bluuebunny/crossref_metadata_2025 huggingface dataset:
Physician Practice Characteristics and Satisfaction: A Rural‐urban Comparison of Medical Directors at US. Community and Migrant Health Centers
Authors: Shi Leiyu , Samuels Michael E. , Cochran Christopher R. , Glover Saundra , Singh Douglas A.
Published: April 2008

Abstract: For this study, the association between physician practice characteristics and satisfaction of medical directors at rural and urban Community and Migrant Health Centers (C/MHCs) was investigated. Data for this study came from a 1996 cross‐sectional survey of C/MHCs' medical directors. A total of 411 centers (68.3 percent) responded to the survey, including 240 rural (67.4 percent) and 171 urban (68.7 percent) C/MHCs. Factor analysis was used to synthesize physician practice characteristics related to overall satisfaction. The resulting factors were entered as new variables in a predictive logistic regression model of overall satisfaction. Growing up in an inner‐city community was significantly associated with practicing in an urban center; whereas, growing up in a rural or frontier community was more likely to result in practicing in a rural center. The majority of medical directors (82.3 percent) were either somewhat satisfied or very satisfied with their work. Satisfaction with work was most significantly associated with overall level of satisfaction, followed by satisfaction with administration, peers and patients. Recruitment efforts are more likely to succeed when they target individuals with prior exposure to underserved areas. Improving the working conditions and interactions with administrators would help sustain the high level of satisfaction experienced by medical directors at CIMHCs.
Hospital Mergers and Closures: Survival of Rural Hospitals
Authors: Sinay U. Tony
Published: April 2008

Abstract: There are two major models to save financially failing rural hospitals: (1) expanding through an affiliation or merger with other hospitals to increase the utilization and diversity of services, or (2) downsizing by employing the limited‐service model and providing only emergency and primary care service with limited acute care. This study investigates hospital mergers and closures from 1990 to 1992 using the American Hospital Association's (AHA'S) data from the Annual Survey of US. Hospitals. The presence of potential scale and scope economies among merging and closing hospitals prior to the merger or closure suggests that rural hospitals are operating at a size level that has great potential for achieving scope and scale efficiencies through mergers.
Issues in Rural Health Programming: A Center Perspective
Authors: Peterson Michael , Dunnagan Tim
Published: April 2008

Abstract: The purpose of this conceptual paper is to review select issues associated with rural health programs that have a number of satellite sites (periphery) coordinated through a primary supervisory body (center). The paper provides suggestions for fostering more effective programming to rural populations and generating further dialogue about center‐periphery issues from diverse perspectives. Based on literature and interviews with four rural health professionals who administer programs from a central location, three common center‐periphery challenges are identified and discussed: control, communication, and competency. To address these challenges and facilitate high‐quality programming, suggestions, including the effective use of dialogue and discussion, consensual decision‐making, a communication of care, and a center's role in staff recruitment and retention, are discussed.
An Overview of Adolescent Pregnancy in Rural Areas
Authors: Skatrud Julia DeClerque , Bennett Trude A. , Loda Frank A.
Published: April 2008

Abstract: Although explanations for high rates of adolescent pregnancy in the United States are not conclusive, adverse outcomes associated with early childbearing are well‐documented. Little is known about the specific circumstances and consequences of adolescent pregnancy in rural areas. This article summarizes a systematic review of literature relevant to pregnancy and pregnancy prevention for rural adolescents for 1980 to 1995. The primary focus of this study was on the eight southeastern states in Department of Health and Human Services Region IV From approximately 500 relevant citations in the database collected for this review, few dealt explicitly with adolescent pregnancy in rural areas, and an even smaller subset of the literature used empirical data. No data were found that indicated sexual activity was lower among rural teens, or that the risks of adolescent pregnancy and behaviors detrimental to pregnancy outcomes were less common in rural areas. Social isolation, lack of educational and economic opportunities, and limited access to health services are key issues with respect to rural youth and their healthy development. The relatively fewer numbers of health professionals in rural areas, weaker infrastructures for transportation and information, heightened concerns about confidentiality, low rates of insurance coverage, and reluctance to accept social services reduce the likelihood of rural teens receiving adequate preventive or reproductive care. Future research should address the social circumstances of rural adolescents to design effective interventions for teen pregnancy prevention and appropriate reproductive health services for young mothers and families in rural areas.
Rural‐Urban Differences in Service Use and Course of Illness in Bipolar Disorder
Authors: Rost Kathryn , Owen Richard R. , Smith Jeffrey , Jr. G. Richard Smith
Published: April 2008

Abstract: Policy analysts have long been concerned that the reduced availability of mental health professionals in rural areas prohibits rural individuals from getting the care they need for serious psychiatric conditions like bipolar disorder. Through a community‐based telephone survey, the researchers recruited 54 subjects with bipolar disorder who were currently experiencing depressive episodes. Forty‐six (85.1%) of them were reinterviewed one year after the first survey. Multivariate models indicate that while rural subjects were just as likely to receive nonacute services for mental health problems as their urban counterparts, the rural residents had 22.1 times the odds (95% confidence interval 2.5 to 198.3, P=0.006) of receiving such services exclusively from a general medical provider. Rural subjects had 5.8 times the odds (95% confidence interval 0.8 to 40.7, P=0.07) of using hospital or emergency room services and 4 times the odds (95% confidence interval 0.8 to 20.5, P=0.10) of experiencing a manic episode during the year following baseline. While rural individuals with bipolar disorder have a comparable likelihood of receiving care for their mental health problems, they utilize more acute services and experience worse outcomes. Further research is warranted to deter‐mine what causes these differences before developing cost‐effective ways to improve the care delivered to individuals with this serious illness.
Developing Community Partnerships to Enhance Care for Rural Families With Low Birth Weight Children
Authors: Sachs Barbara , Hall Lynne A.
Published: April 2008

Abstract: This paper describes one strategy, a participatory conference, for building partnerships among health professionals who provide care for rural families living in eastern Kentucky with low birth weight children. The long‐term goals are to improve coordination and to supplement care for these children and their families. A two‐round Delphi technique was used prior to the conference—Rural Low Birth Weight Children and Their Families: Visions for the Future—for providers, families, and policy‐makers to identify the major health needs and concerns of these families. At the conference, speakers presented data and examples of successful interventions used in other rural areas. In small groups, conference participants explored barriers to care and strategies to overcome them. They also made recommendations to improve service delivery. Based on conference ideas, a support program for families with low birth weight children is being implemented and evaluated in one rural county.
Antitrust Immunity in Rural Washington: A Good Answer, but What's the Question?
Authors: Saver Barry G. , Casey Susan , House Peter J. , Lishner Denise M. , Hart L. Gary
Published: April 2008

Abstract: State action immunity from antitrust liability has been proposed as an important tool for preserving and strengthening fragile rural health care delivery systems. Washington is a leader in the use of state action immunity, having passed a statute and having approved several applications for immunity. This paper summarizes the current status of state action immunity, both in general and in Washington, including a review of the literature and an explication of issues of particular relevance to rural areas. Additionally, a summary is presented of inter‐views with key informants in nine rural Washington communities, including an organization that had received a grant of immunity, one rural community just across a state border, and one other organization with rural operations that was given a grant of immunity. The interviews suggest that antitrust immunity, given the current interpretations of laws and guidelines by the courts, the Federal Trade Commission, and the Department of Justice, is not playing a significant role in the plans and decisions of health care providers in rural Washington. In larger rural areas, it was thought that activities could be structured to avoid antitrust liability without needing to apply for immunity; in smaller areas, there was little knowledge of antitrust issues, few resources to obtain knowledgeable advice, and little activity for which immunity might be useful. Overall, the authors did not find a large role for state action antitrust immunity in health care in rural Washington under current conditions.
Eliminating Primary Care Health Professional Shortage Areas: The Impact of Title VII Generalist Physician Education
Authors: Politzer Robert M. , Hardwick Kevin S. , Cultice James M. , Bazell Carol
Published: April 2008

Abstract: Most policy‐makers and researchers agree that although the United States is headed for a significant physician surplus, problems of equity in access to care still remain. To help meet this challenge, Title VII of the Public Health Service Act focuses on producing generalist physicians to serve in medically underserved areas (MUAS). This study estimates the impact Title VII support for generalist training has on reducing and eliminating health professional shortage areas (HPSAs) under multiple scenarios that vary either the Title VII funding level or the percentage of Title VII‐finded program graduates who practice in MUAs. For each scenario, the number of Title VII‐funded residency graduates who initially practice in MUAs and the time it would take to eliminate HPSAs are estimated. Using 1996 rates, the analysis predicts that 1,214 generalist physicians will enter practice in HPSAs annually, leading to elimination of HPSAs in 24 years. In 1997, Title VII‐funded programs increased the rate of graduates entering HPSAs, resulting in 1,357 providers and reducing the time for HPSA elimination to 15 years. Doubling the funding for these programs would increase the number of Title VII‐funded generalist physicians entering MUAs and could decrease the time for HPSA elimination to as little as 6 years. The study concludes that eliminating HPSAs requires broader Title VII influence and continuous improvement in rates of production of graduates who practice in MUAs. Without Title VII graduates and continuous improvement of Title VII program, MUA rates, the number of HPSAs and the number of Americans with reduced access to essential health care will continue to expand.
The Balanced Budget Act of 1997 and Rural Training Supported by Medicare Graduate Medical Education Funds
Authors: Crittenden Robert Andrew
Published: April 2008

Abstract: The Balanced Budget Act of 1997 promised a number of changes in medical education to benefit rural communities. The changes suggested that physician training would be more available in rural communities, programs training physicians for work in rural communities would be better supported, and residency programs would be allowed to be separate from hospitals. The regulations developed by the Health Care Financing Administration to implement the act are reviewed in the context of these expectations. Limitations in the regulations indicate that rural communities will see little benefit from this legislation. This article is a commentary on the expectations and reality of the effects of the Balanced Budget Act of 1997 on rural training supported by Medicare.
Proposed Changes to Designations of Medically Underserved Populations and Health Professional Shortage Areas: Effects on Rural Areas
Authors: Goldsmith Laurie J. , Ricktts Thomas C.
Published: April 2008

Abstract: This paper reports an analysis of the proposed rule to combine medically under‐served population (MUP) and health professional shortage area (HPSA) designations, as published by the Bureau of Primay Health Care (BPHC) in the Federal Register on Sept. 1, 1998 (Department of Health and Human Services, 1998). The efects of the proposed rule overall and on rural communities were examined, particularly with respect to current whole county HPSA designations and eligibility for federal assistance programs. National, county‐level estimates of primay care provider counts and other measures included in the proposed rule were used. Different primary care provider sources were compared; results were highly dependent on the data source and the inclusions of counts of nurse practitioners and physician assistants. The projections of losses from the proposed rule were higher than those of the BPHC, probably due to the use of different sources for provider counts. Overall, the authors projected that more than 50 percent of current whole‐county HPSAs would lose designation using the proposed rule. The proportion of rural counties that lost designation was not significantly greater than the proportion of urban counties, but because there are many more rural counties, more de‐designations were projected to occur in rural areas. The researchers also predicted that 58 percent of rural whole‐county HPSAs with National Health Service Corps providers would lose their designation, but most rural whole‐county HPSAs with Community and Migrant Health Centers or Rural Health Clinics retained their MUP designation using the proposed rule. The proposed rule likely has a larger effect on current designations than originally projected by the BPHC.
Do Targeted Efforts for the Rural Underserved Help Kill Comprehensive Reform?
Authors: Taylor Donald H.
Published: April 2008

Abstract: There has been a shift during the past 60 years from a broad notion of the entire nation as underserved to a more focused effort to identify particular areas (often rural) thought to be underserved. This approach was formalized with the advent of the war on poverty. This focused approach has been cemented during the past 30 years, in part by the success of various federal health center programs that have remained funded during this period in spite of opposition. This paper concludes that the consensus view that rural underserved areas represent an “exception” phenomenon that is properly addressed with special responses (organizations or physicians) has had two major effects: (1) the political survivability of focused programmatic responses (such as Community Health Centers) has been enhanced; and (2) the existence of an “elastic net” policy network to advocate for the expansion of such remedial efforts may play a contributory role in helping to defeat comprehensive health reform.
AHCPR‐funded Rural Managed Care Centers: Report From the Field
Authors: Hartley David , Jackson Jodie , Mueller Keith J. , Nichols Andrew , Williams Valerie
Published: April 2008

Abstract: In 1994, the Agency for Health Care Policy and Research awarded cooperative agreements to five University‐based groups to promote the establishment of managed care institutions and development of rural health networks. This paper summarizes the experiences of these rural managed care centers in the first three years of this initiative. Key ingredients for achieving the project's goals that are identified by the project directors are reported as “foundations” that must be in place from the outset, or “building blocks” that can be developed along the way. The development of information systems and efforts to foster leadership in the medical community are areas in which grant funding of this type can be most effective.
Risk‐adjusted In‐hospital Death Rates for Peer Hospitals in Rural and Urban Regions
Authors: Glenn L. Lee , Jijon Caroline R.
Published: April 2008

Abstract: The purpose of this research project was to compare inpatient mortality rates for rural hospitals with mortality rates of urban hospitals of given sizes and ranges of service. Statistical adjustments for risk were made in the probability of death during hospitalization for 43,000 patients across 166 hospitals by age, gender, principal diagnosis, principal surgical procedure, characteristics of the secondary diagnoses, and whether or not cancer was a seconday diagnosis. Eighty‐three small hospitals that had a relatively unspecialized range of services constituted the study group. Patient characteristics of this study group were moderately representative of the national population. A standardized score was calculated for each hospital using a formula based on the actual hospital death rate and the death rate expected for a given hospital with patients of the same demographic and medical characteristics. Patients admitted to hospitals in nonmetropolitan areas had a mortality rate of 0.41 percent compared with a mortality rate of 0.66 percent in peer hospitals in metropolitan areas. After mortality rates were risk‐adjusted and converted to z scores, nonmetropolitan areas had an average z of +0.16, and metropolitan areas had an average z of ‐0.25, where positive z scores reflect a lower‐than‐average adjusted mortality rate. The metropolitan‐nonmetropolitan (urban‐rural) difference was not statistically significant, but it is meaningful in that rural hospitals tended to have a lower adjusted mortality rate than urban hospitals of the same size and type, indicating that rural hospitals had the same or lower adjusted mortality rates. The possibility of urban hospitals having riskier patients was minimized but could not be definitively ruled out. Taken together with other studies, the data are consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients.
Primary Cesarean Section Rates in Uninsured, Medicaid and Insured Populations of Predominantly Rural Northern New England
Authors: Onion Daniel K. , Meyer Daniel L. , Wennberg David E. , Soule David N.
Published: April 2008

Abstract: Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age‐adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age‐adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.
Impact of Physicians' Perceptions of Malpractice and Adaptive Changes on Intention to Cease Obstetrical Practice
Authors: Burns Lawton R. , Connolly Terry , DeGraaff Robert A.
Published: April 2008

Abstract: Physicians who provide obstetrical care in rural areas face exposure to liability action and confront a critical decision–––whether to continue to offer these services. This paper draws upon social‐psychological and decision theories to investigate this decision. Ninety four percent of all obstetricians and family and general physicians practicing in the 22 non metropolitan counties of one state responded to a mail survey that asked about their intention to continue or discontinue obstetrical practice, two dimensions of subjective risk (perceived likelihood of threats in the malpractice environment and perceived magnitude of negative consequences from being sued), and adaptive changes to protect against malpractice. The results suggest that (a) perceived extent of negative consequences (but not perceived likelihood of malpractice threats) drives intention to leave obstetrics, (b) the professional and reputational impacts of a suit–––not the dollar amount of award or settlement–––predicts intention to stop practicing obstetrics, and (c) physicians planning to continue providing obstetrical care in the future have made recent practice changes that may further exacerbate access problems.
A Rural Cancer Outreach Program Lowers Patient Care Costs and Benefits Both the Rural Hospitals and Sponsoring Academic Medical Center
Authors: Desch Christopher E. , Grasso Michael A. , McCue Michael J. , Buonaiuto Debra , Grasso Kay , Johantgen Mary K. , Shaw James E. , Smith Thomas J.
Published: April 2008

Abstract: The Rural Cancer Outreach Pmgram (RCOP) between hoo rural hospitals and the Mediral College of Virginia's Massey Cancer Center (MCC) was developed to bring state‐of‐the‐art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre‐ and post‐RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, huo rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the pgram. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient setvices, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapd growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals fiwn RCOP Service areas by 330 percent for cancer patients and by 9 percent for non‐cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and acadmic medical center hospitals, provided state‐of‐the‐art care near home for rural patients and was associated with lower mall cancer treatment costs.
Rural Health Policy: A Limited‐service Rural Hospital Model: The Freestanding Emergency Department
Authors: Avery Sharon
Published: April 2008

Abstract: A rural hospital that has been downsized to a freestanding emergency department is an important model in that it offers a possible solution to a community's need to have emergency‐care services locally available. This model could include other important local services, such as skilled‐nursing and outpatient services. This study looks at the financial feasibility of a rural hospital shutting down acute‐care services and maintaining emergency services. Expenses were determined, and changes to revenue and expenses were estimated. Reimbursement was assumed static. Medicare cost reports and hospital financial disclosure reports were used in investigating three model categories: an urgent‐care clinic with emergency services; a hospital‐based emergency department with an outpatient clinic; a hospital‐based emergency department with an outpatient clinic and a hospital‐based skilled‐nursing facility. Even with best‐case assumptions regarding continued reimbursement, results show only a small increase in net income and, in two cases, large losses compared with the size of the hospital operations. A subsidy would be required from the community or an afiliated hospital or network for the model to remain financially stable. The regulatory barriers to implementation are noted, as well as the potential problems with the human aspects of implementation–––staffing, recruitment and retention, professional education and quality. If the model rural hospital is an affiliate or partner with one or more health care facility, which could assist with financial and staffing needs, it may be feasible.
Rural Health Research: Do Advanced Practice Nurses and Physician Assistants Benefit Small Rural Hospitals?
Authors: Bergeron Jeanette , Neuman Kimberly , Kinsey Jennifer
Published: April 2008

Abstract: Advanced practice nurses and physician assistants have offered small, rural hospitals an alternative to scarce primary care physicians for 30 years. This paper uses survey data from 285 small rural hospitals and case studies of 36 of these hospitals to answer questions about the extent to which advanced practice nurses and physician assistants provide primary care in small, rural hospitals, the benefits that might bring to the hospitals as well as the reactions of the public. The study used survey data collected as part of an evaluation of 285 hospitals, which received a Rural Health Care Transition grant from the Health Care Financing Administration in 1993 and 1994. Most of the hospitals used the practitioners; 70 percent used nurse practitioners; 30 percent used physician assistants; and 20 percent used both. There were some negative reactions to the use of the practitioners, but, overall, there was acceptance and benefits to the hospitals in the form of reduced recruitment costs, increased revenues and increased service offerings. These practitioners are beneficial to rural hospitals, and mechanisms to encourage their acceptance should be developed and implemented.
Rural Health Research: Rural and Urban Physicians: Does the Content of Their Medicare Practices Differ?
Authors: Baldwin Laura‐Mae , Rosenblatt Roger A. , Schneeweiss Ronald , Lishner Denise M. , Hart L. Gay
Published: April 2008

Abstract: Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994

Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board‐certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician‐gynecologists, the diagnostic scope of practice was specialty‐specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician‐gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician‐gynecologists need training outside their traditional specialty areas to optimally care for their patients.
Rural Health Policy: Physician Assistants and Nurse Practitioners: Rural‐Urban Settings and Reimbursement for Services
Authors: Anderson Donna M. , Hampton Mary B.
Published: April 2008

Abstract: Evidence based on productivity measures, salaries and costs of medical education indicates that physician assistants and nurse practitioners are cost‐effective. Managed care suggests that health maintenance organizations (HMOs) would seek to utilize these professionals. Moreover, underserved rural areas would utilize physician assistants and nurse practitioners to provide access. This study examined the role of payment sources in the utilization of physician assistants and nurse practitioners using the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the National Center for Health Statistics, U.S. Centers for Disease Control and Prevention. Rural us. urban results were compared. The study found that significant rural‐urban differences exist in the relationships between payment sources and the utilization of physician assistants and nurse practitioners. The study also found that payment source affects varied for physicians, physician assistants and nurse practitioners who saw outpatients in hospital settings. Surprisingly, prepaid and HMO types of reimbursements are shown to have no relationship with physician assistant and nurse practitioner utilization, and this finding is the same for both rural and urban patient visits. After controlling for other influences, the study shows that physicians, physician assistants and nurse practitioners are each as likely as the other to be present at a rural managed care visit. However, physicians are much more likely than physician assistants and nurse practitioners to be present at an urban managed care visit.
Analysis of Tractor‐related Deaths in North Carolina From 1979 to 1988
Authors: Bernhardt Judy Hayes , Langley Ricky L.
Published: April 2008

Abstract: This descriptive study examined 342 fatalities involving tractors and attachments that occurred during a 10‐year period in North Carolina from 1979 to 1988. Reports of the North Carolina Office of the Chief Medical Examiner and medical examiner's certificates of death were reviewed using the public health model of causation. Data were collected on characteristics of the fatally injured (host), including age, occupation, blood alcohol concentration and length of survival; characteristics of the injury event (environment), including type of accident, weather conditions and terrain; and characteristics of the agent, including both the tractor and attachments, if any, in place at the time of injury. Ninety‐eight percent of the victims were male. Victims ages 65 and older accounted for 38 percent of fatal injuries, and 11 percent were 18 years of age or younger. Only slightly more than one‐half of the victims (54 percent) were full‐ or part‐time farmers. Forty‐four percent of the deaths were to non farmers who were not in the act of farming. Nineteen percent of tested victims had a detectable blood alcohol level. Almost three‐fourths of the victims died in the first hour after injury and 87 percent within the first 24 hours. In the majority of accidents, the tractor operator was a victim of a rollover or runover. This study provided detailed characterization of the fatally injured and, to the extent possible, the tractor involved and the injury event itself. However, additional methods of data collection are needed to provide further characterization of the injury event and the injury agent to design and support prevention programs for tractor users.
Characterization of Rural Mental Health Service Systems
Authors: Calloway Michael , Fried Bruce , Johnsen Matt , Morrissey Joseph
Published: April 2008

Abstract:This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on non specialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit thede factohypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on non mental health agencies, rural mental health agencies are more interdependent.
Dimensions of Retention: A National Study of the Locational Histories of Physician Assistants
Authors: Larson Eric H. , Hart L. Gay , Goodwin Mary‐Katherine , Geller Jack , Andrilla Catherine
Published: April 2008

Abstract: This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as “all rural,”“all urban,”“urban to rural” or “rural to urban.” The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings let for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 22 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.
Consumer and Provider Evaluation of Rural Pharmacy Services
Authors: Straub LaVonne A. , Straub Stephen A.
Published: April 2008

Abstract: This paper compares consumer and provider perceptions regarding access to pharmacy services in rural Illinois, given a decrease in the number of pharmacies. Consumer data are from the Illinois Rural Life Panel in which more than 1,800 respondents answered questions about availability and use of pharmacy services and about insurance coverage and cost. A survey of all licensed retail pharmacies in 74 rural Illinois counties and in seven non‐rural counties provided pharmacy background information and was the source of data on changes in profitability and payment sources. The data provided insight on factors that affect access. Descriptive statistics were used to analyze data from both groups to compare perceptions about access. The objective was to evaluate current access to pharmacy services and implications for future access from the perspective of consumers and pharmacists. Results from rural consumers show access is currently good; 77 percent have a local pharmacy, and 64 percent prefer this source. Future access is of more concern. Pharmacy survey results show 81.5 percent of rural pharmacies are experiencing declining profits from drug sales. Restricted reimbursements from third‐party payers, demands of managed care and expanded competition are seen as threats to retention of local pharmacies and continued good access. An important finding, especially given survey evidence of increased managed care penetration, is the difference in views of pharmacists and consumers regarding the effects of managed care on access. Pharmacy survey data also revealed differences between rural and non‐rural pharmacies.
What We Say and What We Do: County‐level Public Spending for Health Care
Authors: Zimmerman May K. , McAdams Rodney
Published: April 2008

Abstract: The purpose of this study is to examine county‐level public spending for health care services in Kansas and to explain variation in spending levels with a model composed of population density, population age and per capita income. Data are abstracted from budget documents for all 105 counties in Kansas for the years 1994, 1995 and 1996. Health care expenditures are defined as county tax revenues spent for ambulance, hospitals, ambulatory care, home health services, nursing homes, and mental health and substance abuse services. Results show that Kansas counties spent between 12.1 percent and 23.6 percent of their budgets to fund local health care services between 1994 and 1996, spending more than $133 million in 1996 alone. In 10 counties, one‐quarter to one‐third of the budget went for health services. Low population density and relatively high per capita income explained nearly one‐third of the variation in how much counties spent and an even greater proportion when analysis was limited to the most rural counties. Findings from this study suggest there may be a significant local commitment in the United States to publicly supported health care services, more support than typically recognized and perhaps more than is estimated in national health care spending data. Future research on the economic effects of the health sector on local communities should take account of local spending for health care, especially at the county level.
Human Immunodeficiency Virus Infection in Rural Areas and Small Cities of the Southeast: Contributions of Migration and Behavior
Authors: Lansky Amy , Nakashima Allyn K. , Diaz Theresa , Fann S. Alan , Conti Lisa , Herr Mary , Smith Donna , Karon John , Jones Jeffrey L. , Ward John W.
Published: April 2008

Abstract: The design of education and prevention strategies to stem the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in rural areas depends on having accurate patterns of risk behavior and transmission in local areas. Interviews were conducted with people in rural areas and small cities in Delaware, Florida, Georgia and South Carolina who were at least 18 years old and infected with HIV in order to describe demographic characteristics, migration patterns and risk behaviors. Interviews were conducted with 608 people. Most respondents were male (66 percent), black (63 percent of men, 85 percent of women) and had been infected through sexual contact (67 percent of men, 66 percent of women). Most (65 percent) had lived away from a rural area or small city for at least one month; of those, 71 percent had moved from an urban area. Twenty‐seven percent of respondents indicated they had been infected locally. People with a history of injection drug use were less likely to have been infected locally than those who had no history of injection drug use (6 percent vs. 26 percent among men, 3 percent vs. 40 percent among women, P<0.001). Further understanding of the role of socioeconomic factors in HIV transmission in rural areas and small cities is needed. Programs designed to prevent HIV acquisition among people living in rural areas and small cities in the Southeast should focus on sexual behavior.
Socioeconomic Distress and Health Status: The Urban‐rural Dichotomy of Services Utilization for People With Sickle Cell Disorder in North Carolina
Authors: Haque Akhlaque , Telfair Joseph
Published: April 2008

Abstract: Research on sickle cell disorder has not focused attention on the socioeconomic background and geographic distribution of people with the disease. This study examines 1,189 persons with sickle cell disorder in North Carolina during 1991 to 1995. Three indices were developed using clients' medical, psychosocial and socioeconomic characteristics for the purpose of analyzing the urban‐rural difference in treatment for sickle cell disease. The study observed a wide disparity in these indices between urban and rural population groups. Also, differences were observed in the utilization of services and clients' health status. The findings suggest that utilization of services is directly related to socioeconomic condition facing clients and clinic distance from clients. They further suggest that people in rural areas who have high distress levels and are far from clinics have limited access to health care. The limited availability of medical and health care in rural areas, as well as other support systems calls for an increase in community based healthcare services. These findings should be of particular interest to the state level sickle cell disorder program in North Carolina and other areas with a large rural population. Enhanced support for all persons with sickle cell disorder in North Carolina, particularly those in rural areas, is critical.
Educating Generalist Physicians for Rural Practice: How Are We Doing?
Authors: Geyman John P. , Hart L. Gary , Norris Thomas E. , Coombs John B. , Lishner Denise M.
Published: April 2008

Abstract: Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to “small rural” communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.
The Use of Community Surveys for Health Planning: The Experience of 56 Northwest Rural Communities
Authors: Hagopian Amy , House Peter , Dyck Sarah , LeMire Joyce , Billett Daniel , Knievel Mark , Hart L. Gary
Published: April 2008

Abstract: A rural health services development program of the University of Washington School of Medicine has worked for 15 years with communities throughout the five‐state region of Alaska, Idaho, Montana, Washington and Wyoming to strengthen their health systems. In the course of that work, 56 communities were surveyed about their utilization and opinions of local health systems. This database allows the following generalizations to be made about rural Northwest communities: (1) People think highly of their local hospitals, physicians and other key components of the acute medical care system and want their hospitals to remain open. Older respondents are more satisfied than younger respondents; (2) the typical hospital market share is 36 percent, the typical physician market share is 50 percent (3) satisfaction with discrete, well‐funded services such as pharmacy, ambulance and dentistry is quite high, whereas satisfaction with mental health and substance abuse treatment is significantly lower; (4) the most commonly cited serious problems in surveyed communities were “too few physicians or‐services” and “care is too expensive”; and (5) there is great variation between communities in both satisfaction and utilization.
Delivering Mental Health Services to the Persistently and Seriously Mentally Ill in Frontier Areas
Authors: Wagenfeld Morton O.
Published: April 2008

Abstract: Frontier areas (defined as six or fewer persons per square mile) are at the extreme end of the urban‐rural continuum. Whereas they occupy almost half of the land mass of the United States, they constitute only about 2 percent of the population. Exigencies of harsh climate and vast distances make the delivery of health and human services even more difficult than in other rural areas. This paper describes several innovative models for delivering mental health services to the persistently and seriously mentally ill in rural areas.
Critical Access Hospitals: How Many Rural Hospitals Will Meet the Requirements?
Authors: Blanchfield Bonnie B. , Franco Sheila J. , Mohr Penny E.
Published: April 2008

Abstract: Although the Medicare Rural Hospital Flexibility Program (MRHFP), which establishes a new designation for limited‐service hospitals called critical access hospitals (CAH), intends to assist small rural hospitals having financial difficulty, it is unclear how many hospitals will qualify for the program. Potential CAHs are identified and the strategic issues that will impact actual participation in the program are discussed. Potential CAHs are identified by applying the legislative criteria for designation to a data set created from both the 1992–1995 Medicare Hospital Cost Report Information System and the 1993 and 1995 Prospective Payment Systems Impact files. Descriptive analyses are used to identify potential CAHs by three parameters: distance to nearest hospital, average daily census and operating margin. Results indicate that the majority of potential CAHs have low volume and report poorer operating margins than other rural hospitals. Findings also show that the mileage requirements significantly impact the number of potential CAHs. There is more than a ninefold difference between the 93 hospitals that meet the mileage criterion and the 864 hospitals that might be eligible if certified by the state as “necessary providers,” regardless of distance to the nearest hospital. The MRHFP is designed to prevent small, isolated hospitals from closing and thus to ensure continued access to care for rural residents. However, the number of potential CAHs that participate will clearly hinge on the flexibility of the program and the ability of states to determine “necessary providers.”