Uninsured rural families.

CONTEXT: Although research shows higher uninsured rates among rural versus urban individuals, prior studies are limited because they do not examine coverage across entire rural families. PURPOSE: This study uses the Medical Expenditure Panel Survey (MEPS) to compare rural and urban insurance coverage within families, to inform the design of coverage expansions that build on the current rural health insurance system. METHODS: We pooled the 2001 and 2002 MEPS Household Component survey, aggregated to the family level (excluding households with all members 65 and older). We examined (1) differences in urban, rural-adjacent, and rural nonadjacent family insurance coverage, and (2) the characteristics of rural families related to their patterns of coverage. FINDINGS: One out of 3 rural families has at least 1 uninsured member, a rate higher than for urban families-particularly in nonadjacent counties. Yet, three fourths of uninsured rural families have an insured member. For 42% of rural nonadjacent families, this is someone with public coverage (Medicaid/SCHIP or Medicare); urban families are more likely to have private health insurance or a private/public mix. CONCLUSIONS: Strategies to expand family coverage through employers may be less effective among rural nonadjacent than urban families. Instead, expansions of public coverage or tax credits enabling entire families to purchase an individual/self-employment plan would better ensure that rural nonadjacent families achieve full coverage. Subsidies or incentives would need to be generous enough to make coverage affordable for the 52% of uninsured rural nonadjacent families living below 200% of the federal poverty level.     

Insulin-dependent diabetes in a Scottish region: incidence and urban/rural differences.

The incidence of insulin-dependent diabetes mellitus in the 0-18 year age group was studied in Tayside Region for the years 1980 to 1983. The mean annual rate of 21.7 per 100,000 is high in international terms and suggests that the rise in incidence observed in Scotland in the 1970s has continued. Urban and rural incidences were compared using postcodes. Rural rates were significantly (0.02 greater than p greater than 0.01) higher, due mainly to the difference in rates for the 0-9 age groups.     

Cancer mortality differences among urban and rural residents in Lithuania

Background  

The aim of this study was to describe and to compare the cancer mortality rates in urban and rural residents in Lithuania.     

Child health inequities in developing countries: differences across urban and rural areas

Objectives  

To document and compare the magnitude of inequities in child malnutrition across urban and rural areas, and to investigate the extent to which within-urban disparities in child malnutrition are accounted for by the characteristics of communities, households and individuals.     

Child health inequities in developing countries: differences across urban and rural areas

Background

The reduction of health inequalities is a focus of many national and international health organisations. The need for pragmatic evidence-based approaches has led to the development of a number of evidence-based equity initiatives. This paper describes a new program that focuses upon evidence- based tools, which are useful for policy initiatives that reduce inequities.

Methods

This paper is based on a presentation that was given at the "Regional Consultation on Policy Tools: Equity in Population Health Reports," held in Toronto, Canada in June 2002.

Results

Five assessment tools were presented. 1. A database of systematic reviews on the effects of educational, legal, social, and health interventions to reduce unfair inequalities is being established through the Cochrane and Campbell Collaborations. 2 Decision aids and shared decision making can be facilitated in disadvantaged groups by 'health coaches' to help people become better decision makers, negotiators, and navigators of the health system; a pilot study in Chile has provided proof of this concept. 3. The CIET Cycle: Combining adapted cluster survey techniques with qualitative methods, CIET's population based applications support evidence-based decision making at local and national levels. The CIET map generates maps directly from survey or routine institutional data, to be used as evidence-based decisions aids. Complex data can be displayed attractively, providing an important tool for studying and comparing health indicators among and between different populations. 4. The Ottawa Equity Gauge is applying the Global Equity Gauge Alliance framework to an industrialised country setting. 5 The Needs-Based Health Assessment Toolkit, established to assemble information on which clinical and health policy decisions can be based, is being expanded to ensure a focus on distribution and average health indicators.

Conclusion

Evidence-based planning tools have much to offer the goal of equitable health development.     

城乡健康老龄化差异及影响因素探究

目的 探究城乡健康老龄化的差异及影响因素,为进一步实现“健康老龄化”提供参考。方法 本研究基于中国健康与养老追踪调查(CHARLS)2018年的数据进行分析,对城市、农村的老年人的生理健康及心理健康进行描述性和比较性分析,选取相关因素纳入二元logistic回归分析。结果 Logistic回归分析结果显示,城市样本中,性别(OR=1.349,95%CI:1.05～1.733)、有无娱乐活动(OR=1.559,95%CI:1.243～1.955)、有无养老保险(OR=0.404,95%CI:0.313～0.521)是城市老年人认知能力的主要相关因素; 患三种以上慢性病(OR=2.507,95%CI:1.903～3.304)、有无娱乐活动(OR=0.656,95%CI:0.519～0.828)、有无养老保险(OR=1.645,95%CI:1.278～2.118)是城市老年人抑郁倾向的主要相关因素。农村样本中,性别(OR=1.815,95%CI:1.529～2.155)、有无娱乐活动(OR=1.544,95%CI:1.318～1.808、有无医疗保险(OR=0.401,95%CI:0.215～0.751)是农村老年人认知能力的主要相关因素; 性别(OR=0.533,95%CI:0.467,0.607)、患慢性病情况(OR=1.615,95%CI:1.435～1.817)、子女探望频率(OR=0.795,95%CI:0.696～0.909)、有无养老保险(OR=0.783,95%CI:0.676～0.908)是农村老年人抑郁倾向的主要相关因素。结论 城乡老年人健康状况的影响因素不同,在推进建设“健康老龄化”时,应考虑到城乡差异,并针对性地采取相关措施。     

Trauma-related hospitalizations among urban adolescents in New Zealand: priorities for prevention.

PURPOSE: To: (a) determine the magnitude, characteristics, and in-patient costs of injury among hospitalized urban adolescents in New Zealand (NZ); (b) identify regional priorities for injury prevention and investigative research; and (c) compare the study findings with published data from other industrialized countries. METHODS: The 1989-1993 files of the NZ Hospital Discharge Database were accessed to identify and analyze trauma-related admissions of adolescents residing in NZ's largest metropolitan region. RESULTS: The estimated 9569 hospitalizations for injury accounted for one-fourth of all adolescent admissions in the region, a mean annual hospitalization rate of 1292/100,000 population and a minimum annual cost of NZ $5.8 million for in-patient care. Males and indigenous Maori youth had comparatively higher rates of hospitalizations for most major causes of injury. Falls, pedal cyclist injury, cuts, and piercing injuries were leading causes of hospitalization for trauma in early adolescence. Admission rates for motorcylist and other motor vehicle occupant trauma and self-inflicted injury increased substantially among older adolescents. Sport and recreational activities comprised at least one-sixth of injury admissions. CONCLUSIONS: The overall rates of injury resulting in hospitalization among Auckland adolescents were comparable to those reported from Australia and France, but higher than those from the United States, Canada, and Israel. By identifying priority issues and high-risk groups, this study provides a foundation for regional injury control initiatives. It also demonstrates the utility and limitations of E-coded hospital discharge registries in defining the burden of serious nonfatal trauma.     

Uninsured working-age adults: characteristics and consequences.

While estimates of the country's uninsured vary, ranging from 10 to 18 percent of the general population, virtually every study on use of medical services reports that lack of health insurance represents a major barrier to medical care. Based on the 1986 national Robert Wood Johnson Access Survey of 10,130 noninstitutionalized persons, the characteristics of working-age adults without health insurance, and the consequences, are examined. Among working-age adults, the uninsured are most likely to be poor or near-poor, Hispanic, young, unmarried and unemployed. Compared with the insured, they have significantly fewer ambulatory visits during a year, are less likely to have contact with a medical provider during a 12-month period, and are more likely to receive their care in a hospital outpatient clinic or emergency room. Differences in health status do not account for these findings. Especially among persons with chronic and serious illnesses, the uninsured are less likely than the insured to receive medical care. Further, the uninsured are significantly more likely to report needing but not receiving medical care, primarily for economic reasons, and although poorer, they have higher out-of-pocket medical expenses than others in the population.     

Gender and ethnic differences in urban and rural first-contact schizophrenia outpatients in Trinidad

This study investigated gender and ethnic differences in the rate of first contact outpatients with schizophrenia in the setting of a more-urban region (MUR) and a less-urban region (LUR) in Trinidad. In a prospective study, 134 first-contact patients with a diagnosis of schizophrenia were selected from two ecologically different regions. RESULTS: Of this population, 56.7% were of African origin and 32.1% were of Indian descent. Gender differences were significant, with males accounting for 66.4% (n=89) of patients with schizophrenia (chi2 = 14.45, d.f. = 1, p = 0.0001). Further analysis by age categories revealed a significant male predominance at ages 20-24 (p = 0.0001) and 25-29 (p = 0.002). Young African males (15-19 y, p = 0.049) predominated in MUR compared with LUR. The results showed a marked presence of Afro-Trinidadian males in both outpatient clinics (p < 0.05). We conclude that gender and ethnicity are important variables in the presentation of schizophrenia in Trinidad, whereas neither rural nor urban environments appeared to influence the expression of schizophrenia.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

Similarities and differences between an urban and a rural hospital based home care program

Over a 3 month period, 116 patients assigned on the basis of geographical proximity to an urban or rural Hospital Based Home Care Program were examined to determine whether services provided by an urban-based HBHC team could be extended by a rural-based team to a similar but rural, chronically ill patient population. Variables reflecting medical and socio-economic patient characteristics and level of services provided were gathered to test for significant differences between the two programs. Two-tailed difference of group means t-tests of the data revealed that only number of medications and supplies dispensed attained significance; patients in the urban program received more than their rural counterparts, a result probably due to the greater proximity of the program physician to the urban-based team. The results appear to indicate that it is possible to maintain severely disabled patients in their own homes in rural as well as urban settings.     

An exploration of urban and rural differences in lung cancer survival among medicare beneficiaries

Objectives. We tested the relationship between urban or rural residence as defined by rural–urban commuting area codes and risk of mortality in a sample of Medicare beneficiaries with lung cancer.Methods. We used Surveillance, Epidemiology, and End Results data linked with Medicare claims to build proportional hazards models. The models tested hypothesized relationships between individual and community characteristics and overall survival for a cohort of Medicare beneficiaries 65 years and older who were diagnosed with lung cancer between 1995 and 1999 (N=26073).Results. We found no evidence that lung cancer patients in rural areas have poorer survival than those in urban areas. Rather, individual (Medicaid coverage) and regional (lower census tract–level median income) socioeconomic factors and a smaller supply of subspecialists per 10000 individuals 65 years and older were positively associated with a higher risk of mortality.Conclusions. Although urban versus rural residence did not directly influence survival, rural residents were more likely to live in poorer areas with a smaller supply of health care providers. Therefore, we still need to be aware of rural beneficiaries’ potential disadvantage when it comes to receiving needed care in a timely fashion.Rural areas are characterized by low population density, isolation of and long distances between individuals and communities, and long distances from urban centers. Rural communities face difficulties protecting their supply of health care providers; such difficulties include recruitment and retention of physicians and maintenance of the viability of rural hospitals.1^,2 Elderly people in rural areas also travel longer and wait longer for outpatient care and use fewer preventive services than do their urban counterparts.3^,4 In a recent study by Pathman et al.,5 older adults who lived in rural areas with low physician density were significantly more likely to travel 30 or more minutes to a provider. These factors predict negative effects on the health of the rural population, which suggests that urban and rural differences in health outcomes may exist because of differential access to services.Lung cancer is the second most common cancer and the leading cause of cancer death for both men and women.6^,7 The American Cancer Society estimates that approximately 174470 Americans will be diagnosed with lung cancer and approximately 162 460 individuals will die from it this year.6 Early diagnosis of the disease is challenging and often achieved by chance rather than by intention. Generally, by the time lung cancer is diagnosed, it has spread to regional lymph nodes or other sites in the body.8 The 5-year survival rate for those presenting with localized disease is approximately 50%; however, only about 16% of patients present with localized disease.6 The average survival across all stages is approximately 15%.6The probability of developing lung cancer is higher among those 70 years and older relative to other age groups, equivalent to 1 in 16 men and 1 in 24 women in this age group.6 The US population is aging such that by the year 2030, the number of those 65 years and older is projected to increase to 70 million, or 20% of the total population.9 The impact of this demographic boom will be felt most strongly in rural areas, where older adults are already 20% of the population and their presence continues to grow at a faster rate than in urban areas.10 Given that there is a high incidence of lung cancer among older populations, the increase in the elderly population may result in substantial increases in diagnosed cases of lung cancer.The limited existing literature does not report a consistent story of geographic variation in the United States for the incidence, treatment, or survival associated with lung cancer. In an early study of lung cancer incidence rates, Blot and Fraumeni11 found that incidence was higher in the South, in both urban and rural areas. Iezzoni et al.12 examined geographic variation in the purpose of hospital admissions for cancer treatment in 1985 and found that rural hospitals were more likely to admit patients for palliative care, whereas urban hospitals were more likely to admit patients for active intervention.In more recently published studies that explored these issues in non–US populations,13^–15 rural residents were found to be at a disadvantage when it comes to diagnosis and treatment of lung cancer and to experience poorer survival. Much of the difference is attributed to rural residents having more-advanced disease at the time of diagnosis. Wilkinson and Cameron reported better survival rates among urban residents relative to rural residents for 10 cancer types.16 Mikeljevic et al.17 found that survival was influenced by longer travel times to required treatment centers in a cohort of breast cancer patients. In another study,18 the supply of important medical resources (e.g., computed tomography scanners) was positively associated with cancer survival. Given our understanding of urban and rural differences in health care access, supply, and utilization, we might expect to find similar patterns of care in the United States.Patients who present with symptoms suggestive of lung cancer may first visit their primary care doctor, who may, in turn, refer them to a specialist to receive a definitive diagnosis. In the process of being diagnosed and beginning treatment, there may be delays in getting care, which can significantly influence survival. Both physician- and patient-related factors may influence the likelihood of delays in diagnoses or obtaining treatment.Delays in the referral process may occur between primary care and specialty care or, once a referral has been made, with the oncologist beginning treatment. Although there is a body of literature that describes delays in beginning cancer treatment,19^–21 these studies concentrated on provider delays in care rather than on patient delays, and none compared the length of delays across urban and rural regions. However, physician supply and provider payments are lower in rural areas,22 which might contribute to greater delays in care for rural than for urban residents.Although rural residents may be more likely to have a regular source of care, they report fewer visits to the doctor.23 Rural residents may delay seeing a doctor because of problems with transportation or the cost of care.22^,24 A recent study suggested that fewer primary care providers located in close proximity is associated with longer travel distances to obtain outpatient care.5 For specialty care, such as cancer treatment, bypassing local providers may also be preferred or necessary to receive appropriate care.25^,26 However, elderly adults, especially those in rural areas, may lack the means to travel necessary distances and generally prefer to stay with local providers,24^,27 the implication being that older adults in areas with fewer providers may not be receiving timely, appropriate care for their condition. Rural residents perceive fewer access problems,28 but objective measures of access suggest a different story. As a result, rural residents may be more likely to experience delays in care once symptomatic, which may affect survival.For our study, we explored the relationship between rural residence and survival for a cohort of Medicare beneficiaries diagnosed with lung cancer.     

Exploring differences in caseloads of rural and urban healthcare providers in Alaska and New Mexico

OBJECTIVES: Although it is commonly accepted that rural healthcare providers face demands that are both qualitatively and quantitatively different from those faced by urban providers, this conclusion is based largely on data from healthcare consumers and relies on qualitative work with small sample sizes, surveys with small sample sizes, theoretical reviews and anecdotal reports. To enhance our knowledge of the demands faced by rural healthcare providers and to gain the perspectives of healthcare providers themselves, this study explored the caseloads of rural providers compared with those of urban providers. METHOD: An extensive survey of over 1500 licensed clinicians across eight physical and behavioural healthcare provider groups in Alaska and New Mexico was undertaken to explore differences in caseloads based on community size (small rural, rural, small urban, urban), state (Alaska, New Mexico) and discipline (health, behavioural). RESULTS: Findings indicated numerous caseload differences between community sizes that were consistent across both states, with complex case presentations being described most commonly by small rural and rural providers. Substance abuse, alcohol use, cultural diversity, economic disadvantage and age diversity were issues faced more often by providers in rural and small rural communities than by providers in small urban and urban communities. Rural, but not small rural, providers faced challenges around work with prisoners and individuals needing involuntary hospitalization. Although some state and discipline differences were noted, the most important findings were based on community size. CONCLUSIONS: The findings of this study have important implications for provider preparation and training, future research, tailored resource allocation, public health policy, and efforts to prevent 'burnout' of rural providers.