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.     

Receipt of cancer screening services: surprising results for some rural minorities

Background: Evidence suggests that rural minority populations experience disparities in cancer screening, treatment, and outcomes. It is unknown how race/ethnicity and rurality intersect in these disparities. The purpose of this analysis is to examine the cancer screening rates among minorities in rural areas. Methods: We utilized the 2008 Behavioral Risk Factor Surveillance System (BRFSS) to examine rates of screening for breast, cervical, and colorectal cancer. Bivariate analysis estimated screening rates by rurality and sociodemographics. Multivariate analysis estimated the factors that contributed to the odds of screening. Results: Rural residents were less likely to obtain screenings than urban residents. African Americans were more likely to be screened than whites or Hispanics. Race/ethnicity and rurality interacted, showing that African American women continued to be more likely than whites to be screened for breast or cervical cancer, but the odds decreased with rurality. Conclusions: This analysis confirmed previous research which found that rural residents were less likely to obtain cancer screenings than other residents. We further found that the pattern of disparity differed according to race/ethnicity, with African Americans having favorable odds of receipt of service regardless of rurality. These results have the potential to create better targeted interventions to those groups that continue to be underserved.     

Self‐Reported Cancer Screening Among Elderly Medicare Beneficiaries: A Rural‐Urban Comparison

Purpose: We examined the rural‐urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening. Methods: Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural‐urban disparity and rurality's independent impact on cancer screening, controlling for patient, and area factors. Results: From urban, large rural, small rural, and isolated rural areas, the rates for mammogram last year were 53%, 52%, 45%, and 44%, respectively. They were 56%, 50%, 48%, and 43% for CRC screening, respectively. After controlling for patient and area level characteristics, rurality is significantly associated with CRC screening, but not mammogram. Conclusions: We found rural‐urban disparities for both mammogram and CRC screenings. Patient and area factors totally eliminated the rural‐urban disparity for mammogram but not CRC screening. Health promotions to improve cancer screening should focus more on small and isolated rural areas.     

The Relationship Between Rural Status,Individual Characteristics,and Self‐Rated Health in the Behavioral Risk Factor Surveillance System

Purpose: To examine rural status and social factors as predictors of self‐rated health in community‐dwelling adults in the United States. Methods: This study uses multinomial logistic and cumulative logistic models to evaluate the associations of interest in the 2006 US Behavioral Risk Factor Surveillance System, a cross‐sectional survey of 347,709 noninstitutionalized adults. Findings: Self‐rated health was poorer among rural residents, compared to urban residents (OR = 1.77, 95% CI: 1.54, 1.90). However, underlying risk factors such as obesity, low income, and low educational attainment were found to vary by rural status and account for the observed increased risk (OR = 1.03, 95% CI: 0.94, 1.12). There was little evidence of effect modification by rural status, though the association between obesity and self‐rated health was stronger among urban residents (OR = 2.50, 95% CI: 2.38, 2.64) than among rural residents (OR = 2.18, 95% CI: 2.03, 2.34). Conclusions: Our findings suggest that differences in self‐rated health by rural status were attributable to differential distributions of participant characteristics and not due to differential effects of those characteristics.     

Dental visits in older Western Australians: a comparison of urban, rural and remote residents

OBJECTIVE: It has been reported that the aged in rural areas may not access regular dental care. The aim of this study was to describe dental visits for those 60 years of age and older living in urban, rural and remote locations in Western Australia and to determine factors associated with such visits. The main outcome was having had a dental visit in the previous 12 months. DESIGN: A cross-sectional telephone survey was conducted. SETTING: Urban, rural and remote locations in Western Australia. SUBJECTS: A total of 2100 participants, 60 years of age and older. RESULTS: The present study demonstrated that people in rural and remote areas of Western Australia had a longer time since their last dental visit than people in urban areas. Within each sex, age, country of birth, income, occupation and education group, the highest proportion of people having attended a dentist in the previous 12 months was in urban areas and the lowest was in remote areas. Controlling for sex, age, education and oral health status, compared to urban residents, rural residents were 14% less likely to have seen a dentist and remote residents were 27% less likely. CONCLUSION: The present study demonstrated that for the aged sector of the Western Australian population, geographical location is a major factor in the frequency of use of dental services and the reasons for dental visits. This raises concerns that improvement of oral health by prevention and early detection of tooth and gum problems is less likely to occur in rural and remote areas than in urban areas.     

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.     

Racial/ethnic disparities in potentially preventable readmissions: the case of diabetes

OBJECTIVES: Considerable differences in prevalence of diabetes and management of the disease exist among racial/ethnic groups. We examined the relationship between race/ethnicity and hospital readmissions for diabetes-related conditions. METHODS: Nonmaternal adult patients with Medicare, Medicaid, or private insurance coverage hospitalized for diabetes-related conditions in 5 states were identified from the 1999 State Inpatient Databases of the Healthcare Cost and Utilization Project. Racial/ethnic differences in the likelihood of readmission were estimated by logistic regression with adjustment for patient demographic, clinical, and socioeconomic characteristics and hospital attributes. RESULTS: The risk-adjusted likelihood of 180-day readmission was significantly lower for non-Hispanic Whites than for Hispanics across all 3 payers or for non-Hispanic Blacks among Medicare enrollees. Within each payer, Hispanics from low-income communities had the highest risk of readmission. Among Medicare beneficiaries, Blacks and Hispanics had higher percentages of readmission for acute complications and microvascular disease, while Whites had higher percentages of readmission for macrovascular conditions. CONCLUSIONS: Racial/ethnic disparities are more evident in 180-day than in 30-day readmission rates, and greatest among the Medicare population. Readmission diagnoses vary by race/ethnicity, with Blacks and Hispanics at higher risk for those complications more likely preventable with effective postdischarge care.     

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.     

Geographic Access to Health Care for Rural Medicare Beneficiaries

CONTEXT: Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. PURPOSE: To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington. METHODS: Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient's and the provider's zone improvement plan codes. FINDINGS: There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Rural residents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists. CONCLUSIONS: Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.     

The impact of geographical location on trends in hospitalisation rates and outcomes for fall‐related injuries in older people

Objective : This population‐based study investigates the influence of geographical location on hospital admissions, utilisation and outcomes for fall‐related injury in older adults, adjusting for age, sex and comorbidities. Methods : A linked dataset of all admissions of NSW residents aged 65 and older, hospitalised at least once for a fall‐related injury between 2003 and 2012, was used to estimate rates of hospitalisations, total lengths‐of‐stay, 28‐day readmissions, and 30‐day mortalities. These were standardised for age, sex, comorbidity, and remoteness. Results : Compared to urban residents, rural residents were hospitalised less (p<0.0001) and hospitalisation rates increased at a lower rate (0.8% vs 2.6% per year) from 2003 to 2012. Rural residents had a shorter median total length of stay (5 vs 7 days, p<0.0001), a higher 28‐day readmission rate (18.9% vs 17.0%, p<0.0001) and higher 30‐day mortality (5.0% vs 4.9%, p=0.0046). Conclusions : Over the study period, rural residents of NSW had lower rates of fall‐related injury hospitalisation and a lower annual increase in hospitalisation rates compared to urban residents. When hospitalised, rural residents had a shorter length‐of‐stay, but higher rates of readmission and mortality. These differences existed following standardisation. Implications : This study highlights the need for further research to characterise and explain this variability.     

Medicare hospital charges in the last year of life: distribution by quarter for rural and urban nursing home decedents with cognitive impairment.

BACKGROUND: Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence. METHODS: We analyzed Medicare hospital charges in the last year of life for nursing home residents with severe cognitive impairment, focusing on rural-urban differences. The study population consisted of 3,703 nursing home residents (1,882 rural, 1,821 urban) in Minnesota and Texas who died in 2000-2001. Data on Medicare hospital charges were obtained from 1998-2001 Centers for Medicare and Medicaid Services MedPAR files. RESULTS: During the last year of life, unadjusted charges averaged $12,448 for rural subjects; $31,780 for urban. The charges were distributed across the last 4 quarters similarly for the 2 populations, with 15%-20% of charges incurred in each of the first 3 quarters, and 47% (rural) and 52% (urban) in the last quarter. At the individual level, a higher percentage of hospital charges were incurred in the last 90 days by urban than by rural residents (P < .001). A larger proportion of urban (43%) than rural (37%) residents were hospitalized in the final quarter. The charges for hospitalized residents (N = 1,994) were distributed similarly to those of the entire study population. DISCUSSION: Medicare hospital charges during the last year of life were lower for rural nursing home residents with cognitive impairment than for their urban counterparts. Charges tend to be more concentrated in the last 90 days of life for urban residents.     

Differences in Late‐Stage Diagnosis,Treatment, and Colorectal Cancer‐Related Death Between Rural and Urban African Americans and Whites in Georgia

Purpose: Disparities in health outcomes due to a diagnosis of colorectal cancer (CRC) have been reported for a number of demographic groups. This study was conducted to examine the outcomes of late‐stage diagnosis, treatment, and cancer‐related death according to race and geographic residency status (rural vs urban). Methods: This study utilized cross‐sectional and follow‐up data from the Surveillance, Epidemiology, and End Results (SEER) Program for all incident colon and rectal tumors diagnosed for the Atlanta and Rural Georgia Cancer Registries for the years 1992‐2007. Findings: Compared to whites, African Americans had a 40% increased odds (OR, 1.40; 95% CI, 1.30‐1.51) of late‐stage diagnosis, a 50% decreased odds (OR, 0.50; 95% CI, 0.37‐0.68) of having surgery for colon cancer, and a 67% decreased odds (OR, 0.33; 95% CI, 0.25‐0.44) of receiving surgery for rectal cancer. Rural residence was not associated with late stage at diagnosis or receipt of treatment. African Americans had a slightly increased risk of death from colon cancer (HR, 1.11; 95% CI, 1.00‐1.24) and a larger increased risk of death due to rectal cancer (HR, 1.24; 95% CI, 1.14‐1.35). Rural residents experienced a 15% increased risk of death (HR, 1.15; 95% CI, 1.01‐1.32) due to colon cancer. Conclusions: Further investigations should target African Americans and rural residents to gain insight into the etiologic mechanisms responsible for the poorer CRC outcomes experienced by these 2 segments of the population.     

Do Older Rural and Urban Veterans Experience Different Rates of Unplanned Readmission to VA and Non‐VA Hospitals?

ABSTRACT:  Context: Unplanned readmission within 30 days of discharge is an indicator of hospital quality. Purpose: We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts. Methods: We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity. Findings: Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital. Conclusions: Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.     

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.     

The Metabolic Syndrome: Are Rural Residents at Increased Risk?

Purpose: The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural‐urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural‐urban disparity. Methods: Data came from the 1999‐2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Program's Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural‐Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban‐rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. Results: The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02‐1.49), which was attenuated to 1.06 (95% CI, 0.90‐1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome. Conclusion: Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity‐related behavioral factors between urban and rural residents.     

Rural, Suburban, and Urban Variations in Alcohol Consumption in the United States: Findings From the National Epidemiologic Survey on Alcohol and Related Conditions

CONTEXT: Alcohol consumption is a major public health problem nationally, but little research has investigated drinking patterns by rurality of residence. PURPOSE: To describe the prevalence of abstinence, alcohol use disorders, and risky drinking in rural, suburban, and urban areas of the United States. METHODS: Analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were conducted to estimate prevalence rates for abstinence, a current alcohol use disorder, and exceeding recommended daily and weekly drinking limits. Logistic regression analyses were conducted to test for rural and urban versus suburban differences after adjusting for potential confounders. Additional analyses were stratified by Census Region. FINDINGS: Nationally, the odds of abstinence and, among drinkers, the odds of a current alcohol disorder and exceeding daily limits were higher in rural than suburban areas. Stratified analyses revealed differences in the associations between rurality of residence and drinking across Census Regions. Rural residents of the Northeast, Midwest, and South and urban residents of the Northeast had higher odds of abstinence than their suburban peers. Among drinkers, rural and urban residents of the Midwest had higher odds of a current alcohol disorder and exceeding daily limits; urban residents of the Midwest had higher odds of exceeding weekly limits. CONCLUSIONS: Abstinence is particularly common in the rural South, whereas alcohol disorders and excessive drinking are more problematic in the urban and rural Midwest. Health policies and interventions should be further targeted toward those places with higher risks of problem drinking.     

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban,Micropolitan, and Rural Nursing Homes

ObjectivesHospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).DesignThe longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs.Setting and ParticipantsIn total, 14,600 unique NHs.MeasuresRisk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File.ResultsOver the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs.Conclusions/ImplicationsRurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.     

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003

ABSTRACT:  Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.     

The Influence of Rural Versus Urban Residence on Utilization and Receipt of Care for Chronic Low Back Pain

Purpose : (1) To describe demographic and health‐related characteristics among rural/urban residents with chronic low back pain (LBP); (2) To determine if the utilization of diagnostics and treatments differs between rural and urban residents with chronic LBP; and (3) To determine the association between rural/urban residence and health care provider usage and if associations differ by race or gender. Methods : A 2006 cross‐sectional telephone survey of a representative sample of North Carolina residents. Subjects with chronic LBP were questioned regarding their health and health care use. Wald and chi‐square tests were used to determine differences between demographic and health‐related characteristics of rural/urban residents. Logistic regression was used to determine the association between rural/urban residence and health care provider use. Differences in race or gender were explored with stratified analysis with a P < .10. Findings : 588 residents of North Carolina with self‐reported chronic LBP sought care from a provider in the previous year. In bivariate analyses, when compared to urban residents, rural residents were younger, more likely to be uninsured, reported significantly higher levels of disability, and reported more depression/sadness. Rural residents were less likely to receive care from a rheumatologist (adjusted odds ratio [aOR] 0.47 [95% CI, 0.22‐0.99]). Rural blacks were less likely to receive care from a physical therapist when compared to urban blacks (aOR 0.26 [95% CI, 0.07‐0.87]). Conclusion : Despite similarities of high provider use, imaging and therapeutics, when compared to urban residents, rural residents reported higher levels of functional limitation and depression.