Rural Hospital Patient Safety Systems Implementation in Two States

CONTEXT AND PURPOSE: With heightened attention to medical errors and patient safety, we surveyed Utah and Missouri hospitals to assess the "state of the art" in patient safety systems and identify changes over time. This study examines differences between urban and rural hospitals. METHODS: Survey of all acute care hospitals in Utah and Missouri at 2 points in time (2002 and 2004). Factor analysis was used to develop 7 latent variables to summarize the data, comparing rural and urban hospitals at each point in time and on change between the 2 survey times. FINDINGS: On 3 of the 7 latent variables, there was a statistically significant difference between rural and urban hospitals at the first survey, with rural hospitals indicating lower levels of implementation. The differences remained present on 2 of those latent variables at the second survey. In both cases, 1 of those variables was computerized physician order entry (CPOE) systems. Rural hospitals reported more improvement in systems implementation between the 2 survey times, with the difference statistically significant on 1 of the 7 latent variables; the greatest improvement was in implementation of "root cause analysis." CONCLUSIONS: Adoption of patient safety systems overall is low. Although rates of adoption among rural versus urban hospitals appear lower, most differences are not statistically significant; the gap between rural and urban hospitals relative to quality measures is narrowing. Change in rural and urban hospitals is in the right direction, with the rate of change higher in rural hospitals for many systems.     

Uninsured hospitalizations: rural and urban differences.

CONTEXT: Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences. PURPOSE: To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations. METHODS: We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Project's National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations. FINDINGS: Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than $35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals. CONCLUSIONS: The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.     

Lengthening Spells of Uninsurance and Their Consequences

The lengths of time adults are without health insurance have increased since 1988, as shown by data from 1,235 household interviews completed during 1992 in Nebraska. Rural residents without insurance have experienced longer such spells than their urban counterparts. Thus, while rates of uninsurance are nearly the same between urban and rural residents, important differences exist. The relationship between insurance status and physician utilization is consistent during the five years (1989 to 1993) covered in this study. Continuously insured persons have the most physician visits, followed by those intermittently insured, followed by those continuously uninsured. The number of physician visits was expected to increase when respondents moved from uninsured to insured status. However, among urban respondents, the number of visits declined; among residents in rural frontier counties (fewer than six person per square mile) and for respondents in rural nonfrontier counties, there was no significant difference. This study points out some differences between rural and urban populations regarding insurance status, even when the overall rates of uninsurance are equal.     

Rural Residence and Poor Birth Outcome in Washington State

It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome.     

An empirical comparison of rural and urban safety-net hospitals

This study compares the characteristics of rural hospitals with urban safety-net hospitals and with "other urban hospitals" (non-teaching, non-safety-net urban hospitals that provide mainstream care in the United States). The objective is to examine if there are similarities between rural and urban safety-net hospitals, both of which serve underserved populations. The authors also wish to study if there are areas in which rural and urban safety-net hospitals are closer together compared to "other" urban hospitals. Based on the results, some potential areas of cooperation between rural and urban safety-net hospitals are discussed.     

A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States.

OBJECTIVE: Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. This may be especially true for critical access hospitals since these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. The purpose of this paper was to compare quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals. DESIGN: Cross-sectional study analyzing secondary Hospital Compare data. T-test statistics were computed on weighted data to ascertain if differences were statistically significant (P=0.01). SETTING: Centers for Medicare and Medicaid Services hospitals. PARTICIPANTS: US Acute Care and Critical Access hospitals. MAIN OUTCOME MEASURES: Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia. RESULTS: For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant (P=0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals CONCLUSIONS: Although this study focused on only three disease states, these are among the most common clinical conditions encountered in inpatient settings. The findings suggested that there may be differences in quality in rural critical access hospitals and urban acute care hospitals and support the need for future studies addressing disparities between urban acute care and rural critical access hospitals.     

Has Medicare Been a ‘Bad Deal’ for Rural Hospitals?

Understanding the links between Medicare involvement and financial performance in rural hospitals is important for evaluating reimbursement policy under Medicare's prospective payment system (PPS). While simple comparisons between urban and rural hospitals suggest that the latter have lower PPS profit margins on average, there is little multivariate evidence on how Medicare involvement affects financial performance in rural hospitals and whether this relationship differs between rural and urban hospitals. Existing multivariate evidence suggests that Medicare involvement improves PPS profits in both rural and urban hospitals after controlling for other hospital- and market-specific factors. By contrast, the present analysis considers the relationship between Medicare involvement and broader measures of profitability than PPS profits. This provides insight into whether Medicare reimbursement is adequate relative to other forms of third-party payment. The results indicate that Medicare involvement has a markedly different effect on the profitability of rural versus urban hospitals. Greater Medicare involvement is associated with lower patient care profitability in rural hospitals but has a strong positive and significant effect on both patient care and overall (i.e., patient and nonpatient) profitability in urban ones. Medicare involvement is not significantly related to overall profitability in rural hospitals, however, suggesting that these hospitals may be able to mitigate patient care revenue shortfalls from greater Medicare involvement by increasing their nonpatient care revenue sources.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Rural physician assistants: a survey of graduates of MEDEX Northwest.

Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural- and urban-practicing physician assistants are remarkably similar in most respects--income, hours worked, levels of practice satisfaction, for example--those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants.     

Rural Medicare Beneficiaries'Use of Rural and Urban Hospitals

This report examines the use of rural and urban hospitals by rural Medicare beneficiaries. Many rural Medicare beneficiaries are treated in urban hospitals, primarily for specialized care that is not available locally. This study examines Medicare inpatient hospital discharge data for rural beneficiaries from fiscal year 1990 to fiscal year 1998. Utilization patterns by diagnosis-related group (DRG) are examined for fiscal year (FY) 1997. The percentage of rural beneficiaries treated in urban hospitals ranged from 30 percent to 36 percent during the study period. For the most frequently occurring DRGs among rural beneficiaries, which were those for routine conditions, treatment occurred predominantly in rural hospitals. The conditions most often responsible for rural beneficiaries' use of urban hospitals during this period reflected the need for coronary and other specialized surgical care. The stability of volume and case-mix throughout the study period underscores the viability of rural hospitals during a period of substantial change in the organization of health care provision.     

Lower Rehospitalization Rates Among Rural Medicare Beneficiaries With Diabetes

Purpose: We estimated the 30‐day readmission rate of Medicare beneficiaries with diabetes, across levels of rurality. Methods: We merged the 2005 Medicare Chronic Conditions 5% sample data with the 2007 Area Resource File. The study population was delimited to those with diabetes and at least 1 hospitalization in the year. Unadjusted readmission rates were estimated across levels of rurality. Multivariate logistic regression estimated the factors associated with readmissions. Findings: Overall, 14.4% had a readmission; this was higher among urban (14.9%) than rural (12.9%) residents. The adjusted odds indicated that remote rural residents were less likely to have a readmission (OR 0.74, 0.57‐0.95) than urban residents. Also, those with a 30‐day physician follow‐up visit were more likely to have a readmission (OR 2.25, 1.96‐2.58) than those without a visit. Conclusion: The factors that contribute to hospital readmissions are complex; our findings indicate that access to follow‐up care is highly associated with having a readmission. It is possible that residents of remote rural counties may not receive necessary readmissions due to lower availability of such follow‐up care. Policy makers should continue to monitor this apparent disparity to determine the impact of these lower rates on both patients and hospitals alike.     

Understanding hospital referrals to home health agencies

Using resource dependency theory and transaction-cost economics theory, we examined the simultaneous effects of a vertical integration strategy and environmental complexity on home health agency (HHA) referrals by hospitals. Discharge data for calendar year 1990 from 61 Pennsylvania hospitals were analyzed. Using hospital ownership of home health agencies and urban versus rural location as the primary independent variables, a logistic regression model calculated the probability of HHA referral, after controlling for long-term care beds and patient characteristics. Results showed that HHA ownership was a significant predictor of home health referrals for both rural and urban hospitals, although the effect was greater for urban hospitals. These results suggest that hospitals are actively using referrals to home healthcare in response to environmental pressures. As these pressures increase, hospitals will benefit from tight linkages with home health providers.     

军队医院委托管理乡镇卫生院的实践

为深化驻地农村医疗卫生体制改革,推进城乡卫生统筹发展,构建城乡医疗卫生一体化发展格局,本院在农村医疗卫生体制改革过程中,对驻地两个卫生院实行托管,探索“城市带乡镇、乡镇带村组、大院带小院、城乡同发展”的“造血式”医院托管模式,为推进驻地城乡医疗资源均等化起到作用.     

Comparison of Rural and Urban Residents'' Implicit and Explicit Attitudes Related to Seeking Medical Care

CONTEXT: The decision whether or not to consult a physician draws from a variety of attitudes within an individual's health schema. While rural Americans are in greater need of health care, many of them have fewer external resources than urbanites available to them. PURPOSE: The objective of this study was to elicit implicit and explicit attitudes related to seeking medical treatment for a condition described as fairly serious. Participants were asked to rate how often they comply with treatment regimens and practice good health habits. METHODS: The sample of rural (N = 586) and urban (N = 433) North Carolina residents was derived based on random-digit dialing. Multiple regression analyses were performed to investigate how attitudes associated with perceived compliance and health behaviors. FINDINGS: While rural and urban residents offered very similar responses, the associations between attitudes and behaviors were different. One healthy and 2 unhealthy schema patterns emerged. First, fear of hospitals was associated with effective compliance for rural residents and good health habits for urbanites. Second, affordability concerns were ascribed to rural community residents but seemed to reflect personally relevant implicit attitudes since they were associated with poor health adherence and habits for rural residents. Third, mistrust of doctors predicted low adherence for both groups and was also associated with poorer health habits for urbanites. With inconsistencies among implicit and explicit attitudes and behaviors, some residents seemed to be ambivalent about seeking health care.     

Adjusting Measures of Physician Availability to Reflect Importation of Physician Services into Rural Areas

Recent changes in the organization and delivery of physician services in rural areas suggest the need to update how physician availability is viewed and measured. The objective of this study was to empirically examine the effect of rural hospitals contracting with outside physicians for part or all of their emergency room coverage, and the use of urban specialists to staff outpatient clinics, on measures used to assess physician availability. Based on data from one rural state, the findings demonstrate the importance of adjusting for the importation of physician services into rural areas.     

Physician Perceptions of Practice Environment and Professional Satisfaction in California: From Urban to Rural

CONTEXT: Few studies have systematically examined the experience of rural practice from the physician's perspective or included physicians from an array of specialties, particularly non-primary care. PURPOSE: To better understand differences between rural and urban physicians in perceptions of their practice environment. METHODS: In 2001-2002, self-administered questionnaires were sent to a probability sample of primary care and specialist physicians identified from the American Medical Association's Physician masterfile in California. Logistic regression was performed to model the effect practice location had on key variables, controlling for physician demographics, specialty, and the insurance profile of the physician's patients. FINDINGS: Completed questionnaires were obtained from 1,365 of 2,240 eligible urban physicians (61%), and 398 of 632 rural physicians (63%). Among primary care physicians, those in rural areas defined as nonadjacent or small non-metropolitan counties were the least likely to report pressures to see more patients, limit referrals, and limit treatment options. In contrast, among specialists, those in rural areas within metropolitan areas (or in large adjacent non-metropolitan counties) were more likely than urban specialists to report practice pressures. Although rural physicians in both primary care and specialist fields were more likely than urban physicians to report difficulty attracting new physicians to their communities, they perceived their overall practice climate to be better. Physicians in the nonadjacent-or-small non-metropolitan category were the most satisfied, but specialists in the nonadjacent-or-small non-metropolitan category were the least satisfied. CONCLUSION: Physicians in rural California appear to have maintained a greater sense of clinical autonomy and higher professional satisfaction compared with their urban counterparts.     

A logit analysis of hospital choice behavior in Chollabukdo Province of Korea

This paper analyzes hospital choice behavior of inpatients in Chollabukdo Province of the Republic of Korea. By applying a binary logit model on the disaggregate basis, we examine how individual inpatients select tertiary hospitals with high-level services as opposed to secondary low-level hospitals. From the analysis, we have found significant differences in the hospital choice behavior among the different socioeconomic groups of population. Especially meaningful differences were observed between urban and rural residents. The present policy focusing on the construction of low-level hospitals is thought to be reasonable to cope with the needs of rural residents, whereas increasing demand for high-level services is expected in the urban area.     

Hospital-physician integration: case studies of community hospitals.

Hospitals are attempting more meaningfully to involve physicians in management as one approach to increasing the efficiency and effectiveness of their operations. The purpose of this research was to explore the relationship between the structure of the medical staff organization, the extent to which physicians are integrated into hospital decision making and the hospital's financial performance. A measure of hospital-physician integration was developed based on Alexander et al's (1986) dimensions of hospital-physician integration which were based on Scott's (1982) organizational models, ie, autonomous, heteronomous and conjoint. A multiple case study design, which comprised eight community non-teaching hospitals over 200 beds located in the Province of Ontario, Canada, was used to examine the relationship between variables. Study results suggest that there is variation among community hospitals on both contextual and organization factors. Hospitals with high levels of hospital-physician integration were located in highly populated areas, had formulated and implemented a strategic plan, had highly structured medical staff organizations, and had no budgetary deficit. In contrast, hospitals with moderate or low levels of integration were more likely to be located in lowly populated areas, had little planning activity, had a moderately structured medical staff organization, and had deficit budgeting. Suggested areas for future research include examining the role of the Board of Trustees in determining physicians' organizational roles and identifying differences in commitments, characteristics, and motivations of physicians working in rural versus urban hospitals and their impact on integrative strategies.     

军队医院开展新农合促进军地融合式发展

军队医院兼具社会公益性和军事保障性的双重性质。新型农村合作医疗是新时期政府为了解决＂三农＂问题,促进城乡医疗公平所实施的一项重大民生工程。军队医院是军队卫生机构开展新农合的前沿和重点,开展新农合对促进军队医院军地融合式发展起到了重要的作用。