Gender as a Moderator Between Having an Anxiety Disorder Diagnosis and Coronary Artery Bypass Grafting Surgery (CABG) Outcomes in Rural Patients

Purpose: This paper examines gender as a moderating variable between having an anxiety disorder diagnosis and coronary artery bypass grafting surgery (CABG) outcomes in rural patients. Methods: Using the 2008 Nationwide Inpatient Sample (NIS) database, 17,885 discharge records of patients who underwent a primary CABG surgery were identified. Independent variables included age, gender, race, median household income based on patient's ZIP code, primary expected payer, the Deyo, Cherkin, and Ciol Comorbidity Index, and an anxiety comorbidity diagnosis. Outcome variables included in‐hospital length of stay and patient disposition (routine and nonroutine discharge). A 2 × 2 analysis of variance and logistic regression analyses were used to assess the interaction between gender and an anxiety disorder diagnosis on in‐hospital length of stay and patient disposition. Findings: Twenty‐seven percent of rural patients undergoing a CABG operation had a comorbid anxiety diagnosis. Rural patients who had nonroutine discharge were more likely to have comorbid anxiety diagnosis compared to rural patients who had a routine discharge. There was a significant interaction effect between having an anxiety diagnosis and gender on length of hospital stay but not for patient disposition. Conclusions: Three findings were noteworthy. First, anxiety disorder is prevalent in rural patients who are undergoing a CABG operation. Second, anxiety was a significant independent predictor of both length of hospital stay and nonroutine discharge for patients receiving CABG surgery. Last, having an anxiety disorder diagnosis increased hospital stay for both males and females; however, females seemed to be impacted more than males.     

Acute Myocardial Infarction and Coronary Artery Bypass Grafting Outcomes in Specialty and General Hospitals: Analysis of State Inpatient Data

Objective. Compare characteristics and outcomes of patients hospitalized in specialty cardiac and general hospitals for acute myocardial infarction (AMI) and coronary artery bypass grafting (CABG).
Data. 2000–2005 all-payor administrative data from Arizona, California, Texas, and Wisconsin.
Study Design. We identified patients admitted to specialty and competing general hospitals with AMI or CABG and compared patient demographics, comorbidity, and risk-standardized mortality in specialty and general hospitals.
Principal Findings. Specialty hospitals admitted a lower proportion of women and blacks and treated patients with less comorbid illness than general hospitals. Unadjusted in-hospital AMI mortality for Medicare enrollees in specialty and general hospitals was 6.1 and 10.1 percent ( p <.0001) and for non-Medicare enrollees was 2.8 and 4.0 percent ( p <.04). Unadjusted in-hospital CABG mortality for Medicare enrollees in specialty and general hospitals was 3.2 and 4.7 percent ( p <.01) and for non-Medicare enrollees was 1.1 and 1.8 percent ( p =.02). After adjusting for patient characteristics and hospital volume, risk-standardized in-hospital mortality for all AMI patients was 2.7 percent for specialty hospitals and 4.1 percent for general hospitals ( p <.001) and for CABG was 1.5 percent for specialty hospitals and 2.0 percent for general hospitals ( p =.07).
Conclusions. In-hospital mortality in specialty hospitals was lower than in general hospitals for AMI but similar for CABG. Our results suggest that specialty hospitals may offer significantly better outcomes for AMI but not CABG.     

Variation in management of community-acquired pneumonia requiring admission to Alberta,Canada hospitals

Previous studies have shown small area variation in the rate of admission to hospital for patients with community-acquired pneumonia. We determined the rates of admission and length of stay for patients with community-acquired pneumonia in Alberta and the factors influencing admission rates and length of stay. Using hospital abstracts, hospital admissions for community-acquired pneumonia from 1 April 1994 to 31 March 1999 were compared. We classified Alberta hospitals according to geographical regions, by the number of beds, and by number of community-acquired pneumonia cases. There were 12,000 annual hospital discharges for community-acquired pneumonia costing over $40 million per year. The overall in-hospital mortality rate was 12% and the 1 year mortality rate was 26%. Compared with rural hospitals, regional and metropolitan hospitals admitted patients with greater severity of illness as demonstrated by greater in-hospital mortality, cost per case and comorbidity. Age-sex adjusted hospital discharge rates were significantly below the provincial average in both urban regions. Hospital discharge rates for residents in all rural regions and 4 of 5 regions with a regional hospital were significantly higher than the provincial average. After adjusting for comorbidity, the relative risk for a longer length of stay was 22% greater in regional hospitals and about 30% greater in urban hospitals compared to rural hospitals. Seasonal variation in the admission rate was evident, with higher rates in the winter of each year. We conclude that rural hospitals would be likely to benefit from a protocol to help with the admission decision and urban hospitals from a programme to reduce length of stay.     

Depression Screening Patterns for Women in Rural Health Clinics

Context: Rates and types of screening for depression in rural primary care practices are unknown.
Purpose: To identify rates of depression screening among rural women in a sample of rural health clinics (RHCs).
Methods: A chart review of 759 women's charts in 19 randomly selected RHCs across the nation. Data were collected from charts of female patients of rural primary care providers, using trained data collectors (inter-rater reliability .88 to .93). The Women's Primary Care Screening Form, designed by the authors, was used to collect demographic, health, and screening data. Data describing the characteristics of the clinics were collected using the National Rural Health Clinic Survey. Data regarding formal screening (validated instrument used) or informal (documentation of specific questions and answers regarding depression) in the previous 5 years were recorded.
Findings: Characteristics of participating clinics and demographics of the women were similar to published data. Formal screening was documented in 2.4% of patients' charts. Informal screening was documented in 33.2% of charts. Patients with a history of anxiety were more likely to be screened ( P < .001), and younger women were more likely to be screened than older women ( P < .001).
Conclusions: Primary care providers in RHCs use more informal than formal depression screening with their female patients. Providers are more likely to screen younger patients or patients with a diagnosis of anxiety.     

Are High-Quality Cardiac Surgeons Less Likely to Operate on High-Risk Patients Compared to Low-Quality Surgeons? Evidence from New York State

Context. It is unknown whether high-risk cardiac surgical patients have less access to high-quality surgeons compared with lower-risk patients.
Objective. To determine whether high-quality surgeons are less likely to perform coronary artery bypass graft (CABG) surgery on high-risk patients compared with low-quality surgeons.
Design, Setting, and Patients. Retrospective cohort study using the New York State (NYS) CABG Surgery Reporting System (CSRS) of all patients undergoing CABG surgery in NYS who were discharged between 1997 and 1999 (51,750 patients; 2.20 percent mortality). Regression modeling was used to estimate the association between surgeon quality and patient risk of death. Surgeon quality was quantified using the observed-to-expected mortality ratio (O-to-E ratio).
Results. Higher-risk patients are more likely to receive CABG surgery from higher-quality surgeons. For every 10 percentage point increase in patient risk of death (e.g., from 5 to 15 percent), there is an absolute reduction of 0.034 in the surgeon O-to-E ratio ( p < .001).
Conclusion. This study suggests that high-risk CABG patients are significantly more likely to receive care from high-quality surgeons compared with lower risk patients.     

Rural–urban disparities in health: How does Canada fare and how does Canada compare with Australia?

Objective:  To analyse rural–urban and intra-rural disparities in health status in Canada and to compare Canada with Australia with respect to such disparities.
Design:  Four indicators were used to show rural–urban and intra-rural differences in health status: (i) mortality due to circulatory diseases, (ii) mortality due to cancer, (iii) injury-related mortality; and (iv) all-cause mortality. Rural was disaggregated into finer categories based on degree of remoteness, using the Metropolitan Influence Zone classification in Canada and the Accessibility/Remoteness Index of Australia. Comparisons were made using age-standardised mortality rates and standardised mortality ratios.
Participants:  Rural and urban populations of Canada and Australia.
Results:  The study confirmed previous findings that rural Canadians tended to have poorer health status than their urban counterparts. However, when rural was disaggregated into finer categories, different health status patterns emerged. Although the most rural areas tended to have the worst health status, the least rural areas generally enjoyed good health. The Canada–Australia comparisons revealed convergence and divergence.
Conclusions:  The similarities between Canada and Australia show that rural–urban disparities in health status are not limited to a particular country. For several causes of death, whereas the mortality risks in Rural 1 areas in Canada are significantly lower than in urban areas, the opposite is true in Australia, suggesting that although there are some common patterns across the two countries in relation to rural–urban health status disparities, nation-specific uniqueness is to be expected.     

Using Medicare claims data to assess provider quality for CABG surgery: does it work well enough?

OBJECTIVES: To assess the relative abilities of clinical and administrative data to predict mortality and to assess hospital quality of care for CABG surgery patients. DATA SOURCES/STUDY SETTING: 1991-1992 data from New York's Cardiac Surgery Reporting System (clinical data) and HCFA's MEDPAR (administrative data). STUDY DESIGN/SETTING/SAMPLE: This is an observational study that identifies significant risk factors for in-hospital mortality and that risk-adjusts hospital mortality rates using these variables. Setting was all 31 hospitals in New York State in which CABG surgery was performed in 1991-1992. A total of 13,577 patients undergoing isolated CABG surgery who could be matched in the two databases made up the sample. MAIN OUTCOME MEASURES: Hospital risk-adjusted mortality rates, identification of "outlier" hospitals, and discrimination and calibration of statistical models were the main outcome measures. PRINCIPAL FINDINGS: Part of the discriminatory power of administrative statistical models resulted from the miscoding of postoperative complications as comorbidities. Removal of these complications led to deterioration in the model's C index (from C = .78 to C = .71 and C = .73). Also, provider performance assessments changed considerably when complications of care were distinguished from comorbidities. The addition of a couple of clinical data elements considerably improved the fit of administrative models. Further, a clinical model based on Medicare CABG patients yielded only three outliers, whereas eight were identified using a clinical model for all CABG patients. CONCLUSIONS: If administrative databases are used in outcomes research, (1) efforts to distinguish complications of care from comorbidities should be undertaken, (2) much more accurate assessments may be obtained by appending a limited number of clinical data elements to administrative data before assessing outcomes, and (3) Medicare data may be misleading because they do not reflect outcomes for all patients.     

Use of Psychotherapy by Rural and Urban Veterans

Purpose: To examine whether differences exist between rural and urban veterans in terms of initiation of psychotherapy, delay in time from diagnosis to treatment, and dose of psychotherapy sessions. Methods: Using a longitudinal cohort of veterans obtained from national Veterans Affairs databases (October 2003 through September 2004), we extracted veterans with a new diagnosis of depression, anxiety, or posttraumatic stress disorder (PTSD) (n = 410,923). Veterans were classified as rural (categories 6-9; n = 65,044) or urban (category 1; n = 149,747), using the US Department of Agriculture Rural-Urban Continuum Codes. Psychotherapy encounters were identified using Current Procedural Terminology codes for the 12 months following patients’ initial diagnosis. Findings: Newly diagnosed rural veterans were significantly less likely (P < .0001) to receive psychotherapy (both individual and group). Urban veterans were roughly twice as likely as rural veterans to receive 4 or more (9.46% vs 5.08%) and 8 or more (5.59% vs 2.35%) psychotherapy sessions (P < .001). Conclusions: Rural veterans are significantly less likely to receive psychotherapy services, and the dose of the psychotherapy services provided for rural veterans is limited relative to their urban counterparts. Focused efforts are needed to increase access to psychotherapy services provided to rural veterans with depression, anxiety, and PTSD.     

Risk adjustment for coronary artery bypass graft surgery: an administrative approach versus EuroSCORE.

OBJECTIVE: To determine the ability of administrative data in predicting in-hospital mortality for patients undergoing coronary artery bypass graft surgery. METHODS: Patient data were obtained from the administrative databases on hospital discharge abstracts of the Italian region Emilia Romagna for the years 2000-2001. We used a multivariate logistic regression analysis to compare an ICD-9-CM risk adjustment approach based on administrative variables (such as age, gender, principal diagnosis, combined operation, previous cardiac surgery, emergency admission, and Charlson comorbidity index) with a risk adjustment approach based on the clinical European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict in-hospital mortality and to assess hospital performance. In order to distinguish complications of care from comorbidities, we linked hospital data across multiple episodes of care up to 1 year before the admission for coronary artery bypass graft (CABG). RESULTS: The risk adjustment approach based on ICD-9-CM data provides good explanatory ability in models assessing in-hospital mortality (the c statistics obtained are very close: c = 0.76 in 2000 and c = 0.80 in 2001 for the administrative model versus 0.78 in 2000 and 0.77 in 2001 for the clinical one) and in those ranking the centres (c = 0.78 in 2000 in both approaches, and c = 0.82 for the administrative model versus c = 0.78 for the clinical one in 2001). CONCLUSIONS: Adding some administrative variables considered proxy for clinical complexity to the administrative model and linking hospital data across patients' multiple episodes of care eliminated much of the difference in effectiveness between the clinical and administrative risk adjustment approach. Focusing on the health policy context of measuring CABG death rates, our study strengthened the thesis that, with the growing improvement in accurate coding practice, administrative databases could provide a valuable and economical source for health planning and research.     

In a retrospective study of chronic obstructive pulmonary disease inpatients, respiratory comorbidities were significantly associated with prognosis

BACKGROUND AND OBJECTIVE: Comorbidities may be related to the prognosis for chronic obstructive pulmonary disease (COPD). We examined respiratory comorbidities associated with length of stay and in-hospital mortality among COPD patients. METHODS: We used the Hospital Person Oriented Information (HPOI) database of Statistics Canada for a 5-year period. Over 4 years (fiscal years 1994-1995 to 1998-1999), 143,135 records listed COPD as the most responsible diagnosis for men and 122,065 records for women aged 40 years or more, and 75,780 men and 69,539 women were admitted to hospital at least once. Logistic regression modeling was used to examine the relationships between respiratory comorbidities and hospital outcomes adjusting for covariates. RESULTS: Of the COPD patients, 10% had pneumonia-influenza and 3% had asthma as comorbid conditions. Women had a higher prevalence of asthma than men. The median length of stay at hospital was approximately 7 days, and 95% of patients were discharged alive. The odds ratio (95% confidence interval) for pneumonia-influenza in relation to in-hospital death was 3.56 (3.31, 3.83) for men and 3.29 (3.00, 3.61) for women. For comorbid asthma the corresponding odds ratios were 0.56 (0.36, 0.61) and 0.54 (0.35, 0.57), respectively. CONCLUSIONS: COPD inpatients with pneumonia-influenza had a worse prognosis and those with asthma had a better prognosis.     

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

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

Effect of prophylactic low dose of methylprednisolone on postoperative new atrial fibrillation and early complications in patients with severe LV dysfunction undergoing elective off-pump coronary artery bypass surgery

Atrial fibrillation (AF) is the most common arrhythmia after cardiothoracic surgery. AF following coronary artery bypass graft (CABG) is associated with an increase in morbidity, mortality, hemodynamic instability, thromboembolic events, severity of heart failure and ICU and hospital stay. Corticosteroids have a variety of beneficial effects on recovery after elective surgery. This study was designed to test the hypothesis that low dose of Methylprednisolone (MP) can affect post-CABG AF and early complications in patients with severe left ventricle dysfunction who underwent elective off-pump coronary artery bypass. A total of 120 patients with LV dysfunction undergoing elective off- pump CABG randomly received either MP or placebo. Diabetic patients and those who were receiving corticosteroids were excluded. The MP group received 5mg/kg of MP intravenously after induction of anesthesia and the placebo group received an equal volume of normal saline. We evaluated Post-CABG variables including incidence, duration and frequency of AF recurrence and early morbidity such as bleeding, infection, vomiting, renal and respiratory dysfunctions, ICU or hospital stay and early mortality. The mean age of patients was 62.11 ± 12.34 years with the 2.4 male to female ratio. AF occurred in 23(19.2%) patients. No significant difference in the incidence of new AF was found between the placebo (21.7%) and MP group (16.7%) (P=0.47). MP did not affect postoperative bleeding, infection, vomiting, renal and respiratory dysfunction and mortality; however, MP significantly reduced ICU and hospital length of stay. MP did not affect the incidence, duration and frequency of AF recurrence in patients with severe LV dysfunction undergoing off-pump CABG. However, MP could reduce ICU and hospital stay significantly in these patients.     

Access to and Use of Eye Care Services in Rural Arkansas

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

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.     

Increasing the value of cardiac care: the Dartmouth approach

A cardiac services team at Dartmouth-Hitchcock Medical Center (DHMC) launched multiple efforts to improve the quality and value of their services. The team developed a critical path for coronary artery bypass grafting (CABG) and tracked important clinical outcomes, such as mortality rates and wound complications. The team also studied the patient's view of the process. Staff used focus groups and surveys to distill the "voice of the customer" into six quality characteristics and developed methods to better involve patients in clinical decision making and evaluation of treatment efficacy. Results: CABG mortality declined from 5.7 percent in 1992 to 2.7 percent in 1994, 16 months after the critical path was developed. Mean total intubation time for patients following open-heart surgery was reduced from 22 hours to 14 hours. Median postoperative length of stay decreased from seven days to six for elective CABG patients. The number of patients discharged in five days or less increased from 20 percent to 40 percent. Readmission to the hospital following discharge remained stable, despite the shorter length of stay.     

Comorbidity adjustment index for the international classification of diseases, 10th revision

OBJECTIVE: To develop a Charlson-like comorbidity index based on clinical conditions and weights of the original Charlson comorbidity index. METHODS: Clinical conditions and weights were adapted from the International Classification of Diseases, 10th revision and applied to a single hospital admission diagnosis. The study included 3,733 patients over 18 years of age who were admitted to a public general hospital in the city of Rio de Janeiro, southeast Brazil, between Jan 2001 and Jan 2003. The index distribution was analyzed by gender, type of admission, blood transfusion, intensive care unit admission, age and length of hospital stay. Two logistic regression models were developed to predict in-hospital mortality including: a) the aforementioned variables and the risk-adjustment index (full model); and b) the risk-adjustment index and patient's age (reduced model). RESULTS: Of all patients analyzed, 22.3% had risk scores > or = 1, and their mortality rate was 4.5% (66.0% of them had scores > or = 1). Except for gender and type of admission, all variables were retained in the logistic regression. The models including the developed risk index had an area under the receiver operating characteristic curve of 0.86 (full model), and 0.76 (reduced model). Each unit increase in the risk score was associated with nearly 50% increase in the odds of in-hospital death. CONCLUSIONS: The risk index developed was able to effectively discriminate the odds of in-hospital death which can be useful when limited information is available from hospital databases.     

Disparities in breast cancer stage at diagnosis in urban and rural adult women: a systematic review and meta-analysis

PurposeSurvival from breast cancer is dependent on stage at diagnosis and some evidence suggests that rural women are more likely than urban women to be diagnosed with advanced stage disease. This systematic review and meta-analysis compared the stage of breast cancer at diagnosis between women residing in urban and rural areas.MethodsPubMed (1951–2012), EMBASE (1966–2012), CINAHL (1982–2012), RURAL (1966–2012), and Sociological abstracts (1952–2012) were systematically searched in November 2012 for relevant peer reviewed studies. Studies on adult women were included if they reported quantitative comparisons of rural and urban differences in staging of breast cancer at diagnosis.ResultsTwenty-four studies were included in the systematic review and 21 studies had sufficient information for inclusion in the meta-analysis (N = 879,660). Evidence indicated that patients residing in rural areas were more likely to be diagnosed with more advanced breast cancer. Using a random effects model, the results of the meta-analysis showed that rural breast cancer patients had 1.19 higher odds (95% confidence interval, 1.12–1.27) of late stage breast cancer compared with urban breast cancer patients.ConclusionsRural women were more likely than urban women to be diagnosed at a later stage. Preventive measures may need to target the rural population.     

Regional variation in the survival and health of older Australian women: a prospective cohort study

Objective: Older people may act as sensitive indicators of the effectiveness of health systems. Our objective is to distinguish between the effects of socio-economic and behavioural factors and use of health services on urban-rural differences in mortality and health of elderly women.
Methods: Baseline and longitudinal analysis of data from a prospective cohort study. Participants were a community-based random sample of women (n=12778) aged 70-75 years when recruited in 1996 to the Australian Longitudinal Study on Women's Health. Measures used were: urban or rural residence in Australian States and Territories, socio-demographic characteristics, health related behaviour, survival up to 1 October 2006, physical and mental health scores and use of medical services.
Results: Mortality was higher in rural than in urban women (hazard ratio, HR 1.14; 95% CI, 1.03,-1.26) but there were no differences between States and Territories. There were no consistent baseline or longitudinal differences between women for physical or mental health, with or without adjustment for socio-demographic and behavioural factors. Rural women had fewer visits to general practitioners (odds ratio, OR=0.54; 95% CI, 0.48-0.61) and medical specialists (OR=0.60; 95% CI, 0.55-0.65).
Conclusions: Differences in use of health services are a more plausible explanation for higher mortality in rural than urban areas than differences in other factors.
Implications: Older people may be the 'grey canaries' of the health system and may thus provide an 'early warning system' to policy makers and governments.     

Do rural hospitals lag behind urban hospitals in addressing community health needs? An analysis of recent trends in US community hospitals

Objective:  This study examined whether rural and urban hospitals differ in their level of responsiveness to community health needs.
Design:  This study used a multivariate, longitudinal research design.
Research setting:  A cross-sectional survey was the setting for this study.
Participants:  The participants were rural or urban hospitals in the United States.
Main outcome measures:  The dependent variables were selected from the American Hospital Association hospital survey questions that are related to community health needs. The independent variable was rural or urban location.
Results:  Rural hospitals improved more than urban hospitals in addressing community health needs from 1997 through 2006 for most of the indicators, especially in working with other providers to conduct a community health assessment. However, rural hospitals still lag significantly behind urban hospitals in tracking health information.
Conclusions:  This study suggests that rural hospitals do not lag behind urban hospitals in addressing community health needs. Further research is needed to understand the role of community hospitals in influencing local health delivery system activities regarding the potential community benefits and their impact on improving health of local populations.