bluuebunny/crossref_metadata_2025 huggingface dataset:
Rural Primary Care Providers' Perceptions of Their Roles in the Provision of Mental Health Services: Voices From the Plains
Authors: Geller Jack M.
Published: April 2008

Abstract: Much has been written about the deficiencies of primary care providers in their treatment patterns, referral patterns and training for treating people with mental disorders. However, there is a growing realization that, regardless of these shortcomings, primary care providers will continue to be sought out by patients for care of mental disorders, due to patient preference, lack of alternatives or other reasons. Thus, a more recent focus has been on improving the link between primary care providers and mental health specialists. This may include integrated clinics, telecommunication links or simply enhancing the competency of primary care providers through clinical practice guidelines, utilization of screening instruments and greater contact with mental health professionals. Conspicuously absent from most of these studies, commissioned reports and policy papers is the voice of the rural primary care provider. Perhaps due to their heavy practice schedules, little has been written from their perspective. Accordingly, this paper presents the findings from a focus group held in early 1998, of a group of rural primary care providers who practice on the Western plains. It is in this forum that these providers discuss how they perceive their role, their treatment and referral patterns and their feelings and relationships with psychiatrists and the mental health system.
Can Community Organization Strategies be Used to Implement Smoking and Dietary Changes in a Rural Manufacturing Work Site?
Authors: Fries Elizabeth A. , Ripley Jennifer S. , Figueiredo Melissa I. , Thompson Beti
Published: April 2008

Abstract: A one‐year intervention project was developed and implemented to demonstrate the utility of using community organization methods to mobilize a rural, predominantly minority work site community toward smoking and dietary change. This intervention for smoking and dietary change was conducted in a rural work site (n=235 at baseline) and guided by employees. It involved activities to change the work site environment and the behaviors of individuals. A community advisory board (n=15) made up of members of the work site was established, and it met monthly with members from the research team to design and implement nine cancer prevention activities that were targeted to the needs of this community. Activities and information were disseminated to the employees during a nine‐month period. Surveys were administered prior to and following the delivery of the intervention. This project was successful in engaging a rural manufacturing work site community in thinking about cancer prevention strategies. Results of this intervention demonstrated significant increases in numbers of smoking cessation attempts, reported fruit and vegetable consumption, self‐efficacy for dietary change and perceived risk for cancer. Work site social norms changed as evidenced by employee perceptions of co‐worker support of dietary and smoking change (all ts>1.95, all Ps<0.05). Other results with marginal statistical significance (P<.015) but potentially useful for future studies include increased intentions to reduce the fat in the diet. In light of the low‐intensity and time‐limited nature of this community organization intervention, the observed changes in dietary and smoking behaviors are encouraging and support the use of these strategies in rural, culturally diverse work sites.
Access to Care for Rural Medicare Beneficiaries
Authors: Stearns Sally C. , Slifkin Rebecca T. , Edin Heather M.
Published: April 2008

Abstract: This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self‐reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self‐reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self‐reported access, satisfaction and utilization than does rural residence per se.
Out‐of‐Area Travel From Rural and Urban Counties: A Study of Ambulatory Care Sensitive Hospitalizations for New York State Residents
Authors: Basu Jayasree , Cooper James
Published: April 2008

Abstract: Rural patients who are admitted to hospitals outside their residence county or who travel great distances for hospitalization deprive local rural hospitals of revenue. To provide more information about such rural residents, we studied their characteristics compared to those admitted in the same county. Characteristics studied included illness severity, demographics and county resources. To validate the findings and to provide a different analytic approach, characteristics of residents who travel long distances for admission were also studied. We studied admissions for ambulatory care sensitive conditions, as they might be most responsive to policy changes such as increasing recruitment of local primary‐care physicians. Hospital discharges during 1994 for 248,656 New York State residents were studied. We constructed multivariate models using logistic regression and ordinary least squares methods. The models were applied to residents in three types of geographic location along an urban‐rural continuum. Outside admissions were associated with younger age, higher illness severity and fewer county hospital resources. Same county admissions were associated with nonwhite race, and lack of insurance. Surprisingly, in rural counties, outside admissions were directly associated with increased primary‐care providers. Results from the distance model generally supported findings from the outside admission model.
Maternal Complications of Normal Deliveries: Variation Among Rural Hospitals
Authors: Heaphy Paige E. , Bernard Shulamit L.
Published: April 2008

Abstract: This study examined variation in maternal complication rates fallowing normal vaginal delivery among 282 rural hospitals throughout the United States. Using a risk‐adjusted model to control far case mix, discharge abstracts of more than 84,000 women were analyzed to determine whether there were differences in outcomes resulting from, or concomitant with, their hospital stay. After risk adjustment, the majority of hospitals were found to be performing at an acceptable level; however, there were some factors associated with poor performance. Hospital volume and the availability of obstetricians in the county in which the hospital was located were found to have an inverse association with complication rates, whereas low county per capita income was found to have a positive association with poor facility performance. No association was found between complication rates and general practitioners and the degree of remoteness as defined by distance from the nearest tertiary care facility. The results demonstrate a relationship between volume and outcome and a threshold point at which volume becomes a significant factor in predicting facility performance. As well, a relationship is seen between physician specialty and outcome, in which obstetricians are significantly associated with facility performance at expected or better‐than‐expected levels. Normal vaginal delivery is an important service provided by rural hospitals. The relationships among volume, physician specialty and outcome suggested by these findings require further in‐depth examination of specific factors that affect patient outcomes and overall facility performance.
Safe Handling of Agricultural Pesticides in Minnesota: Results of a County‐wide Educational Intervention
Authors: Mandel Jeffrey H. , Carr W Peter , Hillmer Teresa , Leonard Pamela R. , Halberg Julia U. , Sanderson Wayne T. , Mandel Jack S.
Published: April 2008

Abstract: Safe pesticide handling in a group of Minnesota farmers, aged 40 years and older, was influenced through the use of a multifaceted, countywide educational intervention. Two intervention counties and two control counties were involved in this effort. The intervention consisted of mailed pesticide information to farm households, educational programs on pesticides for county physicians, elementary school training modules on pesticides and the use of safe pesticide handling displays in key business areas by agricultural extension agents. Five hundred eight farmers were identified as pesticide users (186 in the intervention counties and 322 in the control counties). The use of gloves and other protective clothing while handling pesticides increased in the intervention group. Improvement was greater in those who had used protective equipment the least before the intervention. From these results, it appears that a broad‐based educational intervention might have a modest impact in how farmers protect themselves when using pesticides.
Outcomes of Rural Training Tracks: A Review
Authors: Rosenthal Thomas C.
Published: April 2008

Abstract: Rural training tracks (RTTs) have developed as a strategy to encourage family medicine resident entrance into rural practice. Because most programs are small (two to Jour residents), data must be aggregated to determine RTT impact on practice preparation and location. Several studies over the last decade reveal that 76 percent of RTT graduates are practicing in rural America and that graduates describe themselves as prepared for rural practice. Sixty‐five percent are providing obstetrical services, and half are performing cesarean sections. From 1989 to 1999, there were a total of 107 graduates of rural training programs, making it unlikely that, without significant investment, this model could supply an adequate quantity of family physicians for rural America.
Medical Residencies and Increased Admissions in Rural Hospitals With Fewer Than 200 Beds
Authors: Connor Robert A.
Published: April 2008

Abstract: Medical education programs in general, and rural residency programs in particular, can be beneficial for rural hospitals. This study of 1,792 non‐metropolitan statistical area, acute general hospitals with fewer than 200 beds from 1993 to 1996 was designed to help rural hospitals and communities to quantify the likely effects of rural residency programs on hospital admissions. Data came from the hospital Prospective Payment System minimum data set. The results show that additional residents at rural hospitals with fewer than 200 beds generally result in an increase of approximately 100 to 200 admissions per resident—more for smaller hospitals and fewer for larger hospitals. Because increased admissions generally improve the financial health and continued operation of rural hospitals, this study confirms the importance of education‐based strategies in ensuring access to care in rural communities.
Investment in a Rural Residency Program: A Case Study
Authors: Catalano Robert A.
Published: April 2008

Abstract: Rural hospitals have used numerous strategies over the past several decades to recruit and retain physicians. These have included providing physicians economic incentives, immigration status, professional and technical support and establishing rural training tracks (RTT) in family practice residency programs. This paper presents the experience of an isolated rural region in southwestern New York state that has employed each of these strategies in the past decade. Success as measured by the change in size of the medical staff, hospital operating margins, admissions and employment occurred only after the emphasis changed from meeting hospital needs to physician needs. Pivotal to this strategy was the nurturing and development of an RTT. Investment in the residency program required strong leadership to ensure the political, financial and operational commitment of its affiliated hospital. In addition, the RTT required an affiliation with a financially viable, full‐service hospital, a strong on‐site chief of service, family physicians who performed cesarean sections, midlevel providers and practitioners dedicated to the mission of teaching.
Medical Training Debt and Service Commitments: The Rural Consequences
Authors: Pathman Donald E. , Konrad Thomas R. , King Tonya S. , Spaulding Cora , Jr. Donald H. Taylor
Published: April 2008

Abstract: This study assesses how student ban debt and scholarships, ban repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid‐covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled “moderate” or “great” concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with bans, and one‐quarter received support from federal, state or community‐sponsored scholarship, ban repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p<0.001) and provided care to more Medicaid‐covered and uninsured patients (53 vs. 29 percent, p<0.001), but did not differ in their incomes ($99,600 vs. $93,800, p=0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service‐requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.
Why Rural Residents Migrate for Family Physician Care
Authors: Borders Tyrone F. , Rohrer James E. , Hilsenrath Peter E. , Ward Marcia M.
Published: April 2008

Abstract: Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy‐makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.
Utilization of Preventive Medical Services in the United States: A Comparison Between Rural and Urban Populations
Authors: Zhang Ping , Too Guoyu , Irwin Kathleen L.
Published: April 2008

Abstract: Differences between rural and urban residents in their utilization of three clinical preventive services—Papanicolaou screening tests (Pap smears) for women aged 18 to 65, mammograms for women aged 50 to 69 and flu shots for people aged 65 or older—were examined using a nationally representative sample from the 1994 US. National Health Interview Survey. Eighty‐two percent of urban women and 79 percent of rural women (P=0.11) had Pap smears. Sixty‐eight percent of urban women and 61 percent of rural women (P=0.01) had mammograms. Flu shots were received by 55 percent of urban and 58 percent of rural elderly residents (P=0.11). Of women aged 50 to 69 who had a high school education or whose annual household income was between $15,000 and $34,999, significantly fewer rural than urban women had mammograms (P<0.01). However, the proportion of rural women receiving mammograms was not significantly different from that of urban women after adjusting for their education, household income and health insurance status. Education level, household income and health insurance coverage were positively associated with utilizing mammograms. These results suggest that differences in the utilization of preventive services between rural and urban women vary by services. Improving socioeconomic status and health insurance coverage of rural women may reduce the disparity in mammogram use between rural and urban women. Mechanisms of how a woman's socioeconomic status affects her utilization of mammograms needs further study.
Rural‐Urban Differences in End‐of‐life Care: The Use of Feeding Tubes
Authors: Gessert Charles E. , Calkins David R.
Published: April 2008

Efforts to improve end‐of‐life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community‐to‐community variations in end‐of‐life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n=78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n =4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural‐urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.
Screening for Diabetic Retinopathy in Rural Areas: The Potential of Telemedicine
Authors: Cummings Doyle M. , Morrissey Susan , Barondes Michael J. , Rogers Lance , Gustke Susan
Published: April 2008

Diabetic retinopathy is a common cause of blindness, and screening can identify the disease at an earlier, more treatable stage. However, rural individuals with diabetes may have limited access to needed eye care. The objective of this project was to demonstrate the feasibility of a diabetic retinopathy screening program using a state‐of‐the‐art nonmydriatic digital fundus imaging system. The study involved a series of patients screened in primary care and public health locations throughout seven predominantly rural counties in eastern North Carolina. Images of each fundus were obtained and sent to a retinal specialist. The retinal specialist reviewed each image, recorded image quality, diagnosed eye disease and made recommendations for subsequent care. Of193 volunteers with a history of diabetes mellitus, 96.3 percent reported that they were very comfortable or comfortable with the camera. Eighty‐five percent of images were rated as good or fair by the retinal specialist. The retinal specialist also reported being very certain or certain of the diagnosis in 84 percent of cases. Image quality correlated highly with the certainty of diagnosis (Spearman's rank order correlation coefficient =0.79; P<0.001). The average time since the previous examination by an eye care specialist for diabetic subjects was two years. Approximately 62 percent of diabetic patients had diagnosable eye conditions, the most common of which was diabetic retinopathy (40.9 percent). In this convenience sample, African Americans, despite similar age and disease duration, were more likely to have retinopathy. Digital imaging is a feasible screening modality in rural areas, may improve access to eye care, and may improve compliance with care guidelines for individuals with diabetes mellitus.
The Economic Realities of Rural Pharmacy Practice
Authors: Stratton Timothy P.
Published: April 2008

TOPIC EDITOR'S NOTE:

The issue of availability of pharmacists is gaining importance in rural health care. In 1999, for example, Congress responded to growing concern over a potential pharmacist shortage by directing the secretary of Health and Human Services to conduct a study of the pharmacist workforce. The agency was to determine the extent of any shortage and was also directed to seek comments regarding the issue. The report, delivered to Congress in fall 2000 with evidence indicating an emerging shortage of these professionals, has important implications for health care in rural areas. This Crossroads feature by pharmacist Timothy P. Stratton, Ph.D., offers additional insight by combining a brief review, personal experience and findings of a preliminary study to help tire journal focus attention on this issue.
An Analysis of Substance Use Among Adolescents From Smaller Places
Authors: Donnermeyer Joseph F , Scheer Scott D.
Published: April 2008

This study examined trends in substance use among 12th grade students who live in smaller places. Subjects from smaller places were defined as those residing in nonmet‐ropolitan and metropolitan counties who reported growing up on a farm, in the country (i.e., living in an unincorporated rural area but not on a farm) or in a small town (i.e, living in a place with fewer than 50,000 residents that is not a suburb or located next to a larger place). Six types of smaller places were created from a cross‐tabulation of nonmetropolitan‐metropolitan status and where subjects reported growing up. Substance‐use rates among 12th graders residing in these six types of smaller places from 1976 to 1997 at three‐year intervals were compared, based on data available from the Monitoring the Future study. For past‐year alcohol use, some differences were found by place, with farm youth showing the lowest rates. Large differences were exhibited for past‐year marijuana use, both across nonmetropolitan‐metropolitan status and across youth from farm, country and small‐town locations within nonmetropolitan counties. Rates of past‐year illicit drug use were essentially the same regardless of location. Overall, when significant differences were found, most revealed less use for the more rural location.
Itinerant Surgical and Medical Specialist Care in Kansas: Report of a Survey of Rural Hospital Administrators
Authors: Kellerman Rick , Ast Terry , Dorsch John , Frisch Larry
Published: April 2008

In most rural areas, specialist nonprimary care, when available, is provided by “itinerant” physicians and surgeons who periodically visit from a distant home base. Little is known about current usage and acceptability of itinerant specialists in rural communities. Administrators of hospitals in rural and frontier Kansas counties were asked to report the frequency of itinerant care in their facilities, the home base of each specialist and a listing of procedures performed during specialist visits. Administrators were also asked to respond on a Likert scale to six questions inviting their assessment of itinerant care. Responses were received from 53 of 56 hospitals. All offered at least one monthly session of itinerant medical or surgical care. The most common specialties represented were cardiology (in 87 percent of hospitals), urology (68 percent), orthopedics (68 percent) and radiology (60 percent). General surgeons consulted in over 80 percent of responding hospitals. Psychiatrists, dermatologists and neurologists were rarely available in the hospitals surveyed. Administrators generally rated itinerant care highly, though some expressed concern about revenue lost when specialists performed procedures in their home‐base office or hospital. No associations were found between amount of care offered and potential explanatory variables such as hospital size, distance from subregional centers, or percentage of patients hospitalized locally. Furttier study is needed to better understand differences in itinerant specialist utilization and acceptance among rural Kansas hospitals. Because Kansas demographics are similar to those of many other American rural areas, such study may offer insights applicable to other regions.
Access and Issues of Equity in Remote/Rural Areas
Authors: Bull C. Neil , Krout John A. , Rathbone‐McCuan Eloise , Shreffler M. Jean
Published: April 2008

This article reports on a workshop in which the major focus was a review of the barriers that prevent access to the array of community‐based services available to the rural elderly. The demographics of the elderly were outlined and key components of the service system described. Attention was given to access hospital‐based care, the closing of hospitals and the reasons for bypassing rural hospitals for those in large towns or cities. Special emphasis also was given to mental health services and their uneven accessibility. A review of the policy implications closed the workshop.
Characteristics of and Issues Faced by Rural Female Family Physicians
Authors: Barley Gwyn E. , Reeves C. Brooke , O'Brien‐Gonzales Ann , Westfall John M.
Published: April 2008

ABSTRACT: The purpose of this study was to identify characteristics of and issues faced by female family physicians practicing in rural areas. A 37‐item survey was designed to obtain demographic information about the background, community and practice of rural female physicians. An open‐ended question regarding the issues and problems faced by female physicians in rural communities was included. Study subjects were identified from the membership of the American Academy of Family Physicians (AAFP). The questionnaire was mailed to all 850 active female AAFP members practicing in communities with less than 50,000 inhabitants during the winter of 1999. Completed and usable surveys were received from 587 (69.9 percent). The average age of respondents was 45. The majority were married (81.1 percent) and had children (80.1 percent). Half of the women had grown up in communities of 25,000 or less population. Twenty‐seven percent of the respondents had no rural exposure in medical school; 39 percent had no rural exposure in residency; and 16 percent had no rural exposure in medical school or residency. The majority of respondents (62 percent) practiced in communities of less than 10,000. A large majority (70 percent) of these women planned to stay in the community for 10 years or more, with 58.6 percent responding that they plan to stay indefinitely. Assumptions regarding rural physicians, especially women, must be updated to accurately assist communities in recruiting rural physicians and to assist medical schools and residencies in adequately preparing graduates for rural practice.
Predicting Level of Mental Health Care Among Children Served in a Delivery System in a Rural State
Authors: Anderson Rachel L. , Estle George
Published: April 2008

ABSTRACT: The purpose of this study was to establish benchmark data to assist in identifying factors associated with mental health service needs and level of care for children living in a rural state. Clinical and psycho‐social needs and strengths were assessed using retrospective chart review for all children and adolescents (n=150) with symptoms or a diagnosis of reactive attachment disorder who presented to a comprehensive treatment facility between January 1997 and December 1999. Logistic regression was used to predict factors associated with inpatient admission (n=15) vs. community‐based care (n=135). Significant individual contributors to the prediction of inpatient care were more limited clinical/psycho‐social strengths, history of inpatient use and history of sexual abuse. Although 80 percent of children admitted to inpatient care had a history of hospitalization, two‐thirds had no history of receiving community‐based services and presented to current treatment with a tivo‐year or longer history of symptoms. Approximately two‐thirds of children admitted to inpatient care had a history of sexual abuse; however, one‐third of these children had no history of mental health service use and presented to current treatment with a two‐year or longer history of symptoms. Findings raise concerns about current efforts in public health education, community awareness and health prevention and early intervention programs for children with mental/behavioral health challenges and children and families at risk for abuse and/or neglect living in rural areas.
The Reported Value of Rural Internal Medicine Residency Electives and Factors That Influence Rural Career Choice
Authors: Jensen Christine C. , DeWitt Dawn E.
Published: April 2008

Abstract: This study examines how rural electives affect medical residents' opinions about rural practice and which factors encourage or discourage choice of rural practice. Participants in a one‐ to two‐month rural elective and a matched group of randomly selected nonparticipants were surveyed. Seventy percent of the elective participants (n = 58) and 61 % of the matched nonparticipants (n = 51) completed the questionnaire. The groups' responses to scaled response measures and open‐ended questions were analyzed using, chi‐square and Mann‐Whitney U tests. A majority of participants stated that the elective was a beneficial experience (n = 36), and participants' interest in rural practice increased significantly after the elective. Elective participants were more likely than nonparticipants to see breadth of practice, continuity of care, quality of life in rural areas, and experiences with mentors as encouraging rural practice. Elective participation did not demonstrably increase rural career choice, although this finding may be attributable to small sample size. Respondents identified means to encourage rural practice, as well as barriers to rural practice: Elective participants suggested that electives may be more effective if they occurred earlier in medical training, lasted for longer periods of time, and addressed the needs of spouses or partners. Generalizability is limited by several factors, including small sample size and the possibility of pre‐existing differences between elective participants and nonparticipants.
Rural‐Urban Differences in Health Risks, Resource Use and Expenditures Within Three State Medicaid Programs: Implications for Medicaid Managed Care
Authors: Bronstein Janet M. , Adams E. Kathleen
Published: April 2008

This study uses Medicaid claims data for income‐eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis‐based Adjusted Clinical Group system. Resource use is compared on a risk‐adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower owerall for rural enrollees, on a risk‐adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under‐reimburse managed care organizations for the care of rural as opposed to urban residents in the study states.
Cervical Cancer Risk as a Predictor of Pap Smear Use in Rural North Carolina
Authors: Cyrus‐David Mfon S. , Michielutte Robert , Paskett Electra D. , D'Agostino Ralph , Goff David
Published: April 2008

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer‐related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross‐sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk‐appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High‐risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low‐risk status was the absence of all factors. A high‐risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low‐risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk‐appropriate screening guidelines. Low‐risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.
Disparities in Mammography Screening in Rural Areas: Analysis of County Differences in North Carolina
Authors: Cummings Doyle M. , Whetstone Lauren M. , Earp Jo Anne , Mayne Linda
Published: April 2008

The extent to which targeted mammography programs have impacted women in rural areas is not well defined. We investigated mammography screening rates among 843 women age 50 and over from a population‐based sample in four predominantly rural eastern North Carolina counties. We examined age, race, education level, county of residence, health insurance, and the self‐reported completion of mammography in the past year using contingency tables and logistic regression. African American females aged 65 years or older had the lowest reported mammography rates (42%), while white females aged 50 to 64 had the highest rates (58%). Uninsured women and those with less education were less likely to have received a mammogram. Logistic regression demonstrated that age, education, and health insurance were significant predictors of mammography completion. A county‐level analysis revealed that three counties had similar rates and one county had substantially laver rates. A higher‐than‐expected rate of screening‐mammography completion among African American women was noted in one predominantly rural county served by a breast cancer screening program. Logistic regression analysis confirmed that county was a significant predictor for mammography completion. In separate regressions run by race, county remained a significant predictor for African American women but not for white women. Differences in mammography screening appear to persist in some predominantly rural areas and are related to age, race, education, and health insurance. Programs that target hard‐to‐reach women with efforts tailored specifically to their needs may be effective in reducing persistent racial differences.
Are Rural Residents and Hispanics Less Satisfied With Medical Care? Evidence From the Permian Basin
Authors: Borders Tyrone F. , Xu Ke Tom , Rohrer James E. , Warner Ronald
Published: April 2008

Few population‐based studies of consumerś perceptions of health care quality have included both rural residents and Hispanics. Using data collected through a random‐digit telephone survey of households in the Permian Basin region of west Texas, an area with a relatively high percentage of Mexican Americans, we tested for rural/urban and ethnic differences in satisfaction with medical care. The study had several limitations, but the findings suggest that rural residents of this region rate the quality of their medical care overall more negatively than do their urban counterparts. No ethnic differences were found when controlling for demographic, social, economic, and health‐status characteristics. Other factors, including part‐time employment, a lack of continuous health insurance coverage, and poor health status appear to have a stronger, negative relationship with satisfaction. The collection and reporting of more specific measures of interpersonal and technical quality would further enable policy‐makers, managers, and clinicians to better serve their patient populations.
Challenges in Evaluating Rural Health Programs
Authors: Beaulieu Joyce , Webb John
Published: April 2008

Complex community‐based prevention programs are being held to scientific euidence of their eflectiveness and rural public health departments that implement such programs often are not equipped fo evaluate them Rural public health departments are fettered by small budgets, small staffs, and less access to evaluation experts and similar resources Community‐based health promotion programs can include complex designs that may work diferently in rural areas and evaluation of rural programs can be hampered by lack of control groups and the instability of results from small populations The University of Kentucky has entered into a contract with the state Department for Public Health to implement an internal, participatory model of evaluation In this model, the university evaluation expert trains local public health department staff in technical skills for program evaluation and acts as mentor and technical consultant to local public health departments on an ongoing basis Through training and site visits, this model is one approach to addressing the challenges of evaluating rural health promotion programs
In‐Hospital Stroke Mortality, Hospital Transfers, and Referral Bias at a Rural Academic Medical Center
Authors: Riggs Jack E. , Libell David P. , Hobbs Gerald R.
Published: April 2008

A chart review of acute stroke (DRG 14) discharges from a rural academic medical center in 1999 was performed because of an observed high in‐hospital crude acute stroke mortality rate An analysis of the results of this chart review demonstrated that the odds ratio of intracerebral hemorrhage in patients who had been transferred from other hospitals was 117 compared to intracerebral hemorrhage in nonhospital transfer patients (p >000001) This finding illustrates the potential magnitude and significance of referral bias at a rural academic medical center
Primary Care Practice Management in Rural and Urban Veterans Health Administration Settings
Authors: Weeks William B. , Yano Elizabeth M. , Rubenstein Lisa V.
Published: April 2008

Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care The authors used survey and administrative data from 1999 from the Veterans Health Administration (vHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally Rural VHA hospitals me smaller, less likely to be academically affiliated, and had fewer integrated specialty care services Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings
Where to Seek Care: An Examination of People in Rural Areas With HIV/ AIDS
Authors: Schur Claudia L. , Berk Marc L. , Dunbar Jennifer R. , Shapiro Martin E. , Cohn Susan E. , Bozzette Samuel A.
Published: April 2008

Though HIV/AIDS has spread to rural areas, little empirical evidence is available on where patients living in these areas receive care This article presents estimates of rural residents in care for HIV/AIDS, their demographic and health‐related characteristics, information about whether they receive care in a rural or urban setting, and data on the drug therapies prescribed The estimates come from the HlV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV‐infected adults receiving care in the contiguous United States Regardless of the definition used‐enrollment site, usual source of HIV care, or site of most recent hospitalization‐almost three quarters of rural residents with HIV/AIDS obtained their health care in urban areas The authors find that differences in the demographic characteristics of those using urban vs rural care do not drive the decision on where to obtain care, with the primary difference being that people with a rural provider tend to be older Rural residents with an urban usual source of HIV care incurred significant inconvenience in obtaining care‐the majority said their care was not conveniently located, they had substantially longer mean travel times, and over 25% had put off obtaining care in the past 6 months because they did not have a way to get to their provider Given the considerable burden this places on a chronically ill population, further research is needed to explore how provider supply and provider experience affect the decision to travel for care and how quality of care is affected.
Telehealth: An Assessment of Growth and Distribution
Authors: Grigsby William J.
Published: April 2008

Telemedicine uses telecommunications technologies to deliver health care to populations located at some distance from health care providers Telehealth is a somewhat broader term that includes non‐clinical applications (such as education) This article draws on data from a nationwide survey of telehealth networks that assesses the extent and character of telemedicine activity Although statistics point to increased utilization, the distribution of growth has been skewed a few applications and it is not clear that rural areas would derive substantial benefit in the absence of federal subsidy Reported barriers to building sustainable programs often seem to reflect concerns of large hospitals and health care systems rather than constraints faced by rural organizational and individual network members The potential role of government in addressing barriers is discussed.
Assessment of a Curricular Component Designed to Introduce Physical Therapy Students to Rural Practice Issues
Authors: LaPorta Laura , McWhorter J. Wesley , Naas Edith
Published: April 2008

A rural health curricular component was designed for students enrolled in a physical therapy program in Nevada to change student attitudes about rural practice and to encourage more physical therapy students to seek employment in rural areas postgraduation. Student attitudes and beliefs related to rural practice were investigated following participation in a rural health conference and a full‐time rural clinical afiliation. Twelve students (N = 12) participated. All reported positive impressions of rural practice after participating in the rural clinical afiliation and nine (75%) were favorable toward seeking employment in a rural setting. Two (17%) accepted rural health positions following graduation. Clinical experience in a rural setting m found to have the greatest influence on student attitudes about rural practice.
The Proximity of Predominantly African American and Hispanic Rural Communities to Physicians and Hospital Services
Authors: Pathman Donald E. , Konrad Thomas R. , Schmrtz Robert
Published: April 2008

This study assesses how local physician concentrations and distances to hospitals differ for rural communities of varying African American and Hispanic compositions. The authors used data at the town‐area Ievel (i.e., towns and their immediately surrounding minor civil divisions and census civil divisions) for 9 Southern and 6 Western states, primarily for 1990. Data wre from the US. Census, American Medical Association, and American Hospital Association. Analyses compared nonmetropolitan town‐areas with low, medium, and high proportions of African Americans and Hispanics on their local physician‐to‐population ratios and distances to nearest hospitals offering each of four levels of services. The authors found that Western town‐areas having over 50% Hispanic populations had lower physician densities than other Western town‐areas that were predominantly non‐Hispanic White (24.2 vs. 31.2 physicians per 100,000 population). In Southern town‐areas, physician densities did not covary meaningfully with the proportion of African Americans. Distances to the nearest hospitals offering basic, intermediate, and tertiary subspecialty services were generally 25% to 35% farther for Southern town‐areas composed of over 60% African Americans and for Western tmn‐areas composed of over 50% Hispanics, compared to communities with more than 80% non‐Hispanic White populations within each region. These relationships were not attributable to confounding by extraneous state factors, but in some cases were explained by community sociodemographic diflerences other than race. Thus, the authors learned that rural communities with populations that are predominantly Hispanic, but not those predominantly African American, face longer travel distances to physicians, and both groups face longer distances to some types of hospital services than rural communities with few minorities.