Health services access and use among older adults in North Carolina: urban vs rural residents.

OBJECTIVES. This study compared health service use and satisfaction with health care among older adults living in urban vs rural counties in North Carolina. METHODS. A stratified random sample of 4162 residents of one urban and four rural counties of North Carolina was surveyed to determine urban/rural variation in inpatient and outpatient health service use, continuity of care and satisfaction with care, and barriers (transportation, cost) to care. RESULTS. Inpatient and outpatient service use did not vary by residence in controlled analyses. Continuity of care was more frequent in rural counties. Transportation was not perceived as a barrier to health care more frequently in rural than in urban counties, but cost was a greater barrier to care among rural elderly people. CONCLUSIONS. In this sample, older persons living in rural counties within reasonable driving distance of urban counties with major medical centers used health services as frequently and were as satisfied with their health care as persons in urban counties. Cost of care, however, was a significant and persistent barrier among rural elderly people, despite Medicare coverage.     

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.     

Insurance status and access to health services among poor persons.

OBJECTIVE: We examine the relationship between health insurance status and access to care among low-income persons 65 years of age and under, taking into account their social demographic characteristics and health care needs. DATA SOURCES AND STUDY SETTING. Study groups consist of the subsamples of persons with incomes between 100 and 150 percent of the federal poverty level and those below the federal poverty level interviewed in the 1983, 1984, and 1986 Health Interview Surveys (HIS) of the National Center for Health Statistics. Sample sizes range from about 6,000 to 11,000 depending on the proportion of each study group administered the insurance supplement. STUDY DESIGN. Annual visits and whether hospitalized during a year are used as measures of access to medical care. The analysis consists of identifying predictors of use of services (i.e., health status and social characteristics) and, taking them into account, examining the relationship of insurance status to access to care. This was first undertaken on the 1983 survey; the models obtained then are replicated on the other two years of data. DATA COLLECTION/EXTRACTION METHODS. The HIS utilizes in-person interviews to gather health and medical history information from a stratified random sample of the U.S. population. Data were obtained through public use tapes distributed by the National Center for Health Statistics. PRINCIPAL FINDINGS. Results are consistent for all three years among persons in poverty. Being covered by Medicaid, in contrast to having private insurance or being without health insurance, is related to use of both ambulatory care and hospital care. The access differences for persons in poverty, regardless of their vulnerability or "risk" of requiring medical care, are marked and generally statistically significant. Among the near-poor the same findings occur, although the differences are less sharp and less often statistically significant. CONCLUSIONS. The most obvious explanation is that the poor, and to a considerable extent the near-poor, have limited access because of copayments and deductibles that are typically part of private insurance coverage. The findings raise policy questions regarding the utility of either "play or pay" employer-provided insurance or income tax deductions to increase access.     

Utilization of district health services by injured persons in a rural area of Ghana

INTRODUCTION: Injury is a significant health problem in many less developed countries. However, strategies for dealing with it have been only minimally addressed. GOALS: We ought to assess the pattern of health care utilization by injured persons in rural Ghana. We thus hoped to provide data that would assist in strengthening injury treatment in this setting. METHODS: Using household interviews, we surveyed 9442 person. We sought information on any injury during the previous year that resulted in one or more days of disability. Injured persons were interviewed regarding the mechanism of injury, treatment obtained and length of disability. RESULTS: During the previous year, 923 nonfatal injuries were reported. Half the injured persons (49%) received no formal medical care. When treatment was received, it was primarily delivered by a non-doctor staffed primary health care (PHC) clinic. Such clinics provided treatment for 30% of all injured persons (58% of those receiving formal medical care). Twenty percent of the injured received hospital-based care (39% of those receiving formal medical care). Among those using hospitals, the majority (92%) used district hospitals. CONCLUSIONS: In this setting, efforts to improve injury treatment should include district hospitals and PHC clinics. At both there is a need to advance the concept of 'essential' injury treatment services, addressing equipment, supplies and training.     

论乡镇卫生院与农村社区卫生服务中心的异同

1　比较的背景社区卫生服务这种模式在国外也不过肇始于 6 0年代前后。与此同时 ,我国广大农村乡镇卫生院所提供的基层医疗保健服务亦颇有特色。二者虽然足迹不同 ,但不乏许多相似之处。只是在当时的历史条件下 ,我们还不可能自觉地意识到这一点罢了。一方面我们当时实行的政社合一的政治经济体制 ,行政包揽一切 ,对社区的地位和职能认识上非常隔膜 ,另一方面 ,后来不少乡镇卫生院又纷纷仿效城市综合性医院 ,走上专科化发展道路 ,迷失了自身的前进方向。星转斗移 ,90年代以来 ,城镇社区卫生服务工作异军突起 ,方兴未艾 ,并在一些先行的地区…     

Use of technology to increase access to mental health services in a rural Texas community

The Leon County Health Resource Commission sought to increase access to mental health services for their rural community. The commission formed a network of partners who collaborated to increase free transportation to mental health services outside the community and developed a telehealth-based counseling program through a counseling psychology training program. Learning opportunities emerged during the development and implementation of these activities for both the students and the community in how to successfully utilize and sustain this service. This article describes the telehealth counseling model, presents lessons learned in the process, and presents recommendations for others interested in utilizing similar strategies.     

Orthopedic surgery in rural American hospitals: a survey of rural hospital administrators

Rural American residents prefer to receive their medical care locally. Lack of specific medical services in the local community necessitates travel to a larger center which is less favorable. This study was done to identify how rural hospitals choose to provide orthopedic surgical services to their communities. Methods: All hospitals in 5 states located in communities that met the criteria for a rural town according to the Rural Urban Commuting Area codes were included. A survey with topics including community and hospital demographics, orthopedic surgical workforce and demand, surgical services, and the perceived benefit of orthopedic services was sent to the hospital administrators. Results: Of the 223 rural hospitals surveyed, 145 completed the survey. Of those completing the survey, 30% had at least one full‐time orthopedic surgeon, 25% did not provide any orthopedic surgical services, 65% never had an orthopedic surgeon on ER call, 33% were recruiting an orthopedic surgeon, 52% stated that it is more difficult to recruit an orthopedic surgeon vs a general surgeon, and 71% of the administrators acknowledged a need for additional orthopedic surgical services in their community. For those hospitals that did not have a full‐time orthopedic surgeon, members of those communities traveled a mean distance of 55 miles for emergency orthopedic surgical care as reported by the hospital administrators. Conclusions: There are many rural communities that have limited access to orthopedic surgical services. While many of the rural hospital administrators feel that there is a need for additional orthopedic surgical services in their communities, it is difficult to recruit orthopedic surgeons to these areas.     

Health status and access to health care services: a comparison between Ohio's rural non-Appalachian and Appalachian families

Comparisons in the health status of rural dwellers and care access have not traditionally considered culturally defined areas such as Appalachia. This study examined differences in parent health status, child health status, and access to care between those living in Ohio's 29 Appalachian counties and those living in Ohio's 30 rural counties. We analyzed data from the 2008 Ohio Family Health Survey including Bayesian hierarchical modeling. Child health differed by gender and ethnicity. Parent health status differed by region. Parent and child health status were related to care access. Health and access disparities exist within rural and Appalachia Ohio.     

Implementing EACHs (essential access community hospitals) and RPCHs (rural primary care hospitals) on a statewide basis: a preliminary analysis.

Declining hospital utilization has created excess hospital capacity in rural areas, has depressed occupancy rates, and threatens the financial viability of rural hospitals. Access to hospital care could be reduced and rural economies damaged if rural hospitals close. The federal Essential Access Community Hospital (EACH) demonstration program is an attempt to address these issues by establishing regional hospital networks. A preliminary analysis of the impact of state-wide implementation of the EACH program in Iowa suggests that about 60% of rural hospital beds and about 28% of all hospital beds would be eliminated. The EACH program could well prove difficult to implement because of the need to select hospitals for reduced services.     

A systematic review of different models of home and community care services for older persons

Background

The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap.

Methods

Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007.

Results

The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals.

Conclusions

The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies.     

Utilization of health services among rural women in Gujarat, India

This study examined the effects of four sets of factors on use of curative health services among rural women living in Gujarat, India. The sets of factors analyzed were as follows: (1) the demographic characteristics of the women; (2) the characteristics of the household in which they lived; (3) the characteristics of the environment in which they lived; and (4) the price and convenience of care. The study focused on rural married women aged 17–45 who had at least one child. Nested multiple logistic regressions were computed on cross-sectional data to assess the simultaneous influences of the independent variables on (1) reports of episodes of illness (2) use of curative services among rural women who reported an illness and (3) use of a specific service. Four types of service were examined as outcomes of interest, namely, private doctors, Aga Khan Health Services centres, government health centres, and traditional healers. Other things being equal, women's education, income, family structure and kinship affiliation were significant predictors of use of service. Women seemed to be more sensitive to travel time to the health service and its associated costs (purdah restrictions, transportation and time costs) than to the direct costs of service. Factors such as women's occupation and sanitation facilities, while associated with use of service in the expected direction, were not significant predictors of use of service. Implications for health planning are offered, including initiatives to implement health promotion and disease prevention programs in addition to increasing access to the existing health services. Avenues for future studies are suggested, particularly in regard to decision-making processes affecting the health-seeking behavior of rural women. It is recommended that such policies and studies should consider the cultural environment in addition to the existing pluralistic health system.     

Utilization of VA and Medicare services by Medicare-eligible veterans: the impact of additional access points in a rural setting

The Veterans Health Administration (VA) has recently established community-based outpatient clinics (CBOCs) to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare-eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolied in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded by Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.     

Critical access hospitals: hubs for rural health care

A 1997 federal law created a new type of rural hospital called the Critical Access Hospital (CAH). Having CAH designation allows a facility to receive cost-based reimbursement from Medicare in exchange for providing services such as emergency care and limiting the number of beds and the average length of stay. Minnesota has 79 CAHs. This article describes how having the designation has allowed these facilities to better meet the needs of the populations they serve. It also describes the challenges all CAHs face in light of federal budget constraints and health care reform.     

Utilization of hospital services. A comparison of internal medicine and family practice

Five hundred twenty new patients were randomly and prospectively assigned to receive care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. Previous analyses of outpatient data demonstrated that the frequency of visits to the clinic of primary care, acute care clinic, emergency room, and consultant clinics were all significantly higher for patients randomized to internal medicine compared with family practice. In the present study, patients' charts were reviewed for information regarding hospitalizations. During the 3.4-year study period, there were a total of 61 hospital admissions for internal medicine (35 of 249 patients), and 58 for family practice (27 to 271 patients). Age (mean 47 years) and sex of patients in both groups were equivalent. The average total cost of hospitalization for each patient was greater for those randomized to the Internal Medicine Clinic: $7,193 for internal medicine patients as compared with $5,764 for family practice patients. The professional costs per hospitalization showed greater variation: $913 for Internal Medicine Clinic patients and $629 for Family Practice Clinic patients. Internal Medicine Clinic patients had a longer mean length of hospitalization (7.5 days) when compared with that of Family Practice Clinic patients (6.3 days). It can be concluded that in this clinical environment the hospitalization patterns are different for patients assigned to the Internal Medicine Clinic compared with the Family Practice Clinic: both cost and length of care for hospitalization are less for those followed by the Family Practice Clinic.     

农村社区老年人精神卫生服务需求与利用情况调查分析

目的:了解农村社区老年人的精神障碍患病率,掌握农村社区老年人精神卫生服务利用和需求情况.方法:在既往队列研究基础上,使用老年精神状况量表GMS(Geriatric Mental Scales)确定该队列人群精神障碍水平,使用自拟问卷测量精神卫生服务需求与利用情况.使用x2检验或Fisher确切概率法进行单因素分析.结果:①该研究实际随访到914名老年人,诊断有精神障碍的146(15.97％)人.②914人中仅有6人使用过精神卫生服务,146人中仅有2人使用过精神卫生服务.③191人(20.9％)表示需要进一步了解精神卫生服务知识.影响知识需求的因素有文化程度、自评经济、躯体疾病和心理障碍.④56人(6.1％)表示需要精神卫生服务.影响精神卫生服务的因素有性别、文化程度和心理健康水平.结论:农村社区老年人精神卫生服务使用率较低,自我心理保健意识较差.政府应加大精神卫生宣教的投入,提高社区老人对心理健康重要性的认识.