Rural‐Urban Differences in Health Services Utilization in the US‐Mexico Border Region

Purpose: Evaluate the association between driving distance to the US‐Mexico border and rural‐urban differences in the use of health services in Mexico by US border residents from Texas. Methods: Data for this study come from the Cross‐Border Utilization of Health Care Survey, a population‐based telephone survey conducted in the Texas border region in spring 2008. Driving distances to the border were estimated from the nearest border crossing station using Google Maps. Outcome measures included medication purchases, physician visits, dentist visits, and inpatient care in Mexico during the 12 months prior to the survey. A series of adjusted logit models were estimated after controlling for relevant confounding factors. Findings: The average driving distance to the nearest border crossing station among rural respondents was 4 times that of urban respondents (42.0 miles vs 10.3 miles [P < .001]). Rural respondents were more likely to be dissatisfied than urban respondents with the health care provided on the US side of the border, yet they were less likely to use health services in Mexico. Driving distance to the border largely explained the observed rural‐urban differences in medication purchases from Mexico. In the case of inpatient care, however, rural respondents reported a higher utilization rate than urban respondents and this rural‐urban difference became more pronounced after adjusting for the effect of driving distance to the border. Conclusions: Dissatisfaction with US health care services in rural communities in the US‐Mexico border region seems to be compounded by the lack of access to health care services in Mexico due to travel distance constraints.     

The adoption and use of health information technology in rural areas: results of a national survey

Context: Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural‐urban differences in HIT adoption at the national level. Purpose: To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption. Methods: A national mail survey of 5,200 primary care offices, stratified by rurality using Rural‐Urban Commuting Area categories, was conducted in 2007‐2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans. Results: A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02). Conclusions: HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.     

Self-reported patterns of health services utilisation: an urban-rural comparison in South Australia

Objective: To compare self‐reported patterns of health service utilisation among residents of urban and rural South Australia. Design, setting and main outcome measures: Secondary analysis of data generated by computer‐assisted telephone interviews of 7377 adults done in 1995–6. Respondents were asked if they had used each of 18 different health services during the previous 12 months. Residence was classified in three ways: (1) capital city versus rest of the state, (2) by the Rural, Remote and Metropolitan Areas classification (RRMA) and (3) by the Accessibility and Remoteness Index for Australia classification (ARIA). Results: General practitioner services were most frequently used, by approximately 89% of respondents. Only 4% reported not using any service. Comparing capital city with rest of the state, modest but statistically significant differences in utilisation (P < 0.01) were measured for nine services. In eight of these nine, utilisation was higher among rural residents. Analysing by RRMA, eight services were reportedly used differently and seven of these were the same as those identified from the capital city versus rest of state comparison. Across the five ARIA categories, six previously identified services were reported as being used differentially. Overall, rural residents had a higher than expected rate of moderate and high level of health service use. Conclusions: Self‐reported use of a range of health services was broadly similar across urban and rural South Australia, with most cases of higher use were reported from rural areas rather than urban areas. Similar results were obtained when residence was classified in the three different ways. What is already known on this subject: It is widely reported that the health status of and access to health services for rural Australians is worse than their urban counterparts. However, while this is clearly the case for some conditions and some groups, further data is needed to understand rural–urban health differentials better. Few explicit comparisons of different methods of classifying rurality (RRMA, ARIA and capital city vs. the rest) have been published. What does this study add: This study demonstrates that the self‐reported utilisation of a wide range of health services in South Australia is no worse, and is often greater, among rural residents compared to those in Adelaide. The same conclusions are reached irrespective of the method of classifying rurality.     

Similar secondary stroke prevention and medication persistence rates among rural and urban patients

Purpose: Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke. Methods: The Adherence eValuation After Ischemic Stroke‐Longitudinal (AVAIL) study is a multicenter registry of stroke patients enrolled in 101 hospitals nationwide. Medications were recorded at hospital discharge and again after 3 and 12 months. Persistence was defined as continuation of prescribed discharge medications. Participants were categorized as living in rural or urban settings by cross‐referencing home ZIP code with metropolitan statistical area (MSA) designation. Findings: Rural patients were younger, more likely to be white, married, smokers, and less likely to be college graduates. There was no difference in stroke type or working status compared to urban patients, and there were minor differences in comorbid conditions. There were no differences based on rural vs urban residence in medication persistence at 3 or 12 months postdischarge and no differences in outcomes of recurrent stroke or rehospitalization at 12 months. Conclusion: Despite differences in patient characteristics, there was no difference in medication persistence or outcomes between rural and urban dwellers after hospitalization for ischemic stroke or transient ischemic attack (TIA).     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

Differences in access to health care services among adults in rural America by rural classification categories and age

Objective: To study differences in excess to health care services between different population groups in rural areas of the United States. Design: Using data from the 1994 National Health Interview Survey and the 1991 Area Resource File, we examined the differences in excess with seven measures: having a regular source of care, having a usual place of care, having health insurance coverage, delaying medical care because of cost for all rural residents; number of doctor visits, number of hospital discharges and length of hospital stay per discharge for those who reported their health as being either poor or fair. Rural residents were classified by ages and grouped into four rural classification categories that were characterised along two dimensions: adjacent to a metropolitan statistical area (MSA) (yes/no) and inclusion of a city of at least 10 000 people (yes/no). Setting: Rural areas Subjects: Rural populations. Results: Residents aged 18–24 years had the worst access to services and the residents aged 65 years and over had the best access to services when measured by regular source of care, a usual place of care and health insurance status. Compared to those aged 50–64 years, residents aged 25–49 years were less likely to report having health insurance and more likely to report delaying seeking medical care because of costs. Rural residents who lived in a county adjacent to an MSA generally were less limited in access than those who lived in a county not adjacent to an MSA. Conclusions: Rural America is not a homogeneous entity in many aspects of the access to health care services.     

Associations of Rural Residence With Timing of HIV Diagnosis and Stage of Disease at Diagnosis,South Carolina 2001-2005

Context: Rural areas in the southern United States face many challenges, including limited access to health care services and stigma, which may lead to later HIV diagnosis among rural residents. Purpose: To investigate the associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis. Methods: Timing of HIV diagnosis was categorized as a diagnosis of acquired immune deficiency syndrome within 1 year of a first positive HIV test or HIV-only. Stage of disease was based on initial CD4+ T-cell count taken within 1 year of diagnosis. County of residence at HIV diagnosis was classified as urban if the population of the largest city was at least 25,000; it was classified as rural otherwise. Logistic regression was used to analyze timing of HIV diagnosis, and analysis of covariance was used to analyze stage of disease. Findings: From 2001 to 2005, 4,137 individuals were diagnosed with HIV infection. Of these, 1,129 (27%) were rural and 3,008 (73%) were urban residents. Among rural residents, 533 (47%) were diagnosed late, compared with 1,258 (42%) urban residents. Rural residents were significantly more likely to be diagnosed late (OR 1.19 [95% CI, 1.02-1.38]). Rural residence was associated with lower initial CD4+ T-cell count in crude analysis (P= .01) but not after adjustment (P > .05). Conclusions: Rural residence is a risk factor for late HIV diagnosis. This may lead to reduced treatment response to antiretroviral medications, increased morbidity and mortality, and greater HIV transmission risks among rural residents. New testing strategies are needed that address challenges to HIV testing and diagnosis specific to rural areas.     

Health Care Utilization Patterns for Young Children in Rural Counties of the I‐95 Corridor of South Carolina

Objective: The objective of this study was to assess health care utilization patterns for young children with Medicaid insurance in the rural counties of the I‐95 corridor in South Carolina relative to other regions of the state. We hypothesize that young children received less well care and higher levels of tertiary care in the rural counties along the I‐95 corridor (I‐95) of South Carolina. Design/Methods: A Medicaid cohort of children less than 3 years of age was used to compare Early, Periodic, Diagnosis, Screening and Treatment (EPSDT) visits; preventable emergency department (ED) visits; and inpatient visits between I‐95, other rural and urban county groupings. Results: The adjusted odds of a child having had 80% of the recommended EPSDT visits were reduced for I‐95 compared to other rural counties. The odds of a preventable inpatient or ED visit were increased for all rural counties, with the highest rates in the other rural counties. Conclusions: Children accessed well care less in the I‐95 corridor compared to other rural areas of South Carolina. Rural children accessed tertiary care more often than urban children, a finding most prominent outside the I‐95 corridor, likely attributable to more available access of tertiary care in rural counties outside the I‐95 corridor.     

Mental Health Differences Between Rural and Urban Men Living with HIV Infection in Various Age Groups

Despite the disproportionate increase in rural, Southern residents and older persons during the third era of the HIV/AIDS epidemic, no known study has examined whether older, rural men living with HIV infection face a double jeopardy and have poorer psychosocial profiles than other subgroups of men. We investigated whether area of residence (rural, urban), age (young, middle-age, old), and the interaction of residence and age would be related to mental health factors by using two measurement methods to categorize rural and urban residence (US Census Bureau classification and The Office of Rural Health Policy’s, Rural Urban Commuting Area Codes [RUCAs]). We conducted 2–3 hour-long, face-to-face interviews with all but 43 patients who met the study criteria and kept their clinic appointments at three different types of healthcare facilities (i.e., VA, university clinic, public health department) over a 20-month period. The sample consisted of 226 men living in the southeastern US. Rural and urban men of various age groups did not differ in socioeconomic factors, travel distance to clinics, use of medications, satisfaction with care, types of severe stressors, and confidentiality concerns. Using two methods to categorize area of residence, we found that rural men as compared to urban men had similar levels of total stress, AIDS-related stress, social support, active coping and avoidance coping, but higher rates of risk for depression. Rural men had higher levels of non-AIDS-related stress only when the US Census Bureau’s categorization was used, which highlights the importance of carefully selecting and describing methods to categorize rural versus urban residence.     

The March to Accountable Care Organizations—How Will Rural Fare?

Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural‐relevant ACO‐performance measures and provide necessary technical assistance to rural providers and organizations.     

Child Nutritional Status by Rural/Urban Residence: A Cross‐National Analysis

Purpose: Rural children in developing countries have poor health outcomes in comparison with urban children. This paper considers 4 questions regarding the rural/urban difference, namely: (1) do individual‐level characteristics account for rural/urban differences in child nutritional status; (2) do community‐level characteristics account for rural/urban differences net of individual‐level characteristics; (3) does type of residence alter the influence of individual characteristics; and (4) does the rural/urban difference vary across national contexts? Method: Analysis is based on Demographic and Health Survey data from 35 developing countries. Multilevel regression is used to examine rural/urban differences in nutritional status net of individual, community and national determinants of health status. Findings: Rural children have a substantially higher risk of poor nutrition. Much of this disadvantage is because of socioeconomic disadvantage, reproductive norms favoring early and more rapid childbearing, and lack of access to modern medicine. Rural residence also structures the nature of the relationships between socioeconomic status, access to medical care, and nutrition. Finally, the rural/urban gap declines as countries develop. Conclusion: Rural/urban differences in child nutritional status are substantial, and some—but not all—of the differences are attributable to socioeconomic status, access to medical care, and reproductive norms.     

Diabetes Burden and Access to Preventive Care in the Rural United States

Context: National databases can be used to investigate diabetes prevalence and health care use. Guideline-based care can reduce diabetes complications and morbidity. Yet little is known about the prevalence of diabetes and compliance with diabetes care guidelines among rural residents and whether different national databases provide similar results.
Purpose: To examine rural-urban differences in the prevalence of diabetes and compliance with guidelines, and to compare the Behavioral Risk Factor Surveillance System (BRFSS) and the Medical Expenditures Panel Survey (MEPS).
Methods: Data for 2001-2002 were analyzed and compared by rural-urban status. Prevalence was calculated as simple unadjusted, weighted unadjusted, and weighted adjusted using a multivariate approach. Results from the 2 databases were compared.
Findings: A slightly higher prevalence of diabetes among rural residents, 7.9% versus 6.0% in MEPS and 7.6% versus 6.6% in BRFSS, was found and persisted after adjustment for age, BMI, insurance coverage, and other demographic characteristics (adjusted OR 1.16 [1.02-1.31] in MEPS; 1.19 [1.01-1.20] in BRFSS). Rural persons in MEPS were less likely to receive an annual eye examination (aOR = 0.85) and a feet check (aOR = 0.89). A significantly ( P < .05) smaller proportion of rural residents in BRFSS received an annual eye examination (aOR = 0.88), feet check (aOR = 0.85), or diabetes education (aOR = 0.83). Rural residents in both datasets were more likely to get a quarterly HbA1c test done.
Conclusion: Rural residents in both datasets had higher prevalence of diabetes. Though not always statistically significant, the trend was to less guideline compliance in rural areas.     

Prevalence of Obesity Among Adults From Rural and Urban Areas of the United States: Findings From NHANES (2005‐2008)

Purpose: Rural residents have higher rates of chronic diseases compared to their urban counterparts, and obesity may be a major contributor to this disparity. This study is the first analysis of obesity prevalence in rural and urban adults using body mass index classification with measured height and weight. In addition, demographic, diet, and physical activity correlates of obesity across rural and urban residence are examined. Methods: Analysis of body mass index (BMI), diet, and physical activity from 7,325 urban and 1,490 rural adults in the 2005‐2008 National Health and Nutrition Examination Survey (NHANES). Findings: The obesity prevalence was 39.6% (SE = 1.5) among rural adults compared to 33.4% (SE = 1.1) among urban adults (P= .006). Prevalence of obesity remained significantly higher among rural compared to urban adults controlling for demographic, diet, and physical activity variables (odds ratio = 1.18, P= .03). Race/ethnicity and percent kcal from fat were significant correlates of obesity among both rural and urban adults. Being married was associated with obesity only among rural residents, whereas older age, less education, and being inactive was associated with obesity only among urban residents. Conclusions: Obesity is markedly higher among adults from rural versus urban areas of the United States, with estimates that are much higher than the rates suggested by studies with self‐reported data. Obesity deserves greater attention in rural America.     

The Impact of Living in Rural and Urban Areas: Vitamin D and Medical Costs in Veterans

Purpose: Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural‐urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization. Methods: Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural. Findings: The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization. Conclusions: Vitamin D deficiency may be an additional health disparity experienced by both rural and inner‐city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.     

Alcohol consumption among urban, suburban, and rural Veterans Affairs outpatients

Purpose: United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care‐based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol consumption among urban, suburban, and rural Veterans Affairs (VA) outpatients. Methods: Outpatients from 7 VA facilities responded to mailed surveys that included the validated Alcohol Use Disorders Identification Test Consumption (AUDIT‐C) screening questionnaire. The ZIP code approximation of the US Department of Agriculture's rural‐urban commuting area (RUCA) codes classified participants into urban, suburban, and rural areas. For each area, adjusted logistic regression models estimated the prevalence of past‐year abstinence among all participants and unhealthy alcohol use (AUDIT‐C ≥ 3 for women and ≥ 4 for men) among drinkers. Findings: Among 33,883 outpatients, 14,967 (44%) reported abstinence. Among 18,916 drinkers, 8,524 (45%) screened positive for unhealthy alcohol use. The adjusted prevalence of abstinence was lowest in urban residents (43%, 95% CI 42%‐43%) with significantly higher rates in both suburban and rural residents [45% (44%‐46%) and 46% (45%‐47%), respectively]. No significant differences were observed in the adjusted prevalence of unhealthy alcohol use among drinkers. Conclusions: Abstinence is slightly more common among rural and suburban than urban VA outpatients, but unhealthy alcohol use does not vary by rurality. As the VA and other health systems implement evidence‐based care for unhealthy alcohol use, more research is needed to identify whether preventive strategies targeted to high‐risk areas are needed.     

Postacute Stroke Rehabilitation Utilization: Are There Differences Between Rural‐Urban Patients and Taxonomies?

Purpose: To assess the association between Veterans Affairs (VA) stroke patients’ poststroke rehabilitation utilization and their residential settings by using 2 common rural‐urban taxonomies. Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received 12‐months poststroke hospitalization. Patients’ urban, rural, or isolated/highly rural status was determined using the Rural‐Urban Commuting Areas (RUCA) and VA Rural Urban (VARU) definitions based on patient residential ZIP code. Logistic regression models were fit for the rehabilitation outcome, adjusting for potential risk factors. Findings: Among the 8,296 stroke patients, 69.6%/61.1% were categorized as urban, 21.3%/37.5% as rural, and 9.1%/1.4% as isolated/highly rural by the RUCA/VARU definitions, respectively. Compared with their urban counterparts, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home, and not intubated. Compared with the rural patients, odds of receiving rehabilitation therapy were 1.2 times (RUCA) and 1.1 times (VARU) by the urban patients, and 0.53 times (VARU only) by the highly rural patients, after risk adjustment. The above comparisons were significant at P < .05. Conclusions: With both taxonomies, the rural patients were less likely to receive postacute stroke rehabilitant therapy than their urban counterparts. With the VARU, the highly rural patients were less likely to receive rehabilitation care than their rural counterparts. Different taxonomy may lead to different rural‐urban classification yields and different yields may lead to different outcomes and conclusions.     

Preventive services for rural and urban African American adults

BACKGROUND: Studies have shown that African Americans and rural patients receive fewer preventive services than other patients. OBJECTIVE: To compare the use of preventive services by African Americans in urban and rural settings to determine if race and rural residence were additive risks for not obtaining preventive services. METHODS: Three hundred African American patients seeking care in family practices in South Carolina were surveyed about preventive health care. RESULTS: Rural and urban African Americans were equally likely to know about preventive services and be up-to-date on receiving these services. In both practices, those with lower incomes were less likely to be up-to-date. Patients seen in the urban setting were more likely to receive counseling regarding exercise and smoking than those in the rural practice (87% vs 71%, P = .003). CONCLUSIONS: For both urban and rural African American patients with access to primary care physicians, preventive service use is high. The best predictor of poor compliance with preventive service recommendations was low income, suggesting that a lack of access to care is the primary reason why rural and African American populations do not receive adequate preventive health care.     

Maternal Obesity and Gestational Weight Gain in Rural Versus Urban Dwelling Women in South Carolina

Purpose: An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality. Methods: The 2004‐2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural‐Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m²), normal weight (18.5‐24.9), overweight (25.0‐29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicine's 2009 GWG guidelines. Chi‐square tests and adjusted multinomial logistic regression were used in analysis. Findings: Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG. Conclusions: Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.     

Edentulism in High Poverty Rural Counties

Purpose: To examine the differences in oral health status among residents of high‐poverty counties, as compared to residents of other rural or urban counties, specifically on the prevalence of edentulism. Methods: We used the 2005 Behavioral Risk Factor Surveillance System (BRFSS) and the 2006 Area Resource File (ARF). All analyses were conducted with SAS and SAS‐callable SUDAAN, in order to account for weighting and the complex sample design. Findings: Characteristics significantly related to edentulism include: geographic location, gender, race, age, health status, employment, insurance, not having a usual source of care, education, marital status, presence of chronic disease, having an English interview, not deferring care due to cost, income, and dentist saturation within the county. Conclusions: Significant associations between high‐poverty rural and other rural counties and edentulism were found, and other socioeconomic and health status indicators remain strong predictors of edentulism.     

Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.