifetime 

face-to-face 

Telephone and face-to-face interviews 1992-93Response: 85% of eligible after face-to-face interview with complete data (interview at 1 yr)

Urban: Metropolitan Statistical Area (MSA)Rural: non-MSA

Age, gender, education, health insurance, marital status, minority status, income, recent manic symptoms, severity of depression, previous psychiatric hospitalizations, recent drug/alcohol problems, psychiatric co-morbidity, physical condition

Low During 12 month follow-up:

a. any non-acute mental health service (-)

b. seen in general medical setting only (+); R>Uc. any acute services for physical or mental health (+); R>Ud. suicide attempt (-)e. manic episode (+); R>Uf. depressive symptoms (-)
82

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 depression 

ons, age 

e 

Statewide Inpatient Database (SID), 2000Census BureauDept. of AgricultureHealth Resources and Services Administration

Urban Influence Codes (UIC) – 12 categories 

Ethnicity, poverty level, education, income, employment, housing stress, county economy source, number of providers, number of hospital beds, penetration rate of HMOs, shortage area, geographic location

Low/Moderate

Hospitalization rate (+); most U>all other UIC categories (5 comparisons were significant)

7 schizo

pitalizae

Statewide Inpatient Database (SID), 2000Census BureauDept. of AgricultureHealth Resources and Services Administration

Urban Influence Codes – 12 categoriesU.S. Office of Management and Budget – MSA/nonMSA

Ethnicity, poverty level, education, income, employment, housing stress, county economy source, providers, hospital beds, penetration rate of HMOs, shortage area, geographic location

Low/Moderate

Hospitalization rate (+);most U>all other UIC categories (8 comparisons were significant)

470 with 

6 months 

view, com

provider in 

t 1999)

See Rost 1999Records from providers, insurers, and pharmacies identifiedGeocoded addresses for travel time

Used travel time Age, gender, ethnicity, 

employment status, education, severity of depression, physical and psychiatric comorbidities, insurance coverage, treatment sector

Low/Moderate

Number of visits (+); increased travel time associated with fewer visitsGuideline concordant treatment (+); increased travel time associated with reduced odds of guideline concordant treatment

al)

care 

ssion 

hrenia and 

2 studies in Quality Improvement for Depression database (through 1999): 1) Partners in Care (PIC), 46 practices (3 rural), 5 states (35% agreed to participate; follow-up 89% at 2 yr)2) Quality Enhancement by Strategic Teaming (QuEST), 12 practices (4 rural), 10 states (73% agreed to participate, follow-up 70% at 2 yr)

Practices designated as urban (MSA) or rural (non-MSA)

Age, gender, minority status, education, marital status, employment, depression, psychiatric or physical comorbidity, antidepressant use, social support, stressful life events

Low Baseline characteristics:

a. use of outpatient care (specialty, medical) - past 6 mos (-)#

b. antidepressant use -past 6 mos (-)#c. any hospitalization - past 6 mos (-)#Hospitalization for physical problems in 6 months after baseline (+); R>U whether or not they received specialty care during those 6 months Hospitalization for emotional problems (+); R>U at 18 months#Unadjusted analysis
83

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 of original 

data

screened 

sion (both 

-to-face 

eaved, 

uicidal

Telephone and face-to-face interviews 1992-93Response: 74% of eligible after screening agreed to faceto-face interview; 92% with complete data

Census data 1990, rural defined as non-metropolitan

Age, gender, education, health insurance, marital status, minority status, employment status, income, living alone, health insurance, severity of depression, physical and psychiatric comorbidity 

Moderate Any outpatient treatment for 

depression (-)Type of outpatient treatment for depression (-)Quality of outpatient depression treatment (-)Outpatient specialty care visits for depression (+); R<U

Outpatient general medicine visits for depression (-)Change in depression severity (-)Hospitalization for physical problems (+); R>UHospitalization for mental health problems (-)

See Rost, 1999 Census data 1990, 

rural defined as non-metropolitan

See Rost, 1999 Moderate Outpatient services for physical 

problems (-)Outpatient services for mental health other than depression (-)

Hospitalizations for physical or mental health problems 1-6 months after baseline (+); R>UHospitalizations in months 7-12 (-)Suicide attempts (+); R>U

PTSD)

52 rural)

gnosed 

tient clinic

d States

Medical chart review (date not reported)

U.S. Census data 1990

Service use adjusted for distance and driving time

Very Low Service use (PTSD clinic, 

primary care, and specialty care visits) within 1 year after initial PTSD evaluation (-)Dissociative Experiences Scale score (+); R>UMMPI-2 clinical scales (-)
84

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

dult drink

DSM-IV 

abuse or 

past year 

meeting 

criteria in 

 (AL, AR, 

Telephone interviewResponse: 76% (baseline); 90% and 82% of baseline completed interview at 6 and 12 months, respectively

Census Bureau definitions of MSA; rural is non-MSA

Gender, ethnicity, age, income, health insurance, average time to provider, days to see MD for advice about drinking, acceptability of treatment, social support, alcohol abuse (past 6 months), alcohol dependence (past 6 months), lifetime drug use, Axis I DIS diagnosis (past 6 months), antisocial personality disorder, social consequences of drinking, negative life events, chronic medical problems, prior treatment for alcohol problems

Moderate/High

Twelve month alcoholism treatment use (-)

+) male 

g inpatient 

nt at VA Al

Treatment 

TPs

VA Patient Treatment File, 1987

Small community (outside an MSA); metropolitan area (MSAs with < 3 million inhabitants);large metropolitan area (MSAs with > 3 million inhabitants)

Distance to VA medical center, age, marital status, illness severity, race

Moderate Attendance at outpatient appointment for alcoholism treatment 30 days after discharge 

from inpatient ADTP (+); small community > metropolitan, large metropolitan < metropolitan

utionalized 

National Longitudinal Alcohol Epidemiological Survey, 1992Response: 97.4% (person); 91.9% (household)

Not provided Gender, age, ethnicity, 

education, marital status, family history of alcoholism, past alcohol disorder and treatment, health insurance, employment, income, children < 14 at home, spouse/partner with alcoholism, onset and severity of alcoholism, daily alcohol intake, major depression, comorbid drug use disorder; illicit drug use in past year 

Moderate Odds of entering treatment in 

the past year for drinking-related problems (-)
85

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 self

≤30 days 

 no active 

days prior 

: Miami 

alee (rural)

In-person interviewResponse: not reported

Not definedImmokalee characterized as an unincorporated area known for agriculture and cattle industries

None Low/

Moderate

Ever in drug-user treatment (+); U>R#

Length of prior treatment (+); U>R#Treatment in past 24 months (+); U>R#Attempted but unable to get treatment in past 12 months (+); U>R#Of those using treatment, use of outpatient treatment (-)#

#Unadjusted analysis

o used an 

 the past 

 non-institu

residential 

National Household Survey on Drug Abuse, 1991Response: not reported

Rural defined as places with <2,500 inhabitants outside of or not next to urban areas (1980 Census)3 residential types: metropolitan-rural (rural area within MSAs); non-metropolitan-rural; nonmetropolitan-urban 

NONE???? For this outcome Low 5.6% of nonmetropolitan-rural drug users sought treatment 

compared with 6.6% of the remaining respondents

ers (coun

ouped with 

es)

ies)

California Departments of a. Health Service, Center for Health Statistics, 1993-2001 (odd years)b. Finance (population data)c. Consumer Affairs (providers)

U.S. Census Bureau; urbanicity of county based on proportion of county residents living in an urbanized area or town with population of ≥2,500

Age Low Suicide rate (+); R>U

Interaction between urbanicity and number of providers (-) (no association with suicide rate)

uals who 

National Vital Statistics (CDC) 1996-98 (suicide rates)IMS Health, Inc (antidepressant medication prescriptions)

Based on county population

Model 1: Age, gender, raceModel 2: Added incomeModel 3: Added county mean drug prescription for each class of drugs

Low Suicide rate (NR); smaller population counties>larger population counties

Ratio of non-tricyclic antidepressants to tricyclic antidepressants (NR); larger population counties>smaller population counties
86

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

on-institu

s

Medical Expenditure Panel Survey (MEPS), 1996-2000 dataResponse: 73%-78% (varied by panel)

Rural-Urban Continuum Codes 1994; collapsed to metropolitan, non-metropolitan least rural, or non-metropolitan most rural

Gender, age, income-toneeds ratio, schooling, geographic region, mental health, physical health, marital status, number of children, usual source of care, insurance type, year

Moderate Any mental health visit (+); 

U>most R and least R>most R for womenSpecialized mental health visit (+) U>most R for women and men 

on-institu

non-His

 American, 

Medical Expenditure Panel Survey (MEPS) 1996-2000 dataResponse: 73%-78% (varied by panel)

Rural-Urban Continuum Codes 1994; collapsed to metropolitan, non-metropolitan least rural, or non-metropolitan most rural

Self-reported mental and physical health, gender, age, education, employment status, marital status, income-to-needs ratio, health insurance

Moderate Receipt of any mental health 

service:(+); African American < nonHispanic white in any location(+); Mexican American < nonHispanic white, urban and least rural non-MSA onlyReceipt of specialty mental health service:(+) African American < non-Hispanic white in urban and least rural locations(+) Mexican American <nonHispanic white in Urban location only

of any 

ment during 

an, non

-64 yrs

Medical Expenditure Panel Survey (MEPS) 1996-98 dataResponse: 78%

Rural-Urban Continuum Codes 1993; collapsed to metropolitan or nonmetropolitan

Gender, race/ethnicity, age, education, employment status, marital status, income-to-needs ratio, health insurance, mental health, physical health

Moderate Any or specialized mental 

health visit:

(+); U>R if reported mental health was good or fair#

(-) if reported mental health was poor#Mental health care use (-); trend for U>REver hospitalized in calendar year (-)Ever saw a medical doctor (-)Primarily saw a medical doctor (-)#Unadjusted analysis
87

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

wed)

, English 

National Comorbidity Survey Replication (NCS-R), 2001-2003 (face-to-face interviews)Response: 71%

U.S. Census Bureau, 2000; large (≥ 2 million) and small central city, large (≥ 2 million) and small suburbs or central city, adjacent area, rural area

Age, gender, race/ethnicity, education, marital status, family income, health insurance

Moderate/High

Odds of receiving any mental health treatment in prior 12 months (+); rural<all non-ruralOdds of receiving specialty mental health treatment in prior 12 months (+); rural<all nonrural except suburb <2 millionMental health treatment adequacy:(+); rural>all non-rural for mental health specialty treatment

(-); any service use, general medical, and non-health care treatment

n

 statistically significant; (-)=difference not statistically significant; (NR)=statistical significance not reported
88

lth Care: A Systematic Review Evidence-based Synthesis Program

 of Medication

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

mitted to a 

enter for 

riteria: 1) 

medical 

condi

gnosis; 3) 

) being 

spital

Medical records and telephone interviewsResponse rate: 50%

Seven-level county designations established by the Pennsylvania Department of Aging Rural Services Task Force merged into two categories (i.e., rural vs. urban)

Age, gender, severity of illness

Low Number of medications (+); 

U>R 

der who are 

or white

orth Caro

Duke Established Populations for Epidemiologic Studies of the Elderly, 1986-1987Response rate: 80.3% (black); 87.2% white

U.S. Census Bureau Definition Gender, marital status, age, education, functional status, 

medical status, self-rated health, number of medical visits in past year, continuity of care, overnight hospitalization in past year, insurance status, income

Low/Moderate

Medication use - elderly whites (+);U>RMedication use - elderly blacks (-)

der who are 

white

orth Caro

Duke Established Populations for Epidemiologic Studies of the Elderly, 1986-1987Response rate: 80.3% (black); 87.2% white

U.S. Census Bureau Definition Age, race, gender, education, functional status, number of 

functional limitations, chronic disease status, number of health visits in past year, hospitalization in past year, continuity of care, Medicaid status

Low/Moderate

Prescription medication use (+); U>RNumber of non-prescription medications (+); U>RUse of non-prescription medications (-)

he Penn

utical 

ct for the 

Claims data for PACE beneficiaries, 1984-1988; Medicare health services records; County-level demographic and health services resources databases

Human Resources Profile County Code from 1980 census data in Area Resource File (ARF; 10 levels depicting degree of rurality)

Age; gender; race; income; marital status; physicians, pharmacies, hospital beds, and nursing home beds per 1,000 population; outpatient physician visits; any physician visits, inpatient days, or any hospital day in past month

Moderate Monthly claims(-); HR, U
89

lth Care: A Systematic Review Evidence-based Synthesis Program

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 ages 66 

s covered 

ionalized 

1990 Elderly Health Supplement to the Panel Study of Income Dynamics (PSID), a nationally representative telephone/mail surveyResponse rate: 99% (telephone survey); 74%(mail survey)

Area Resource File (Department of Health and Human Services)

Age, gender, race, marital status, education, income, current health status, insurance status

Low Twelve-month medication use: 

(-)Prescription cost (+); U>R

 Medicare 

older

1997 Medicare Current Beneficiary Survey; 1996 Medical Expenditure Panel Survey

Rural: any place of residence not in a Metropolitan Statistical Area (MSA)

Insurance status Low/’

Moderate

Total drug expenditures (-)Prescriptions filled (+); R>Uninsured UPrescriptions filled (+): Insured R>insured U

 Medicare 

or older

Panel Study of Income Dynamics (PSID), 1990Response rate: 99% (telephone survey); 74% (mail survey)

Rural: any place of residence not in a MSA

Age, education, gender, race, marital status, income, insurance status, health status

Low Percentage of family income 

spent on medications (-)

 elderly

Telephone survey, 2000Response rate: 71% (phase 1); 89.3% (phase 2); 53.2% (both phase 1 and 2)

Urban (counties in MSA)Rural (counties outside MSA or population < 50,000)Frontier (counties with < 7 people/square mile)

Race, age, gender, employment, income, insurance, usual source of care, physical and mental health-related quality of life, several health beliefs

Low Odds of prescription drug use 

(-) R,U; (+) U>FUsual pharmacy (-) R,U; (+) U>Fe

n

al; F=Frontier; (+)=difference statistically significant; (-)=difference not statistically significant
90

lth Care: A Systematic Review Evidence-based Synthesis Program

dical Procedures and Diagnostic Tests

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 enrollees 

ge renal 

y an HMO

Health Care Finance Administration (HCFA) Medicare Part B Annual Data Beneficiary File, 1986HCFA Health Insurance Skeleton Eligibility Write-off File, 1986

Rural: living in a nonmetropolitan countyUrban: living in a metropolitan county

Age, gender Low Rurality and race interaction 

(+); white-black relative risks for services were higher in rural areas for 12 of 32 studied services (including 8 of 14 outpatient services)

neficiaries 

olled in 

Medicare Part B Annual Data File, 1990 Health Insurance Eligibility Write-off File, 1990

Rural areas are the non-MSA areas of states. Urban areas are subdivided into small MSAs (less than 250,000 inhabitants), large MSAs (250,000 to 3 million), and very large MSAs (3 million or more).

Age, race, gender Low Physician utilization (+); R<U 

(particularly consultations, psychiatric visits, emergency department visits, imaging services, and laboratory tests)

n

 statistically significant; (-)=difference not statistically significant
91

lth Care: A Systematic Review Evidence-based Synthesis Program

dical Appointments with Providers

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

espondents)

 years; 

ounties

 counties in 

Duke Established Populations for Epidemiologic Studies of the Elderly, 1986-1987Response rate: 80%

US Bureau of the Census: rural is county with fewer than 2,500 inhabitantsAlso classified counties as rural or urban

Race/ethnicity, self-rated health, the health index, age, gender, education, marital status, employment status, income, Medicare coverage, Medicaid coverage, private insurance 

Low/Moderate

Ambulatory care visits (-) 

are 

38 Commu

ent Clinics 

ent VA 

AMCs)

s from 16 

d Services 

Austin Automatic Center (AAC) outpatient file, 1995-1998

Comparisons focused on CBOCs vs. VAMCs

Age, gender, marital status, ethnicity, service-connected, percent service connected, VA service use in prior year

Moderate Primary care encounters (+); 

CBOC>VAMCSpecialty care encounters (+); CBOC<VAMCNumber of days to follow-up care for hospitalization or inpatient psychiatric treatment (-)

or 19% 

64

National Health Interview Surveys, 1999-2000Response: 81% (1999) and 83% (2000)

Urban: Metropolitan Statistical AreaRural: Non-MSA

Race/ethnicity, gender, age, region of residence, interview language, limitations in activities, self-reported health status, education, employment, family size, income, marital status, insurance

Moderate Health care use in past 12 

months (-) (within urban and rural, minorities less likely to have visit (+))

utionalized 

nd older

National Health Interview Survey (Supplement on Aging), 1984

Four categories: Metropolitan central city residents (within SMSAs); metropolitan noncentral city residents; nonmetropolitan nonfarm residents (outside SMSA); nonmetropolitan farm residents

Age, gender, ethnicity, marital status, education, health status, limitations in activities of daily living, living arrangement, poverty, region of U.S., bed disability days

Moderate Physician visit in past year (+); 

non-metro<metro
92

lth Care: A Systematic Review Evidence-based Synthesis Program

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

18+ in sec

ws

data for 

riables, or 

utionalized, 

 country in 

Medical Expenditure Panel Survey, 1996

Nine-category Urban Influence Codes: Large MSA with 1million or more; small MSA with less than 1 million; adjacent large MSA with city of 10K or more; adjacent large MSA with city less than 10K; adjacent small MSA with city of 10K or more; adjacent small MSA with city less than 10K; not adjacent with city of 10K or more; not adjacent with city between 2.5-10K; non-adjacent with no town more than 2.5K 

Gender, ethnicity, education, age, insurance, family income, self-reported health, priority condition, limitations in activities of daily living or instrumental activities of daily living, physician availability, region, has usual source of care

Moderate Any ambulatory care visit (+); 

adjacent large MSA (with city <10k or > 10k) < MSA with ≥ 1millionAny ambulatory care visit (-): most rural vs. most urbanNumber of ambulatory care visits (+); most rural < large MSA

are pa

e of 108 

Outpatient 

nd/or one of 

cal Centers 

VA FY2000 Outpatient Care File; VA FY2000 Patient Treatment File; VA FY2000 and FY2001 Decision Support System Outpatient and Inpatient National Extracts

Compared VAMC patients, CBOC patients, and crossover patients

Age, gender, race, marital status, eligibility for free care, service-related disability, DCG risk score, distance to usual source of care

High Primary care visits (+); 

CBOC>VAMCSpecialty care visits (+); CBOC<VAMCTotal outpatient expenditures (+); CBOC<VAMC

s 55 and 

oved, could 

ed, or had 

evant 

National Center for Health Statistics’ Longitudinal Study of Aging, 1984-1986Area Resource File, 1987

U.S. Department of Agriculture (1989) 10-level County Adjacency Codes to create three categories: major urban (MSA counties), less urban (nonMSA counties with towns larger than 2.5K), and rural (non-MSA counties with towns with fewer than 2.5K)

Age, gender, ethnicity, living arrangement, social contact, education, prior service use, Medicaid eligibility, limitations in activities of daily living, health status, chronic conditions, and availability of hospital beds, physicians, and nursing home beds.

Low Use of physician services (-)
93

lth Care: A Systematic Review Evidence-based Synthesis Program

 Study 

le Size, 

on, Region 

Data Source and Year(s) of Sampling (if applicable)Response rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ents under 

National Health Interview Survey, 1992Response rate: 95.7%

Urban: central or noncentral cities located within a MSARural: outside a MSA, either on a farm or not

Age, gender, self-reported health status, presence of acute or chronic health problems, ethnicity, family size, education, insurance status, income, region of country

Moderate Physician visit in past 12 

months:(+); any R<U White (except R African American)

welling 

ears), ≥ 1 of 

ons, resi

most rural 

 counties

Population based phone survey evaluating six common chronic indicator conditions (arthritis, hypertension, cardiac disease, diabetes mellitus, peptic ulcer disease, and chronic obstructive pulmonary disease)Response: 57%

U.S. Department of Agriculture continuum codes. Urban: metro areas with > 250,000 residentsRural: <2,500 residents in a single incorporated place and not adjacent to metro areas

Age, gender, education beyond high school, living on a farm, alcohol use, smoking in the past, medical advice needed in the past year, supplemental private insurance, medication coverage, Medicaid, VA clinic in the past year, Distance from physician, congregate meals, Use of Meals on Wheels, Homemaker service

Low Number of physician visits (-)

 51,899 

99)

erans 65 

enrolled in 

ervice plans

VHA’s Patient Treatment File and Outpatient Clinic File, 1995-1999Medicare Denominator, 100% MEDPAR, Outpatient, and Physician Supply files, 1997-1999

Department of Agriculture Rural/Urban Commuting Area (RUCA) Code; grouped into urban (RUCA codes 1-6) and rural (RUCA codes 7-10)

Age, gender, living in the northern or southern states of New England, number of VHA and Medicare inpatient admissions

Moderate Primary, specialist, and mental 

health visits (+); R<U (across all three study years )

n

al; F=Frontier; (+)=difference statistically significant; (-)=difference not statistically significant
94

lth Care: A Systematic Review Evidence-based Synthesis Program

ual Source of Care

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ent of 

es, active 

vices

Health Care Survey of DoD Beneficiearies (HCSDB) – mailed survey 2002Response: 29%

US Census Bureau – metropolitan (metro), adjacent to metropolitan (adj), or nonadjacent (non adj)

Age, service category, marital status, self-reported health status, race, rank, gender, utilization, years in health plan, health plan, indicator of other health plan

Low Rating of health plan, rating 

of health care, getting care quickly (+); Adj or non-adj> MetroGetting needed care (+); Metro>Adj or non-adj

r 47% ru

plete data 

resident of 

ounties 

Stratified (race & residence) random sample-Duke Established Populations for Epidemiologic Study of the Elderly survey, 1986-87Response: 80%

US Bureau of the CensusRural: fewer than 2,500 inhabitantsAlso classified counties as rural or urban

Race/ethnicity, self-rated health, health index, age, gender, education, marital status, employment, income, Medicare and Medicaid coverage, private insurance

Low/Moderate

Usual source of care (-)Usually sees same provider(+); R>UPut off care due to not knowing where to go (-)Put off care due to transportation difficulties (-)Put off care due to cost (+); R>U 

ty dwelling, 

or non

Telephone surveyResponse: 53%

Rural: county with fewer than 50,000 personsFrontier: county with fewer than 50,000 persons and fewer than 7 persons/mi2

Age, gender, ethnicity, marital status, education, economic factors, insurance, chronic conditions

Low/Moderate

Always/usually see personal doctor/nurse (-)Always/usually able to obtain care without a long wait (-)

or 19% 

64

National Health Interview Surveys, 1999-2000Response: 81% (1999) and 83% (2000)

Rural: any place of residence not in a Metropolitan Statistical Area

Race/ethnicity, gender, age, interview language, region of residence, limitation of activities, self-reported health status, education, employment, family size, income, marital status, insurance

Low/

Moderate

Usual source of care (-) (in rural and urban areas Hispanic adults less likely than white adults to have usual source of care)Health care use in past 12 months (-)
95

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

n, ≥20 

onalized, 

ANES III: 

xamination, 

 files

participate 

the survey

Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994

Urban: MSARural: Non-MSA

Gender, age, BMI, perceived health status, income, insurance status, education, usual place of care, # times seeing physician in past year, duration of diabetes

Moderate Usual source of care (+); U 

Hispanic<R Hispanic, R White, U White#

#Unadjusted analysis

graphic 

ession

utionalized, 

 older

Medical Expenditures Panel Survey (MEPS), 1996Area Resource File (ARF) with Urban Influence Codes (UIC)

UICs by county – large (pop’l >1 million) or small metropolitan areas; non-metropolitan areas distinguished by adjacency and pop’l of largest city (>10,000)

Gender, ethnicity, education, age, insurance, family income, self-reported health, priority condition, limitations in activities of daily living or instrumental activities of daily living, physician availability, region, usual source of care

Moderate Usual source of care (+); most 

R>most U (adj. to large MSA with city <10,000 also greater than most urban)

r 54% rural)

 source of 

and older

Texas Tech 5000 telephone survey, Sept.-Dec. 2000Response: 57%

Rural: county with population less than 50,000

Age, gender, ethnicity, resides in continuing care, health limitations, specific diagnoses, education, income, marital status, medical skepticism, religiousness, insurance status, employment, home ownership

Low Personal doctor or nurse (-)

Usual place to go for care (-)

n

 statistically significant; (-)=difference not statistically significant
96

lth Care: A Systematic Review Evidence-based Synthesis Program

ovider Availability and Expertise

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ns (619 or 

76 patients 

s practicing 

ban areas 

es with at 

 submitting 

urban loca

neficiaries 

Medicare Part B file (billed services), 1994Health Care Financing Administration (HCFA) provider directoryMedicare beneficiary file

Rural Health Service Areas defined as physician practice addresses with ZIP codes closer to rural hospital than urban hospital 

None Low/

Moderate

Family physicians most likely to practice in rural area (25%); psychiatrists (5%), cardiologists (6%), gastroenterologist (8%) least likely#

Family physician age (+); R>U#Patients/physician (+); R>U#Outpatient visits/physician (+); R>U#Diagnostic scope of practice similar except: urban general surgeons >CV disorders; rural general surgeons >GI disorders and urban obstetrician-gynecologists >care for menopausal symptoms; rural obstetrician-gynecologists >diagnoses outside specialty#Procedure rates (+); R>U for family practice, internal medicine, general surgery#

#Unadjusted analysis

 rural coun

or Spanish

 lived in 

ious 12 

elected 

ld reached)

 GA, LA, 

Telephone survey 2002-2003; this report focused on question: How much do you agree with the statement: ‘I feel there are enough doctors in my community?’Response: 51%

Not reportedNOTE: counties selected by project leaders; typically higher poverty and unemployment rates, larger racialethnic minority proportions, and higher infant mortality rates than other rural counties in the state

Age, gender, race, education, children <18 years, self-reported health, health insurance status, travel time to care, problem with cost of care, ease of getting appointment, role of physician care, number of visits in past year, satisfaction with care, confidence in doctor’s abilities, county characteristics 

Low Not enough physicians (+):

a. areas with fewer physicians/pop’l > areas with more physicians/pop’lb. travel time to care more than 30 min > travel time to care less than 30 min
97

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

eported 

cian assis

Web-based survey, 2008 (10 case-scenarios)Response: 49% responded; 44% analyzed

Respondents selfreported rural or urban

None Low Mean score on 10 question 

case-scenario quiz (+); R>U#

PAs reporting they diagnose and treat 50-100% of skin complaints (+); R>U#

Cases referred to specialist per week (-)#

#Unadjusted analysis

3% non

d from 

onsin in 

r siblings; 

ual source 

 specified a 

 (PA), nurse 

r physician 

care spe

ider

Wisconsin Longitudinal Study (WLS) - telephone and mail survey 1993-94 for perceived health, 2004-05 survey defined sample and all other variablesResponse: 80% for graduates, 78% for siblings (telephone); 88% for graduates and 81% for siblings (mailed survey to those who did telephone interview)

Office of Management and Budget (metropolitan, micropolitan, or nonmetropolitan)

Age, gender, marital status, education, personality traits, income, insurance, perceived health, number of diagnoses

Low/Moderate

306 (4.5%) use PA/NPs as usual source of care#

PA/NP as usual source of care (+); non-metro>metro, nonmetro>micro #Unadjusted analysis

nonle to link 

ent with 

nt facility 

MEPS, 2004 plus information from relevant cliniciansResponse (to MEPS): 64%

Metropolitan Statistical Area (MSA) = urban, non-MSA = rural

Age, gender, income, insurance, race/ethnicity Low/ Moderate Odds of visiting family physi- cian, nurse practitioner, and physician assistant (+); nonMSA>MSA

Odds of visiting general internist or non-surgical specialist (+); non-MSA<MSA
98

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

ns (28,053 

20 Wash

patient 

raining, 

ed specialty 

actice, 

pediatrics, 

gy

ton

AMA Physician Masterfile plus WA licensing board information and contacts with rural physicians (physician data)Mailed survey (non-physician data)Response: 64% (CA); 67% NPs in WA, 86% PAs in WA

CA: Medical Service Study Areas (MSSA); rural – population density <250 residents/mi2

with no city of ≥50,000WA: Rural Health Service Areas (HSA) and urban public health department zones; rural – core city or town non MSA or in MSA but >30 min from population base of ≥10,000Census data

Clinician age, gender, and race/ethnicity 

Low 22% of Physician Assistants in 

CA practice in rural area; 28% in WA#

Odds of practicing in rural areas:(+) family physicians, nurse practitioners, and physician assistants more likely relative to obstetricians/gynecologists(+) Asian, African Americans, Latinos (CA only) less likely(+) females less likely#Unadjusted analysis

 who prac

a

s who 

elderly (pri

try, surgery, 

Mailed survey 2003Response: 43%

Rural: one of 33 designated rural counties in Florida, practicing in rural areas of nonrural counties by Rural Urban Commuting Area codes, or Health Resources and Services Administration list of rural ZIP codes

None Low 55% reported decreased or 

eliminated patient services in past year including mental health, (35%), vaccine administration (29%), office-based surgeries (40%), Pap smears (24%), x-rays (24%), endoscopies (43%), and electrocardiograms (11%)#

Physicians in practice where ≥65% of patients were Medicare patients were more likely to reduce or eliminate services compared to those with <28.5% Medicare patients#

#Unadjusted analysis

es in Texas

Texas Medical Board US Census Bureau, 2007

Frontier - ≤6 people per 2.6 km2

None High 17 counties had no licensed 

doctors or physician assistants#

Statewide: 1 physician assistant per 13.6 physiciansFrontier counties: 1 physician assistant per 2.3 physicians#

#Unadjusted analysis
99

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

unties

Area Resource File, 2002 Urban Influence 

Codes, 2003 

None High Mean primary care physician 

supply (per 10,000 population):Metropolitan: 17.8 (large), 16.9 (small)Micropolitan: 12.3 (adj. to large metro), 13.1 (adj. to small metro) Rural: 7.1 (adj.t o small metro), 7.2 (adj. to micro), 9.2 (not adj. to metro or micro)#

#Unadjusted analysis

sicians (176 

Mailed surveyResponse: 42%

Rural: one of 33 designated rural counties in Florida, practicing in rural areas of nonrural counties by Rural Urban Commuting Area codes, or Health Resources and Services Administration list of rural ZIP codes

None Low Overall, 60% reported delivery 

of patient services decreased or eliminated in past year#

Types of services decreased or eliminated (-) (except for office-based surgeries)#

#Unadjusted analysis

s (1,079 

actitioners 

e midwives 

ssistants 

cticing in 

Mailed survey, 1994Response: 62%

Metropolitan Statistical Area (MSA) = urban, non-MSA = rural

None Low/

Moderate

NPs (n=554, 31% rural): older, fewer with bachelor’s degree, fewer specialty credentials, more years in health care, more solo and clinic practice settings, fewer insured patients (+); R vs. U#

CNMs (n=73, 29% rural): fewer specialty credentials, more hours per week, more patients per hour (+); R vs. U#PAs (n=452, 18% rural): older, fewer with bachelor’s degree, more years in health care and years as PA, more patients each hour, more clinic practice settings, fewer insured patients (+); R vs. U#

#Unadjusted analysis
100

lth Care: A Systematic Review Evidence-based Synthesis Program

(Sample 

clusion, 

e)

Data Source, Year(s) (if applicable)Response Rate (if applicable)

Definition of Urban/Rural

Covariates Confidence 

Score*

Results**

 or county 

ngle state 

rged to 

 >50,000)

unties or 

Alaska, 

es with 

definitions 

2000

Numbers of rehabilitation therapists (physical [PT] or occupational [OT] therapists, speech-language pathologists [SLP]) from 1980 and 1990 ARF and 2000 EEOHealth Professional Shortage Area Data

US Office of Management and Budget (OMB) – metropolitan (metro): central county with ≥1 urbanized area and outlying counties economically tied to core county 

None Moderate/

High

PTs, OTs, or SLPs per 100,000 residents (NR); U>R#

PTs, OTs, or SLPs per 100,000 residents (NR); Non-shortage area > partial or total shortage area#

n

 statistically significant; (-)=difference not statistically significant