The Visiting Specialist Model of Rural Health Care Delivery: A Survey in Massachusetts

CONTEXT: Hospitals in rural communities may seek to increase specialty care access by establishing clinics staffed by visiting specialists. PURPOSE: To examine the visiting specialist care delivery model in Massachusetts, including reasons specialists develop secondary rural practices and distances they travel, as well as their degree of satisfaction and intention to continue the visiting arrangement. METHODS: Visiting specialists at 11 rural hospitals were asked to complete a mailed survey. FINDINGS: Visiting specialists were almost evenly split between the medical (54%) and surgical (46%) specialties, with ophthalmology, nephrology, and obstetrics/gynecology the most common specialties reported. A higher proportion of visiting specialists than specialists statewide were male (P = .001). Supplementing their patient base and income were the most important reasons visiting specialists reported for having initiated an ancillary clinic. There was a significant negative correlation between a hospital's number of staffed beds and the total number of visiting specialists it hosted (r =-0.573, P = .032); study hospitals ranged in bed size from 15 to 129. CONCLUSIONS: The goal of matching supply of health care services with demand has been elusive. Visiting specialist clinics may represent an element of a market structure that expands access to needed services in rural areas. They should be included in any enumeration of physician availability.     

Necessary Conditions for Supporting a General Surgeon in Rural Areas*

Loss of a general surgeon in a rural community can alter the referral patterns, the image and utilization of the local hospital, and even the market share of local primary care physicians. Prior research has not defined the necessary and/or sufficient conditions for a rural county to be able to support a local general surgeon. Based upon empirical analysis of 96 rural Missouri counties and the limited literature available on rural surgeons and physician referral rates, a first approximation of those conditions are offered. We conclude that a rural county with a hospital, a population base of more than 15,000 people, and at least 11 potential referring physicians has sufficient conditions to enable it to support a local general surgeon. Among those rural Missouri counties not meeting the above conditions but having a general surgeon in 1984, we estimate that 8 to 10 potential referring physicians appear to be the minimum necessary condition for supporting a rural general surgeon through patient referral. From those conclusions, we argue that any rural hospital currently without a surgeon should re-examine its situation. To prepare for a competitive future, such a hospital should take every opportunity to expand the referral base necessary to support a full-time local surgeon rather than place long-term reliance upon itinerant general surgeons.     

How Does Degree of Rurality Impact the Provision of Surgical Services at Rural Hospitals?

ABSTRACT:  Context: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. Purpose: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. Methods: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. Findings: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. Conclusions: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.     

Market Shares for Rural Inpatient Surgical Services: Where Does the Buck Stop?

Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals' surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals. In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. "Total hospital expenses" from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense. For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)     

Managing health services organizations with an educational mission: the case of Canada

Teaching hospitals represent a major segment of the Canadian health system, accounting for a disproportionate number of beds, patient days, and separations. Thus, although only six percent of hospitals are classified as teaching hospitals, they are responsible for about 36 percent of total hospital operating expenses. While affiliation with a medical school presents unique opportunities for the teaching hospital and increases its prestige, there are clear costs associated with affiliation. Administrators have less control over resource allocation decisions, including the types of teaching programs offered. Teaching hospitals cannot unilaterally design their own teaching programs around specialties and subspecialties of their own choosing; decisions related to teaching programs have a direct impact on the services provided by the hospital and may negatively affect the hospital's ability to fulfill its patient care mission. As education budgets are constrained, teaching hospitals are expected to assume outstanding teaching-related expenses. Teaching hospitals are also expected to shift some of their teaching to alternative settings, such as the community. Thus, teaching hospital administrators will require a strong background in finance as well as negotiation and political skills.     

Lung cancer: An exploration of patient and general practitioner perspectives on the realities of care in rural Western Australia

Objective: This study investigates if the pattern of diagnostic testing for suspected lung cancer, stage at diagnosis, patterns of specialist referral and treatment options offered to people in rural Western Australia are similar to those in the metropolitan area. It then explores the barriers to quality care in rural areas as perceived by GPs and patients. Methods: There was a review of GP records to obtain clinical and referral information and an in‐depth interview with patients and GPs concerning their perspectives of the quality of care. Results/Discussion: We selected age and sex‐matched samples of 22 rural and 21 metropolitan patients. Rural patients had more symptoms and took longer to consult their GPs, leading to later diagnosis and fewer treatment options. They experienced longer waits for specialist consultation and underwent less diagnostic testing. The GPs always referred lung cancer patients to a specialist, usually a respiratory physician. Teaching hospitals were preferred because of their comprehensive facilities and multidisciplinary teams. Rural GPs reported distance, time and availability of appointments as barriers; they also raised concerns about late confirmation of diagnosis. Rural and metropolitan patients were equally satisfied with their quality of care, but rural patients desired more information and better communication between hospital and GPs. Facilities for rural patients at some metropolitan hospitals were criticised. In conclusion, rural patients received a different care pattern from metropolitan patients and they and their GPs raised concerns about the equity and quality of lung cancer care.     

Swing Beds and Rural Hospitals in New York, 1991 to 1994

Abstract: New York implemented a hospital swing bed program in 1991 to allow rural hospitals access to Medicare Part B financing, increase utilization of hospital rehabilitation services, and facilitate the care of patients in their home communities. Between the years 1991 and 1994, 13 hospitals participated in the program. The authors used the New York State Department of Health annual hospital reporting data to examine the hospital swing bed experience for length of stay, payer type, and discharge disposition. Eighty-six percent of swing bed admissions came from the acute care units of the host hospital or a referral hospital. The average length of stay decreased from 25 days to 19 days during the study period with almost one-half of the patients being discharged. Swing bed revenues accounted for 3.4 percent of the total hospital gross revenues by 1994. Respite care, a component unique to New York, accounted for an increasing percent of admissions throughout the study period. The program served a useful rehabilitative function, and it represents one strategy to care for rural patients near their homes.     

试论提高乡镇医院效益

通常乡镇医院的经济效益是由病人的经济支付能力,医院提供卫生服务的可及性和医生的作用三方面因素决定的。对此从理论和实践方面进行了探讨,得出”减轻病人负担,上门为群众提供多功能医疗服务,优势的医疗服务是提高乡镇医院效益的有效途径。     

An assessment of rural hospital trustees' health care knowledge base.

Rural hospital trustees are usually volunteers who serve important roles in the governance of a hospital and, therefore, in defining health care policy in their communities. Because most trustees are not health professionals, their orientation to the hospital and continuing education about the hospital present a special challenge to administrators. One hundred and three trustees from 10 rural hospitals in western New York were surveyed to better understand their demographics, their knowledge base regarding the hospital, and their roles as trustees. Sixty-six percent of the respondents were male and the average age of the sample was 48 years. Trustees had served an average of six years and spent seven hours per month on hospital business. Eighty-three percent recalled receiving some orientation. Answers about average hospital census, length of stay, payor type, and hospital services were correct less than 50 percent of the time. Trustees were aware that recent quality assurance guidelines increased their liability and half believed it was their most important activity. We conclude that greater effort should be applied to the orientation and continuing education of hospital trustees. Given the significant time commitment already asked of trustees, this education should be woven into the hospital governance routine.     

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability

STUDY OBJECTIVE: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. DESIGN: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. SETTING: The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. PARTICIPANTS: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. MAIN RESULTS: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. CONCLUSIONS: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.     

Value of hospital-employed medical officers in rural Australia

The author reports on a unique experience of the issues relating to recruitment and retention of specialist medical staff in a regional hospital in rural Tasmania, Australia. Based on a particular time of a high specialist medical staff resignation, the author identifies the importance to sustainability of rural medical specialists, of quality hospital-employed medical officer (HMO) support staff, a factor that has not been well recognized previously. It was found that HMOs, in particular senior or specialist-in-training HMOs, considerably reduced the workload of rural specialists, especially their after-hours workload. A rating scale to assess the acceptability of after-hours workload for rural specialists, taking into account the impact of HMO support, was developed and is presented in the article. The presence of quality supporting HMOs was a vital recruitment and retention issue for rural medical specialists at that time and can be generalised to other rural situations and should be officially recognised. The observations made support increasing the number of senior or specialist-in-training-HMO positions in rural hospitals in order to retain and recruit more rural specialists.     

Causes and Consequences of Rural Small Hospital Closures from the Perspectives of Mayors

Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community's economy.     

Small Rural Hospitals with Long-Term Care: 1983 to 1987

Rural hospitals were under tremendous stress in the 1980s, as evidenced by decreasing use and closures. Rural populations increased in the two proportions of people older than 65 years relative to urban areas. Rural communities had more chronically ill residents than urban areas. Population aging and hospital stress have opened an option for small rural hospitals to develop long-term care units. Analysis of a national cohort of 750 small rural hospitals was undertaken in 1983, 1985, and 1987 to identify the characteristics of these hospitals, their communities, and the relative contribution of the small rural hospital to long-term care bed supply. Hospitals more likely to have long-term care during this period of time had lower occupancy rates and higher expenses per admission both prior to and after developing long-term care. While only 14 percent of the 750 hospitals studied had long-term care, they contributed nearly 30 percent of the total long-term care bed supply in their counties. Population-based need and bed supply measures were not significantly different in counties having a small rural hospital with long-term care. Areas of further analysis of the small rural hospital as a resource for long-term care are suggested. The implications for the health care system of small rural hospitals with long-term care are discussed.     

Work of female rural doctors

Objectives: To identify the impact of family life on the ways women practice rural medicine and the changes needed to attract women to rural practice.
Design: Census of women rural doctors in Victoria in 2000, using a self-completed postal survey.
Setting: General and specialist practice.
Subjects: Two hundred and seventy-one female general practitioners and 31 female specialists practising in Rural, Remote and Metropolitan Area Classifications 3–7. General practitioners are those doctors with a primary medical degree and without additional specialist qualifications. Main outcome measure: Interaction of hours and type of work with family responsibilities.
Results: Generalist and specialist women rural doctors carry the main responsibility for family care. This is reflected in the number of hours they work in clinical and non-clinical professional practice, availability for oncall and hospital work, and preference for the responsibilities of practice partnership or the flexibility of salaried positions. Most of the doctors had established a satisfactory balance between work and family responsibilities, although a substantial number were overworked in order to provide an income for their families or meet the needs of their communities. Thirty-six percent of female rural general practitioners and 56% of female rural specialists preferred to work fewer hours. Female general practitioners with responsibility for children were more than twice as likely as female general practitioners without children to be in a salaried position and less likely to be a practice partner. The changes needed to attract and retain women in rural practice include a place for everyone in the doctor's family, flexible practice structures, mentoring by women doctors and financial and personal recognition.     

Something Old, Something New: Recent Developments in Hospital–Physician Relationships

Objective. To describe recent developments in hospital–physician relationships in 12 metropolitan areas.
Methods. We analyze qualitative data from a third round of biannual site visit interviews conducted in 12 randomly selected metropolitan areas from 1996 to 2001. The study interviewed 895 respondents during the third round of site visits, conducted in 2000 and 2001.
Principal Findings. As HMO enrollment and capitation contracting has failed to grow in local markets, hospital executives have returned to a strategic focus on improving relationships with specialists in pursuit of fee-for-service revenue. Yet, 65 percent of hospitals interviewed in 2000 and 2001 continued to own primary care physician practices, with ownership more prevalent in highly concentrated hospital markets. A majority (55 percent) of hospitals have decreased the size of these practices in the past two years.
Conclusions. Interest in forming integrated delivery systems has waned. The potential for quality improvement through these organizations systems—by emphasizing primary care and coordinating hospital and physician services—has not been realized. The new emphasis on hospital–specialist partnerships may improve the financial status of hospitals and participating specialists in local markets, and may improve quality of care in selected service areas, but it may also increase health care costs incurred by employers and consumers.     

Organization of Care for Acute Myocardial Infarction in Rural and Urban Hospitals in Kansas

CONTEXT: One in 4 Americans lives in a rural community and relies on rural hospitals and medical systems for emergent care of acute myocardial infarctions (AMI). The infrastructure and organization of AMI care in rural and urban Kansas hospitals was examined. METHODS: Using a nominal group process, key elements within hospitals that might influence quality of AMI care were identified, including personnel, equipment, organizational systems, and quality improvement activities. These elements were included in a survey of 45 rural and 12 urban Kansas hospitals. FINDINGS: Though emergency 911 systems were widely available in both urban and rural communities, paramedics and advanced cardiac life support were less likely to be available in rural communities. Few rural hospitals were capable of emergent catheterization, angioplasty, or coronary artery bypass surgery; cardiologists, though readily available by phone, were rarely available on-site. Nevertheless, most rural ambulances could not bypass local hospitals. Most rural hospitals transferred the vast majority of their patients to urban medical centers within an average distance of 78 miles. Standardized protocols were used for emergent AMI care in 67% of urban and 62% of rural hospitals. Hospitals included aspirin in 53% and beta-blockers in 28% of either protocols or standing orders. CONCLUSIONS: Although faced with more limited resources, some rural hospitals, like their urban counterparts, have implemented protocols to address emergent care of AMI patients. Nevertheless, many of these protocols omit crucial aspects of AMI care. Rural and urban hospitals should jointly develop systems that assure consistent, rapid delivery of AMI care.     

The Impact of Accessibility on the Use of Specialist Health Care in Norway

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.     

Evaluating rural nurses for preparation in implementing nutrition interventions.

With the increase in wellness programs, earlier hospital discharges, higher health care costs, and more home health care, rural nurses are required to generalize their practices and draw from a more extensive knowledge base. The purpose of this study was to examine nursing interventions, specifically nutrition education practices, based on nutrition knowledge that is used in health promotion. A stratified random sample of rural nurses from hospitals, nursing homes, and community health agencies in North Dakota was invited to participate in this study. Data were obtained via questionnaires. The questionnaire consisted of two parts: the first analyzing demographic data and the second analyzing nutrition knowledge. Nutrition information requests were received by 90.9 percent of the practicing registered nurses. The community/public health nurses had the highest nutrition knowledge scores while medical-surgical hospital nurses had the lowest nutrition knowledge scores. With nutrition information and education being a frequently sought intervention by the rural health client, it would seem that registered nurses should be highly prepared and knowledgeable to meet these clients' needs.     

Rural Hospital Inpatient Surgical Volume: Cutting-edge Service or Operating on the Margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.