bluuebunny/crossref_metadata_2025 huggingface dataset:
Legislative and Policy Strategies for Supporting Rural Health Network Development: Lessons from the 103rd Congress
Authors: Coburn Andrew F. , Mueller Keith J.
Published: April 2008

Abstract: There was considerable support in most major health reform bills considered by the 103rd Congress for the development of rural integrated service networks. The demise of comprehensive health reform, together with the pace of current market‐driven changes in the health care system, suggests the need to assess the impact of specific policy strategies considered in the last Congress on rural integrated service network development. Toward this end, this article evaluates the rural health policy strategies of the major bills in relation to three essential preconditions for the development of rural integrated service networks: (1) the need for a more stable financial base for rural providers; (2) the need for administrative, service and clinical capacity to mount a successful network; and finally, (3) the need for appropriate market areas to ensure fair competition among networks and plans. Key policy strategies for supporting rural network development include reform of insurance and payment policies, expansion of targeted support and technical assistance to the underserved, limited‐capacity rural areas, and policies governing purchasing groups or alliances that will ensure appropriate treatment of rural providers and networks.
A 10‐Point Strategic Checklist for Rural Health Care Systems
Authors: Zismer Daniel K. , Hoffman David C.
Published: April 2008

Abstract: A checklist format is used to provide a framework for rural hospital executives and community members for gauging the health and stability of rural hospitals and rural hospital systems. Benchmarks are provided for financial and operational performance and emphasis is placed on medical staff size and physician recruitment. Physician/hospital organizations and regional partnerships are used as examples of strategies available to rural providers. The importance of market knowledge and regional strategic alliances also is stressed. In an era of dwindling resources and tight reimbursement, rural providers are encouraged to consider cooperative clinical programming and technology consolidation.
Two Decades of Experience in the University of Washington Family Medicine Residency Network: Practice Differences Between Graduates in Rural and Urban Locations
Authors: Baldwin Laura‐Mae , Hart L. Gary , West Peter A. , Norris Tom E. , Gore Edmond , Schneeweiss Ronald
Published: April 2008

Abstract: This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27‐item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits.

The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part‐time positions, to facilitate recruitment and retention of physicians, especially women.
Changes in Health Insurance Coverage Within Rural and Urban Environments—1977 to 1987
Authors: Duncan R. Paul , Seccombe Karen , Amey Cheryl
Published: April 2008

Abstract: This study examines changes in the health insurance coverage of the nonelderly population in rural and urban areas between 1977 and 1987, using data from the National Medical Care Expenditure Survey (NMCES) and the National Medical Expenditure Survey (NMES). It was designed to test the hypothesis that differences in the rates of health insurance coverage in rural and urban areas have diminished over time, and to explore the composition of changes in coverage within rural and urban environments. The data suggest that the proportions of the populations that are without health insurance in rural and urban areas have converged since 1977. Although both rural and urban settings witnessed increases in the proportion of their populations without health insurance from any source, urban regions experienced a greater increase than did rural areas. These changes occurred among most subgroups within the population. In no subgroup did the percentage of the population without insurance in urban areas exceed that found in rural areas in either 1977 or 1987.
Availability of Rural Minnesota Obstetric Services: Is It a Problem?
Authors: Yawn Barbara , Wellever Anthony , Hartley David , Casey Michelle , Krein Sarah , Moscovice Ira
Published: April 2008

Abstract: In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota.

A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes.

All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 22 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high‐risk services and consultants.
Adjusting Measures of Physician Availability to Reflect Importation of Physician Services into Rural Areas
Authors: Wakefield Douglas S. , Tracy Roger
Published: April 2008

Abstract: Recent changes in the organization and delivery of physician services in rural areas suggest the need to update how physician availability is viewed and measured. The objective of this study was to empirically examine the effect of rural hospitals contracting with outside physicians for part or all of their emergency room coverage, and the use of urban specialists to staff outpatient clinics, on measures used to assess physician availability. Based on data from one rural state, the findings demonstrate the importance of adjusting for the importation of physician services into rural areas.
Access to Primary Health Care Among Persons With Disabilities in Rural Areas: A Summary of the Literature
Authors: Lishner Denise M. , PhD Mary Richardson , Levine Phyllis , Patrick Donald
Published: April 2008

Abstract:Despite the prevalence of disabilities among persons living in rural areas, scarce data exist on their health care needs. While rural residents generally experience barriers to access to primary health care, these problems are further exacerbated for people with disabilities. This article summarizes findings from the published literature on access to primary health care among people with disabilities living in rural locations. A comprehensive computerized literature search turned up 86 articles meeting the study criteria, focused on the following rural populations affected by disabilities: children and adolescents, working‐age adults, the elderly, the mentally ill, and people with AIDS.

For each of these populations, substantial problems in accessing appropriate health care have been documented. The literature consistently emphasizes the failure of local health care systems in nonmetropolitan areas to adequately address the complex medical and related needs of individuals with disabilities. In the absence of specialized expertise, facilities, and primary care providers trained specifically to care for disabled persons, local programs rely heavily on the use of indigenous paraprofessionals and alternative models of care. Further research is needed to identify and test the efficacy of innovative service delivery strategies to improve health care access for this population.
Economic Effects of the Outmigration of Obstetric Services in a Rural County
Authors: Thompson James G.
Published: April 2008

Abstract: Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural “perimeter” community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.
An Epidemiologic Approach to Assessing Primary Care Needs in Rural Illinois
Authors: Leitner Dennis W. , Gast Julie A. , Sarvela Paul D. , Ring Mary C. , Newell Lesley A.
Published: April 2008

Abstract: One persistent problem that faces state and federal health policy‐makers is determining the level of primary care needs of the citizens they serve. To refine the decision‐making process in Illinois, a model was developed to compare the 84 rural counties of Illinois and their potential need for additional primary care interventions. Using expert panel methods, a group of public health professionals selected a set of 31 health status indicators that were available at the county level throughout the state. Next, the panel developed a weighting system for those indicators. These weighted values were then applied to the demographic and epidemiologic data from each of the counties to rank the counties on the basis of need. Indicators having the highest correlation with the weighted sum were the percent of the population enrolled in Medicaid, lung cancer mortality rate, general population mortality rate, proportion of population at poverty level, and percent of births to teens. Data also showed that the rural counties with the greatest needs clustered in five geographic regions. The identification of these five geographic clusters may facilitate collaborative efforts in meeting the primary care needs of these populations.
Knowledge, Attitudes, and Patterns of Cancer Screening: A Self‐report Among Foreign Born Hispanic Women Utilizing Rural Migrant Health Clinics
Authors: Skaer Tracy L. , Robison Linda M. , Sclar David A. , Harding Gary H.
Published: April 2008

Abstract: Hispanics are the fastest growing minority in the United States and are currently Washington state's largest minority, with the highest growth rates found in the rural agricultural areas of eastern Washington state. Because breast and cervical cancer mortality rates are higher in Hispanics than other U.S. women, subgroups of Hispanic women with the lowest cancer screening utilization rates need to be identified and targeted for cancer control intervention to most effectively reduce late‐stage cancer diagnoses and mortality. A study was conducted at six migrant health clinics located throughout eastern Washington state to discern age‐specific proportions for utilization of mammography, breast self‐examination, and Pap smears among Hispanic migrants to the United States. Knowledge and attitudes regarding these procedures also were assessed and face‐to‐face interviews were completed with 512 women.

Among women 20 years or older, 15 percent had never heard of a Pap smear, only 78 percent had ever received a Pap smear, and only 44 percent had received a Pap smear within the prior year. In all, 73 percent of the women had been taught breast self‐examination, 62 percent performed breast self‐examination, and 41 percent had performed a breast self‐examination in the prior month. Among women 40 years or older, only 38 percent had never heard of a mammogram, 38 percent had ever received a mammogram, and only 30 percent had received a mammogram in the prior two years. Cost was reported as a major barrier for screening in this population. Additionalzy, a substantial proportion of the women perceived Pap smears and mammography as unnecessary or diagnostic procedures, rather than preventive health measures.

The above breast and cervical cancer screening rates fall well below those documented in national studies of US. women and Hispanic women, as well as below the recommended guidelines of the American Cancer Society and the National Cancer Institute. Culturally sensitive in tmentions to increase cancer screening knowledge and rates are urgently needed for high‐risk groups of Hispanic women, especially those 50 years or older.
Is Health Status Related to Residence in Medically Underserved Areas? Evidence and Implications for Policy
Authors: Kohrs Francis P. , Mainous Arch G.
Published: April 2008

Abstract: This study sought to compare the health status of adult residents of medically underserved areas (MUAs) with adult residents of nonshortage areas (non‐MUAs). A random digit dialing telephone survey was used. Respondents were subsequently classified by their county of residence as residing in an MUA or non‐MUA. A sample of 421 adults (aged 18 years or older) residing in Kentucky during 1993 were included in the analysis. Health status was measured by the Medical Outcomes Study 20‐item Short‐Form Health Survey's (SF‐20) six subscales.

After controlling in the multiple regression for demographic variables there were no significant differences between residents of MUAs and non‐MUAs for the physical functioning, role functioning, general mental health, self‐perception of health, or pain subscales. The social functioning subscale was significantly related to the residence in an MUA. The demographic variable “education” was a consistent predictor of each of the health status subscales.

Excepting the social functioning subscale, residents of MUAs do not have significant differences in health status when compared to residents of non‐MUAs. Future policy may need to focus on other health services shortage area designators that are more highly associated with the health status of residents. Consideration should be given to including the education demographics of areas or populations in health services shortage designation criteria.
Predictors of Alcohol Use Among Rural Adolescents
Authors: Felton Gwen M. , Parsons Mary Ann , Pate Russell R. , Ward Dianne , Saunders Ruth , Valois Robert , Dowda Marsha , Trost Stewart
Published: April 2008

Abstract: There is increasing evidence that alcohol use is becoming more common during childhood and early adolescence. However, little is known about alcohol use among rural youths. This article reports a study of alcohol use among 367 fifth‐grade students in two rural South Carolina school districts. More than one third (n=131) of the fifth graders reported having used alcohol. Of these, 34 percent (n=44) reported drinking during the previous month; 8 percent had been intoxicated during the previous two months; and 54 percent reported drinking in the home with or without parental approval. Logistic regression analysis was used to determine the predictors of alcohol use by fifth graders. The results indicated that gender (OR=2.82), mother's alcohol use (OR=1.86), father's alcohol use (OR=2.13), and smoking (OR=8.30) were significantly associated with alcohol use. The findings suggest that prevention programs address cigarette smoking and drinking behaviors of parents to reduce alcohol use and the acquisition of other health compromising behavior by youths. Early intervention approaches must go beyond the schools and target families as well as community populations.
Volume/Outcome Relationships in Small Rural Hospitals
Authors: Schlenker Robert E. , Hittle David F. , Hrincevich Carol A. , Kaehny Margaret M.
Published: April 2008

Abstract: This article summarizes a study of relationships between hospital volume and patient outcomes for diagnoses commonly treated and procedures commonly performed in smaller rural hospitals. Literature review findings and results of analyses using secondary data for several conditions suggest few if any volume/outcome relationships (with mortality being the main outcome for which data were available). A basic finding of the study is that most conditions and procedures for which volume effects on mortality have been found typically do not pertain to small rural hospitals. However, the available secondary data are weak, and many conditions and procedures have not been studied for small rural hospitals. Therefore, continued monitoring and review are important, as well as improved data systems, further research, and information dissemination on volume/outcome relationships. In particular, examining relationships between volume and outcomes in addition to mortality is critical to a thorough understanding of this topic.
An Assessment of Practice Support and Continuing Medical Education Needs of Rural Pennsylvania Family Physicians
Authors: Forti Esther M. , Martin Kenneth E. , Jones Robert L. , Herman James M.
Published: April 2008

Abstract: Family physicians provide the greatest proportion of care in rural communities. Yet, the number of physicians choosing family practice and rural practice has continued to decline. Undesirable aspects of rural practice, such as professional isolation and a lack of or inadequate resources, are assumed to be associated with this decline. This article reports on the practice support and continuing medical education needs of rural family physicians. A mail survey was conducted in 1993 on a purposive sample of family physicians in 39 of 67 rural‐designated or urban Pennsylvania counties with low population densities.

The physicians identified needs that included patient education materials and programs, community health promotion, federal regulation updates, technical assistance with computers and business management, database software and a videotape lending library, a drug hotline, and mini fellowships on clinical skill development. A majority of respondents were willing to participate in clinical educational experiences for students and residents. Some physicians indicated a lack of interest in access to information through telecommunications, e.g., video conference referrals and consultations.

Overall, findings revealed that family physicians need and are receptive to a variety of practice support and continuing education programs. A practice support program coupled with policy coordination among public and private organizations is likely to lessen complaints by rural primary care physicians.
Teens Teach Skin Cancer Prevention
Authors: Reding Douglas I. , Fischer Virginia , Gunderson Paul , Lappe Karen , Anderson Henry , Calvert Geoffrey
Published: April 2008

Abstract: Cumulative sun exposure has been linked to about 95 percent of all skin cancers. Farmers and their families, by nature of their occupations, are exposed to an abundance of sun over a long period of time and, therefore, are at an increased risk for skin cancer. Because education is known to be a primary means of health, Future Farmers of America (FFA) peer facilitators (teen educators) provided third graders in rural communities sun protection education with the hope that the message would reach the entire family. The FFA facilitators (n=217) from 39 FFA organizations throughout Wisconsin were trained with skin cancer and sun protection information. The FFA facilitators then gave presentations on sun protection to third graders (n=2,007) in their school districts. Control schools included 57 facilitators and 669 third graders. Evaluation involved pre‐, post‐, and six‐month follow‐up surveys testing knowledge gained by the third graders. Students who correctly responded to a question on the post‐survey after incorrectly answering it on the pre‐survey were said to have had a knowledge gain for that question. By using chi‐square tests, the intervention group demonstrated a statistically significant (P<0.001) higher proportion of students experiencing knowledge gain than did the control group from pre‐ to post‐surveys for nine of the 10 questions. Summary statistics were used to describe the study population. In addition to skin cancer knowledge questions, the survey of facilitators included sun protection behavior and attitude questions. This intervention was able to use peer educators as instructors to demonstrate knowledge gain in the youths of the target population. The pilot project materials costs were $0.55 per third grade student and $3.50 per facilitator. Using a school‐based organization such as FFA provided a cost‐effective means of reaching the rural population.
Ensuring the Dissemination of Cancer Control Demonstration Projects for Farmers
Authors: Marconi Katherine M.
Published: April 2008

Abstract: The successful dissemination of the Cancer Control Demonstration Projects for Farmers depends not only on the effectiveness of the grants funded under this program but also on factors external to the grants. In this article, three health‐related external factors are examined: the cancers amenable to prevention and control, intervention methodologies, and the organization of rural health care. Changes between 1989 and 1996 in each of these factors and the effects of these changes on the dissemination of grantee findings to public health and medical practitioners are described. Suggestions are offered on actions that the National Institutes for Occupational Safety and Health can undertake to increase the likelihood of adoption of grantee findings.
Alcohol‐related Mortality and Tribal Alcohol Legislation
Authors: Landen Michael C.
Published: April 2008

Abstract: American Indian alcohol‐related mortality rates differ widely among tribes, even within the same geographic region. In addition, there are many different legislative approaches to alcohol beverage control employed by tribes. This paper explores the association between alcohol legislation and alcohol‐related mortality rates among American Indian tribes located in a region of the northwestern United States from 1979 to 1990. Both an unweighted analysis of alcohol‐related mortality and a weighted analysis, using the Alcohol‐Related Disease Impact (ARDI) approach, are used. Alcohol‐related mortality rates did not differ significantly between reservations with alcohol prohibition statutes or where alcohol was legal in this region. How‐ever, evidence suggests that more comprehensive tribal alcohol legislation may be correlated with lower alcohol‐related mortality among American Indian tribes
The Attitudes of Rural Minnesota Family Physicians Toward Nurse Practitioners and Physician Assistants
Authors: Bergeson Jeanette , Cash Richard , Boulger James , Bergeron Dale
Published: April 2008

Abstract: ncreased use of nurse practitioners and physician assistants has been promoted as a possible solution to the shortage of primary care providers in rural locations. If the use of nonphysician providers is to be optimized in these areas, awareness and acceptance of their capabilities by rural family physicians is essential. This study surveyed the attitudes of rural Minnesota family physicians toward the use of physician assistants and nurse practitioners. Forty‐six percent of the 600 rural family physicians surveyed responded to the questionnaire. Approximately 90 percent of responding physicians indicated a high degree of confidence in the abilities of nonphysician providers in the areas of preventive and routine care; some concern was expressed about the proficiency of nonphysician providers taking call, covering the emergency room, and doing hospital rounds—activities that involve a broader base of clinical knowledge and diagnostic skills. Other concerns were an increased workload for physicians due to their assumed supervisory roles, an increase in complexity of cases seen by physicians, increased physician liability, job competition between nonphysician providers and physicians, and the lack of educational opportunities and supervisory guidelines for physicians regarding collaborative relationships. Appropriate roles for family physicians, nurse practitioners and physician assistants are not well‐defined in the minds of respondents, and it appears future acceptance and practice patterns will depend on how these roles are established and accepted.
Delivering Care to Rural HIV / AIDS Patients
Authors: Topping Sharon , Hartwig Lynn C.
Published: April 2008

Abstract: With HIV/AIDS on the rise in rural areas, health care providers must find ways of delivering care with little or no increase in resource support. This paper examines the evolution of a rural HIV/AIDS alliance using a life cycle model to identify each stage of the alliance development and the specific issues associated with each stage. The data were collected through structured interviews and by review of background materials, including budgets, grant proposals, and program reports. The findings identify alliance strategies that can be used in other rural communities facing the challenge of serving an increasing number of HIV/AIDS patients with limited resources. Differing from other models, this rural HIV/AIDS alliance emerged from local government and community support into an independent, nonprofit organization operating through a network of interorganizational relationships
Researching on the World Wide Web / Internet
Authors: Whitener Lynn
Published: April 2008

“Research Reviews” are a regular feature of The Journal of Rural Health, presenting current research about a particular theme or topic of interest.
The Role of Race and Residence in Determining Stage at Diagnosis of Breast Cancer
Authors: Amey Cheryl H. , Miller Michael K. , Albrecht Stan L.
Published: April 2008

ABSTRACT: Breast cancer kills more than 46,000 women each year. Previous research has found that minorities and those who reside in geographically remote settings are particularly vulnerable. However, virtually no research has been done on the potential “double jeopardy” faced by rural minority women. This research examines (1) the extent to which racial and residential differences contribute to differences in stage at diagnosis; (2) the existence of an interaction between race and residence, which may place black rural women at greater risk; and (3) the influence of both individual and structural characteristics on racial and residential differences. The findings indicate that rural black women are diagnosed with breast cancer much later than are black urban women or whites of either residence. A number of individual and structural variables were influential in predicting stage at diagnosis, yet none of these accounted entirely for racial differences
Effects of Physician Outreach Programs on Rural‐Urban Differences in Breast Cancer Management
Authors: Howe Holly L. , Lehnherr Melinda , Katterhagen J. Gale
Published: April 2008

ABSTRACT: In 1986 to 1987, urban‐rural differences in several breast cancer management practices were noted in Illinois data. Several intervention programs for physicians were initiated to improve rural patients' access to state‐of‐the‐art breast cancer management to reduce these differences. This report compares an intensive rural oncology outreach intervention program with a lower intensity physician education program. Medical records from 1986 to 1991 were reviewed on 2,277 breast cancer patients in a 12‐county study area. The care received by urban patients was compared with three groups of rural patients: those managed in rural hospitals with intensive oncology outreach programs beginning in 1988 (Rural Group 1), and in those rural hospitals with less intensive interventions using an audit with feedback strategy beginning in 1989 (Rural Group 2). Rural patients who traveled to one of the urban facilities also were included in the analysis because the less intensive interventions also took place in these facilities, and these patients showed unique patterns of care in the baseline analysis (Rural Group 3). The years 1986 to 1987 constituted the baseline, and 1990 to 1991 constituted the final evaluation period. Chi square and multivariate analyses were conducted to compare the effect of the two types of interventions on changing breast cancer management practices and reducing the urban‐rural differences. By the final evaluation period, the high intensity intervention was not more successful in reducing or eliminating the urban‐rural differences than the low intensity intervention for many practices. However, often the frequency estimates were higher in Rural Group 1, which received the high intensity intervention. The changes noted in Rural Group 3 were not always the same as in Rural Group 2, even though both received the same low intensity interventions, lending evidence to the observation that travel distance and other nonmedical factors affect the choices of management modalities for these patients. Finally, given the nonrandomized study design, other explanations for the changes could not be ruled out.
Ambulatory Care Sensitive Hospitalization Rates in the Aged Medicare Population in Utah, 1990 to 1994: A Rural‐Urban Comparison
Authors: Silver Michael P. , Babitz Marc E. , Magill Michael K.
Published: April 2008

ABSTRACT: The objective of this study is to compare the likelihood of hospitalization for conditions that are related to the adequacy and use of ambulatory health care services for Medicare beneficiaries residing in rural and urban regions in Utah. The Health Care Financing Administration's (HCFA) hospital discharge database (Utah hospitals: 1990 to 1994) was used to estimate hospitalization rates (with adjustment for out‐of‐state admissions) for ambulatory care sensitive conditions. Population estimates were obtained from HCFA beneficiary files. Regional hospitalization rates were obtained through ZIP code matching of the hospital discharge and beneficiary files. Medicare beneficiaries aged 65 and older residing in Utah dvrino 1990 to 1994 are the subiects for the study. The main outcome measures include age and sex‐adjusted hospitalization rates by region for the entire state and rate ratio estimates for nonurban regions. The results of the study show that Medicare beneficiaries residing in two rural frontier regions were more likely than urban beneficiaries to be hospitalized for ambulatory care sensitive conditions. Rate ratio estimates were greater than 1.4 for both regions during the study period. These findings suggest a pattern of an increased burden of avoidable secondary complications and disease progression among Utah Medicare beneficiaries residing in some rural regions. This increased burden may be the result of limitations in the ambulatory care system, medical care provider supply, and/or beneficiary propensity to seek care. Variation in disease prevalence or hospital use patterns for these conditions also may be responsible for all or part of the observed variation in ambulatory care sensitive admission rates.
Farm Work is Dangerous for Teens: Agricultural Hazards and Injuries Among North Carolina Teens
Authors: Schulman Michael D. , Evensen Christian T. , Runyan Carol W. , Cohen Lisa R. , Dunn Kathleen A.
Published: April 2008

ABSTRACT: Children who work in agriculture suffer more than 23,000 injuries and 300 fatalities on American farms every year. Using survey data collected from a random sample of working teens (ages 14 to 17) in North Carolina, the authors analyze the farm‐based hazard exposure and injury experiences of teens who work on farms. The group of farmworking teens (N=141) is 72 percent male, has a mean age of 16.6 years, and is, on average, in the 10th grade. The data show that teens working on farms in North Carolina are exposed to significant safety hazards throughout their farmworking careers. A majority of the respondents in this group of farmworkers reported exposure to tractors, large animals, all‐terrain vehicles, farm trucks, and rotary mowers, and more than one‐third reported exposure to pesticides and tobacco harvesters. Common reported injuries include insect stings, cuts, burns, and falls. The researchers find that gender, age, and farmwork experiences are related to variations in types of hazards to which teens are exposed and in the types of injuries they suffer. These variables also are related to the overall complexity of the teens' farmwork experiences and the burden of injury endured by teens.
Public‐sector Immunization Coverage in 11 States: The Status of Rural Areas
Authors: Slifkin Rebecca T. , Clark Sarah J. , Strandhoy Suzanne E. , Konrad Thomas R.
Published: April 2008

ABSTRACT: This report uses county‐level immunization data generated by state public health agencies to explore the rural‐urban variation in the delivery of childhood immunizations in the public sector. Public health department‐documented immunization coverage rates for 1995 were obtained from 882 counties in 11 states east of the Mississippi River. To assess the possible association between public health department immunization coverage rates and county rurality, descriptive statistics were calculated. A multiple regression model then was estimated. In all states except West Virginia, nonmetropolitan counties averaged higher completion rates than metropolitan counties. Consistent with the descriptive statistics, in the regression analysis nonmetropolitan counties had average immunization rates 2.47 percentage points higher than metropolitan counties, even when controlling for county socioeconomic characteristics. For the 11 states in the analysis, rural children immunized in the public sector had higher completion rates compared with urban children. These data reflect the dependence of rural families on the public health system and the potential for successful health care delivery through public clinics. As new health care systems are brought into rural areas, the success of this existing avenue for care must not be overlooked.
Commentary From the Front Lines: Improving the National Health Service Corps' Use of Medical Providers
Authors: Earle‐Richardson Giulia B. , Earle‐Richardson Andrew F.
Published: April 2008

Abstract: Migrant and community health centers, funded by the Bureau of Primary Health Care (BPHC), provide a vital service to rural communities by ensuring accessible and affordable medical care. One way the BPHC helps communities staff these centers is through the National Health Service Corps (NHSC). In this program, medical professionals receive scholarships or educational loan repayment in return for practicing in medically underserved regions where migrant and community health centers are located. Nurse practitioners, physician assistants, and nurse midwives (nonphysician providers) are a recent addition to the NHSC, and they offer the advantages of reduced cost and a strong primary care orientation. In this commentary, the authors recount their own experiences as a nonphysician provider NHSC scholarship recipient and spouse, and they identify five underlying problems with the current system, which lead to poor nonphysician provider retention. (1) Too few potential placement sites are made available from the outset. (2) NHSC placement deadlines do not allow enough time for making the best possible placement. (3) Many community health centers are not highly supportive of or invested in the program. (4) NHSC efforts to support the development of local medical providers from within underserved regions are inadequate. (5) NHSC officers working with nonphysician providers do not demonstrate a high degree of commitment to achieving an optimal provider‐site match. Changes in the NHSC program based on these five problems are recommended to improve the retention of nonphysician providers in this important program.
Missouri Advantage
Authors: Casey Michelle , Yawn Barbara
Published: April 2008

Missouri Advantage HMO is a newly developed, small HMO based in a rural area. Strongly committed to local control, Missouri Advantage has a highly decentralized organizational structure. Its four rural hospital owners have built Missouri Advantage's initial enrollment base with hospital employees, capitalizing on their positions as the largest employers in their communities. The HMOs future plans include recruitment of additional rural hospitals and physician organizations as new equity owners of the HMO, and development of new products, including a Medicare risk product.
Implications of HMOs for Rural Providers and Consumers
Authors: Wellever Anthony
Published: April 2008

The impact of the six HMOs studied on rural providers has, to this point, been relatively small. To expand their provider networks in rural areas, the HMOs have been responsive to provider concerns, implementing payment arrangements and utilization management approaches that are acceptable to most rural providers. However, at some sites, changes in HMO and provider relations appear to be on the horizon. These changes include the acceptance of greater financial risk by rural providers and the more aggressive management of costs by the HMOs.

With respect to employers, the impact of HMOs have been largely positive. The presence of HMOs in the rural study areas has provided rural employers with new options for structuring health benefits programs. According to some rural employers, health insurance costs have been reduced, or at least constrained, as a result. Rural employers have dealt with employee concerns about access limitations by demanding that HMOs offer broad provider networks and products that permit the use of non‐network providers subject to co‐payments and deductibles.

The impact on rural employees, as evidenced by their responses as well as the views of their employers, has been mixed. Rural employees generally appreciate the broader benefit coverage offered by HMOs as well as reduced paperwork and, sometimes, lower required out‐of‐pocket contributions toward premiums.

However, as with their urban counterparts, rural employees are concerned about restrictions on access to providers of their choice and financial incentives in physician payment arrangements that may discourage the provision of services or the arrangement of referrals.
Networks and the Fiscal Performance of Rural Hospitals in Oklahoma: Are They Associated?
Authors: Broyles Robert W. , Brandt Edward N. , Biard‐Holmes Diane
Published: April 2008

Abstract: This paper uses regression analysis to explore the relation of network membership to the financial performance of rural hospitals in Oklahoma during fiscal year 1995. After adjusting for the scope of service, as measured by the number of facilities or services offered by the hospital, indicators of fiscal status are (1) the cash receipts derived from net patient revenue; (2) the cash disbursements related to operating costs, net of interest and depreciation expense, labor costs and nonlabor costs; and (3) net cash flow, defined as the difference between cash receipts and disbursements. Controlling for the effects of the hospital's structural attributes, operating characteristics and market conditions, the results indicate that members of a network reported lower net operating costs, labor costs and nonlabor expenses per service than nonmembers. Hence, the analysis seems to suggest that the membership of rural hospitals in a network is associated with lower cash disbursements and an improved net cash flow, outcomes that may preserve their fiscal viability and the access of the population at risk to service.
Swing Beds and Rural Hospitals in New York, 1991 to 1994
Authors: Rosenthal Thomas C. , Sokol Rosalie A. , Graham Robin P. , Pasley Beverly , Williams Dwight C.
Published: April 2008

Abstract: New York implemented a hospital swing bed program in 1991 to allow rural hospitals access to Medicare Part B financing, increase utilization of hospital rehabilitation services, and facilitate the care of patients in their home communities. Between the years 1991 and 1994, 13 hospitals participated in the program. The authors used the New York State Department of Health annual hospital reporting data to examine the hospital swing bed experience for length of stay, payer type, and discharge disposition. Eighty‐six percent of swing bed admissions came from the acute care units of the host hospital or a referral hospital. The average length of stay decreased from 25 days to 19 days during the study period with almost one‐half of the patients being discharged. Swing bed revenues accounted for 3.4 percent of the total hospital gross revenues by 1994. Respite care, a component unique to New York, accounted for an increasing percent of admissions throughout the study period. The program served a useful rehabilitative function, and it represents one strategy to care for rural patients near their homes.
A Healthy Health Sector is Crucial for Community Economic Development
Authors: Doeksen Gerald A. , Johnson Tom , Biard‐Holmes Diane , Schott Val
Published: April 2008

Abstract: This study presents a detailed model for measuring the economic effects of the health sector on a local economy. The total effects of the health sector on employment, income, retail sales, and sales tax collection by health category (hospitals, doctors and dentists, nursing and residential facilities, other medical and health services, and pharmacies) is presented. The model's application in nine Oklahoma counties found that approximately 9 percent of the total employment for each county was directly working in the health sector. With multipliers ranging from 1.45 to 1.87 applied to measure the total effects, including secondary employment, the health sector accounted for approximately 14 percent of all employment. This study provides an overview of the model, which employs local data and county input‐output multipliers. The study illustrates the usefulness and simplicity of the model by presenting results for Perry, OK.
Community and Migrant Health Centers
Authors: Whitener Lynn
Published: April 2008

“Research Reviews” are a regular feature of The Journal of Rural Health, presenting current research about a particular theme or topic of interest
The Medicare Critical Access Hospital Program: The First Year
Authors: Reif Susan S. , Ricketts Thomas C.
Published: April 2008

Abstract: The Medicare Critical Access Hospital (CAH) program, part of the Balanced Budget Act of 1997, is a nationwide limited service hospital program. Structured interviews were conducted in August and September 1998 with key people in state offices of rural health, state hospital associations, departments of health or departments of facility licensing in all 50 states to assess their progress in the development of the CAH program. The majority of states expressed interest in the CAH program. Twenty‐one states were moving formally toward involvement in the program. States that had developed or were in the process of developing a state plan estimated that between 183 to 227 hospitals would convert to CAHs in the next one to two years. States that were the most successful with plan development appeared to be states that participated in the Essential Access Community Hospital/Rural Primary Care Hospital program, states where there was dialogue about the possibility of a limited service hospital program and states with widespread support in the state. A pressing need for most states is for reliable fiscal consulting or analysis that could be applied to individual hospitals that are considering conversion to CAHs. The CAH program shows promise for successful implementation based on its early results.
Tracking the Response to the Balanced Budget Act of 1997: Impact on Medicare Managed Care Enrollment in Rural Counties
Authors: McBride Timothy D. , Mueller Keith J.
Published: April 2008

Abstract: The impact of the Balanced Budget Act of 1997 on recent changes in enrollment of Medicare beneficiaries into managed care plans is examined. The Balanced Budget Act of 1997 created a new payment structure for Medicare risk contracts, which, in 1998, resulted in all counties receiving either a minimum payment or a payment with the increase restricted at 2 percent growth over the 1997 rate. Using a baseline of December 1997 and enrollment data through June 1998, differences in early enrollment trends between urban and rural counties and between counties at various rates of payment are examined. As expected, continued enrollment increases in all counties is observed but with some concerns about slow enrollment growth‐und announcements of plan terminations‐in counties with payment rates in the mid‐range, above the floor payment but subject to the 2 percent growth. In addition, evidence of considerable changes in the benefits offered by plans and the premiums charged to beneficiaries also was observed during the first nine months of 1998. The implications for growth of managed care options in rural areas are still unclear. The floor on payments may be helpful, but constraints in payment increases and delays in implementing a blended rate can be expected to create a negative impact on decisions to market managed care plans.