Evidence‐based Synthesis

Program (ESP)

Rural vs. Urban Ambulatory

Health Care

A Systematic Review of the Evidence

Michele Spoont, PhD

Principal Investigator

Nancy Greer, PhD

Co‐Investigator

Minneapolis VA Healthcare Center
Evidence‐based Synthesis

Program (ESP)

Ak ld t Acknowledgements

Co‐Authors/Collaborators

o Jenny Su, PhD

o Patrick Fitzgerald, MPHo Indulis Rutks, BS

o Timothy Wilt, MD, ESP Director

Technical Advisory Panel/Reviewers Technical Advisory Panel/Reviewers

o Byron Bair, MD, Salt Lake City VA;

Dir. RH Resource Center - Western Region

o John Fortney PhD Central Arkansas

o Peter Kaboli, MD, Io

RHResource Center – Ce

o John Fortney, PhD, Central Arkansas oLynn McQueen DrP

Veterans Healthcare System

o Joseph Francis, MD (OQP)o Linda Humphrey, MD, MPH (ESP)

oLynn McQueen, DrPoAmy Wallace, MD, MoAlan West, PhD, White RoSteven Wrig , ht PhD ( 

O 
Evidence‐based Synthesis

Program (ESP)

Disclosure

This report is based on research research conducted conducted by the Evidence Evidence‐based 

Program (ESP) Center located at the Minneapolis VA Healthcare Sys

Minneapolis, MN, funded by the Department of Veterans Affairs, V

Administration Administration, Office of Research Research and Development Development, Health Servic

Servic

and Development. The findings and conclusions in this document a

the author(s) who are responsible for its contents; the findings and 

do not necessarily necessarily represent represent the views of the Department Department of Vetera

Vetera

the United States government. Therefore, no statement in this arti

construed as an official position of the Department of Veterans Affa

in estigators investigators ha ev any affiliations affiliations or financial financial in ol ement volvement (e g. ., em

consultancies, honoraria, stock ownership or options, expert testim

patents received or pending, or royalties) that conflict with materia

the report.
Evidence‐based Synthesis

Program (ESP)

VA Evidence‐based Synthesis (ESP)

Program Overview

• Sponsored by VA Office of R&D and HSR&D.• Established Established to provide provide timely and accurate accurate syntheses/reviews syntheses/reviews 

topics identified by VA clinicians, managers and policy‐maker

work to improve the health and healthcare of Veterans.

• Builds on staff and expertise already in place at the Evidence‐

Practice Centers (EPC) designated by AHRQ. Four of these EPESP Centers:

o Durham VA Medical Center; VA Greater Los Angeles Healt

System; Portland VA Medical Center; and Minneapolis VA 

Center.
Evidence‐based Synthesis

Program (ESP)

• Provides evidence syntheses on important clinical practice to

to Veterans, and these reports help:

o D l eve op cli i l n ca poli i c es if d n ormed by evidence.

o The implementation of effective services to improve 

outcomes and to support VA clinical practice guidelin

performance measures.

o Guide the direction for future research to address ga

knowledge.

• Broad topic nomination process – e.g. VACO, VISNs, field – fa

ESP Coordinating Center (Portland) through online process:

http://www.hsrd.research.va.gov/publications/esp/TopicNomin
Evidence‐based Synthesis

Program (ESP)

• Steering Committee representing research and operations (PC

and VISN) provides oversight and guides program direction.

• Technical Advisory Panel (TAP)

o Recruited for each topic to provide content expertise

o Guides topic develop ; ment refines the key questions

o Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews Reviews and comments comments on draft report

• Final reports posted on VA HSR&D website and disseminated 

through the VA.

http://www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis

Program (ESP)

Rural vs. Urban Ambulatory Ambulatory Health C

Systematic Review

2011

Full‐length report available on ESP website:

http:// / / / //www.hsrd.research.va.gov/publications/esp/reports
Evidence‐based Synthesis Pro

(ESP)

Methods

• Key Questions • Topic area Summaries

• Rese

reco

• ESP Methodology

M th d

• Answer Key Questions • Polic

M 

ethods 
Evidence‐based Synthesis

Program (ESP)

Background

• Rural Veterans

o 37% of the 8 million VA users

o General population 17% rural

• Health of Rural Vets*

o Lower overall physical health quality of life

o Lower health quality of life within disease category

o But, many population differences in rural vs. urban ar

o Higher prevalence rates of numerous chronic con

o Other differences (e.g., lower income, older age, 

insured)

*Weeks, Wallace et al., 2006; Wallace et al., 2010; West & Weeks, 2009
Evidence‐based Synthesis

Program (ESP)

Key Questions

• Key Question 1

o Do adults in rural areas with health care nee

different health outcomes than those in urb

• Key Question 2

o Is the structure or the process of health care 

rural vs. urban areas?
Evidence‐based Synthesis

Program (ESP)

Key Questions (continued)

• Key Question 3

o If there are differences, are they associated 

differential outcomes?

• Key Question 4

o If there are differences in health outcomes, 

healthcare system factors are associated wi

differences?
Evidence‐based Synthesis Pro

(ESP)

• Methods

– OVID MEDLINE, PsycINFO, CINAHL– Limits: Limits: United States, English English, Population Population 

published 1990 through March 2010

– Ambulatory health care– RCT, comparative comparative study, meta‐analysis analysis, re– The Journal of Rural Health
Evidence‐based Synthesis

Program (ESP)

Search

Results

• N=1,381 reviewed

• Excluded n=1,048 Results

• N=333 reviewed

Full Text

Review

N 333 reviewed

• Excluded n=165

St di

• Final exclusion/hand search

N 102 i ldd Studies Included • N=102 included
Disease Topic Areas

• Preventive care/ACSC• Cancer

• Diabetes/End stage renal disease

• Cardiovascular Disease• HIV/AIDS,

• Neurologic conditions

• Mental health
Health Care Topic Areas

• Medication use• Med l ica procedures and tests• P id rov er avail bilit a y and t ii ra n ng• Service utilization
Evidence‐based Synthesis

Program (ESP)

• Studies were observational• Databases: SEER, NHIS, Beh l avioral Ris

Surveillance System (BRFSS), Medicare 

• Defining “Rural”
Rating Studies

Internal Validity Rated G(Good), F(Fair), Sampling Low response rates without correctio

Convenience sampling Convenience sampling

Predictors Omission of SES/insurance factors o

associ d ate wih i ( t service use (e.g., age

Outcomes Unreliable or non-validated measur

Use of proxy variables

Analyses Omission of bivariate or multivariate 

Ignore data clustering
Rating Studies

External Validity External Validity Rated G(Good) F(Fair

Rated G(Good), F(Fair

Agg g re ate measures County level predictors or ou

Dichotomized urban rural

R i epresentativeness S ll li i d Small, limited to one d 

emogr

No bias correction

Study design

Poorly conceptualizedData insufficient to answer p research question
Evidence‐based Synthesis

Program (ESP)

What do we mean by “rura
What do we mean by rura

– Metropolitan Statistical Area (OMB)

• Micropolitan Statistical Area

– Rural Urban Continuum Continuum Codes (USDA)

• 3 metro, 6 non‐metro county pop.

– VA (Urban, Rural, Highly Rural)

• Urban area 50,000 (1,000 per sq mile)+

• Highly rural (7 per sq mile)
What else do we mean by ru

– Rural Urban Commuting Commuting Area (USDA)

• 33 Census tract codes and commuting areas

– Pop. density of census blocks (US Census

• U br an clt/b id luster/urbanized area vs. rural

– Urban Influence Codes ( ) USDA

• Population and location
Preventive Care

Ambulatory Care Sensitive Conditions

1. Immunization Rates2. Prenatal Care3. Cancer Screening Rates

1. Colorectal Cancer2. Breast and Cervical Cancer

4. Amb l u atory Care Sensitive Condition

Hospitalization Rates
Preventive Care

Ambulatory Care Sensitive Conditions

• Immunization Rates

– 2 studies – 1994 and 1997 all 65yr+– US National Health Interview Survey

– BRFSS and Area Resource File

• No Rural vs. Urban difference difference in rates o

influenza or pneumonia vaccinations
Preventive Care

Ambulatory Care Sensitive Con

• Prenatal Care after first trimester

– One retrospective retrospective survey study 2003, Or– No difference rural vs. urban, but not co
Preventive Care

Ambulatory Care Sensitive Con

• Colorectal Cancer (CRC) Screen

– 3 Studies: Studies: 2 national national (1990 s) (1990’s), North Car

Car

– All showed lower rural screening screening rates
Preventive Care

Ambulatory Care Sensitive Con

• Breast and cervical CA screening

– 5 national national studies studies, 2 regional regional– Rural women less likely to get mammogr

PAP tests across studies

– R l ura vs. urban difference not si ifi t ignificant 

adjust for age, education, income, insura

st t a us, ph ii ys c an avail bilit a y
Preventive Care

Ambulatory Care Sensitive Con

• Ambulatory Care Sensitive Conditions

– Three studies– Laditka (2009) eight states

• Step‐wise increase increase in admission admission rates by lev

rurality (demographics and service availabili

• Partially Partially due to lower rural insurance insurance rates

• Over 65 physician supply
Preventive Care

Ambulatory Care Sensitive Cond

Summary

I i ti mmunization R t a es

Prenatal Care

Cancer Screening Rates

ACSC Hospitalization Rates
Cancer Care

1. Mortality (3)2. Stage at time of diagnosis diagnosis (9)3. Relationship between screening an

disease progression (3)

4. Treatment quality (5)
Cancer Care

• Mortality

– No differences differences in breast or cervical cervical CA

• Availability subspecialists was significant

– Nebraska: lymphoma‐related mortality a

with university university vs. community community provider provider
Cancer Care

• Initial Staging

– 3 of 4 studies studies found rural residents residents less l

have CA staged at time of diagnosis

• R l ura di d sa vantage > women and Af ir can A 

m

• Patients categorized by residence rather tha

of care

• Severity of Staged Illness

– Some urban disadvantages, and some d

age, income
Cancer Care

• Lower screening rates associated with 

rates of in situ breast and cervical can

• Treatment Quality:

– Radiation for breast CA among older (bu

younger) women aff d ecte by access

– No other significant significant findings/studies findings/studies
Cancer Care

Mortality

Ut d ns

tage

d Illness

Stage of Illness

Q lit ua

y

o

f

Care
Diabetes/ESRD

1. Diabetes health outcomes (2)2. Diabetes treatment (6)3. ESRD treatment (1)
Diabetes/ESRD

• Diabetes health outcomes

– Over 11,000 veterans, no difference rura

urban (A1c

, eye or foot exams

, BP, LDL)
Diabetes/ESRD

• Diabetes treatment

– No consistent consistent differences differences rural vs. urban– Ma

y be due to variation in rural

‐urban d

across geographic regions

– S i ee ng an en

d i l it ocrinologis

t result de

d in mo

guideline

‐concordant care
Diabetes/ESRD

• ESRD treatment

–

N

o i d ncrease

d

odd

s

o

f ESRD in rural vs. ur

controlled for insurance, illness severity

– Transplant rates and mortality showed a

interaction interaction between between rurality rurality and race/et

race/et

study of 500,000+ patients
Diabetes/ESRD

Diabetes Health Outcomes

Diabetes Treatment

ESRD Treatment
Cardiovascular Disease

5 studies, 3 of low quality

1. 23 000 , vets with HTN

– No difference difference in BP control control across rural‐u

2. Provider survey post‐appt survey stud

difference in quality of treatment urbarural

– Differences in population severity of HTN
Cardiovascular Disease

5 studies, 3 of low quality

1. 23 000 , vets with HTN

– No difference difference in BP control control across rural‐u

2. Provider survey post‐appt survey stud

difference in quality of treatment urbarural

– Differences in population severity of HTN
HIV/AIDS

1. Treatment receipt/access receipt/access (3)2. Treatment quality (1).

– 1 regional, 2 national (HCSUS database– All used data from 1990’s
HIV/AIDS

Treatment receipt/access

– 75% get care in urban area.– No consistent evidence that distance is 

may be for older patients.

Treatment quality

– Less likely to receive HAART or Pneumo

vaccine if treated in rural area.
Neurologic Conditions

1. Multiple Sclerosis (3)

– Same survey dataset, poor methodolog– Rural residents residents less likely to see neurol

neurol

MH providers

2. Availability of rehabilitation therapist

– Fewer reh bilit ti habilitation th i t erapists for TBI 

rural areas
Mental Health

1. Suicide rates and Rx use (3)2. Odds of MH hospitalization (2)3. MH service access ( ) 84. Quality Quality of care (4)5. Alcohol/Drug treatment (5)
Mental Health

• Suicide rates and antidepressant use

– Suicide rates higher in rural areas

• Associated with > tricyclics vs. SSRI’s

• Not associated associated with provider provider availability availability

• Small regional prospective study no differen

q y ualit
Mental Health

• Odds of MH hospitalization

– Two national studies studies– Lower in rural vs. urban areas schizophre

depression

– H i ous ng stress in urban areas predi ti c ve 

hospitalization, rural factors protective (e

b d ase economy)
Mental Health

• MH Service Access

– Rural patients patients less likely to get MH care

• Have fewer visits• Insurance a f t ac or

• Minorities more disadvantaged in urban areas

– National VA MHICM study 5,000+ pts

• Rural pts less likely to get recovery‐oriented M

treatments

– Therapy, SUD tx, rehab services
Mental Health

• Quality of Care

– Better continuity of care in rural areas– A kr ansas: quality of out ti t pa en d i epressio

comparable

– More MH hospitalizations among rural pt

months after initial assessment

– NCS‐R fewer MH specialty services in rura

but MH specialty care better
Mental Health

• Alcohol/Drug treatment

– Lower rates of SUD treatment receipt in ru

areas

– Rural vets better discharge follow‐up treat
Mental Health

Suicide rates and Rx use

Odds of MH hospitalization

MH service access

Quality of careAl h l/D Alcohol/Drug treatment
Health Care Topic Areas

• Medication Use

– 8 studies, 3 nati l ona , all age 66+ or “ ld 

elde

– National National studies studies – mixed results results for expe

expe

and use

– Regional studies ‐ mixed results for use
Health Care Topic Areas

• Medical procedures and tests

– 2 studies, nati l ona , age 65+– Decreased Decreased service service use – rural areas (offic

(offic

imaging, diagnostic testing)

– Use of 32 services – race/rurality interac

greater racial disp y arit in rural areas
Health Care Topic Areas

• Provider availability and training

– 12 studies, 4 nati l ona , 2 mul it ‐state– Fewer physicians physicians per population population in rural 

more NPs and PAs

– Fewer internists and specialists in rural a

more family practice p yh sicians
Health Care Topic Areas

• Service utilization

– M di l e ca appointments wi ht providers

• 10 studies, 7 national; 3 multi‐site VA studie• Mixed results for frequency of visits

• Rural VA patients had fewer visits (1 study)

• More primary care, less specialty care at CB

studies)
Health Care Topic Areas

• Service utilization

– U l sua source of care

• 7 studies, 4 national• No difference in reporting of usual source o

• Some evidence of greater continuity of care 

areas
Health Care Topic Areas

Medication Use

M di l e ca P d roce ures and T t es s

Provider Availability and Training

S i erv ce Utili ti Utilization
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

(ESP)

Key Questions Answered

• Key Question Question 1: Do adults in rural areas with health c

have different health outcomes than those in urban 
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

(ESP)

Key Questions Answered

• Key Question Question 1: Do adults in rural areas with health c

have different health outcomes than those in urban 

– Increasing rurality is associated with a greater frequency o

for ACSC's.

– Cancer mortality

– Greater rates of DCIS and lower rates of invasive cervical c

areas where screening rates are higher.

– Di b t a e es compli ti / l cations/prevalence of ESRD

• Race by rurality interaction *

– Hypertension control
Evidence‐based Synthesis Pro

(ESP)

Key Questions Answered

• Key Question 2: Is the structure or the process of h

different in rural vs. urban areas?
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

• Key Question 2: Is the structure or the process of h

different in rural vs. urban areas?

• Use of Medication

• Medical Procedures and Diagnostic Tests

• Medical Appointments with Providers• Usual Source of Care:• Provider Availability and Expertise

• Quality of Care
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

• Key Question 3: If there are differences, are they as

with differential outcomes?
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

• Key Question 3: If there are d ff i erences, are they a

with differential outcomes?

– Lower rural mammography mammography and cervical cervical cancer screenin

screenin

with higher rates of invasive cancers.

– Rural Health Clinics improved adherence to treatment g

diabetes.

– Limited numbers of providers in rural areas may foster b

continuity of care.

– Limitations in provider availability may be associated w

odds of hospitalization among older rural residents for A

lower odds of psych th o erapy.
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

• Key Question 4: If there are differences in health ou

what non‐healthcare healthcare system factors factors are associated associated 

differences?
Evidence‐based Synthesis

Program (ESP)

Key Questions Answered

• Key Question 4: If there are differences in health ou

what non‐healthcare system factors are associated 

differences?

– Insurance– Travel distance– Patient attitudes– Race disparities
Research Recommendatio

1. The Research Question:

– Differences in health care systems may 

disparities.

– All barriers do not impede treatment.

Better question(s): Are these difference

associ d ate wi ht differences in h lh ea t c

receipt or outcomes?
Research Recommendatio

2. Sampling:

– D fi e ne convention used for “ l” rura

• Provide a rationale for choice and how it aff

outcomes.

• Graded vs. dichotomous is more informativ

• Consider using more than one convention.• Consequences of defining rural by residenc

care.
Research Recommendatio

3. Unit of analysis should match the res

question

– Associations between health care param

h lth ea outcomes may differ on aggregate 

individual level.

– Unit of analysis should reflect local healt

systems or markets.
Research Recommendatio

4. Analyses:

– Many factors factors are correlated correlated with ruralit

ruralit

Adjusting for them all may lead to false

conclusions conclusions re: association association of rurality rurality a

outcomes, and limit development of he

policy.

– Report bivariate associations.– Use contextual approach (e.g., multilev
Research Recommendatio

5. Consider assessing for interactions bet

rurality and race/ i/ reg on/age.

– Few studies assessed them, but those tha

tended to find differences.

– Not doing so may obscure obscure disparities disparities.– Have implications for rural disp y arit interv
Summary

• There is weak evidence that rural healt

di iti sparities exi ts in some areas.

• There are large g pa s in the evidence ba

– Virtually no research in areas the VA cares 

about (e g. ., TBI).

– Methodologically difficult.
Evidence‐based Synthesis

Program (ESP)

Questions?

If you have further questions,

feel free to contact:

Michele Spoont, PhD

612‐467‐1979

Michele.spoont@va.gov

The full report and cyberseminar presentation is available on the E

http gp p ://www.hsrd.research.va.gov/publications/esp/