Quality-of-Care Challenges for Rural Health

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.     

对农村医疗保障制度构建的理论思考

适应我国城乡分治、二元经济的现实,确立政府对农民医疗保障经济责任与当地经济水平相适应的观念;适应我国医疗费用上升,医疗风险日益突出的现状,确立农村医疗保障的重点是缓解因病致贫;针对农村基层医疗卫生机构资源优化的趋势,确立农村医疗保障供方多元化的观念;同时应建立家庭帐户和统筹基金相结合的农村医疗保险模式,以适应农村经济以家庭联产承包制为基础的背景。     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.     

Quality of Care in the Rural Context: A Proposed Research Agenda

The quality of health care provided in rural areas is critical to rural patients and providers and will shape the future evolution of the rural health care system. Past research has focused almost exclusively on disease-specific comparisons of the quality of care rendered in rural as compared with urban areas, which ignores the fact that it is the functioning of the entire system of care that determines whether or not rural residents receive high quality care. Future research should focus on the functioning of the entire rural system of care. To accomplish this objective, we suggest investments in the following areas: the creation of a national database that collects information on the process and outcome of care delivered to rural populations, the incorporation of human factors research into our research agenda, greater emphasis on the importance of sociodemographic and cultural issues to the quality of care, and a shift to a focus on populations as opposed to individuals.     

Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.     

四川省城乡居民就医路径及医疗机构选择的影响因素研究

目的 通过纵向随访数据分析四川省城乡居民的就医路径特征和就医机构选择的影响因素。方法 从四川省第五次卫生服务调查的样本区(县)中抽取1个城市点和1个农村点,监测居民3个月的卫生服务利用行为,定性描述居民就医路径特征,采用重复测量资料的多水平Logistic模型分析就诊医疗机构选择的影响因素。结果 患病后,城市点以遵医嘱治疗为主,农村点则以就诊为主;就诊时,城市以县(市、区)级医疗机构为主,农村以基层医疗机构为主;影响就诊医疗机构选择的因素有就业状况、是否患有慢性疾病。结论 四川省城乡居民就医路径特征不同,城市居民就诊机构的流向存在不合理分布。应加强城市点分级诊疗制度的推行,规范城市居民就医行为。     

Community, service, and policy strategies to improve health care access in the changing urban environment

Urban communities continue to face formidable historic challenges to improving public health. However, reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to residents' health needs. This commentary suggests that health care improvement in metropolitan areas will require setting local, state, and national agendas around 3 priorities. First, health care must reorient around powerful population dynamics, in particular, cultural diversity, growing numbers of elderly, those in welfare-workplace transition, and those unable to negotiate an increasingly complex health system. Second, communities and governments must assess the consequences of health professional shortages, safety net provider closures and conversions, and new marketplace pressures in terms of their effects on access to care for vulnerable urban populations; they must also weigh the potential value of emerging models for improving those populations' care. Finally, governments at all levels should use their influence through accreditation, standards, tobacco settlements, and other financing streams to educate and guide urban providers in directions that respond to urban communities' health care needs.     

Unravelling the extent of inequalities in health across urban and rural areas: Evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000–2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or ‘other cities’) and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.     

Ethical Disparities: Challenges Encountered by Multidisciplinary Providers in Fulfilling Ethical Standards in the Care of Rural and Minority People

ABSTRACT:  Context: Health care disparities are well documented for people living in rural areas and for people who are members of ethnic minorities. Purpose: Our goal was to determine whether providers report greater difficulty in providing care for rural than urban residents and for ethnic minorities than patients/clients in general in 4 practice areas of ethical relevance: attaining treatment adherence, assuring confidentiality, establishing therapeutic alliance, and engaging in informed consent processes. Methods: We received survey responses from 1,558 multidisciplinary medical and behavioral providers across rural and non-rural areas of New Mexico and Alaska in 2004 to assess a wide range of issues in providing health care. Findings: Providers reported some difficulties in fulfilling various ethical practices for all types of patients, but not more difficulty when caring for minority compared to nonminority patients/clients. However, they do report more frequent additional problems related to the practice issues of treatment adherence, therapeutic alliance, informed consent, and confidentiality with minority patients than others. Difficulties and more frequent additional problems are greater for providers in rural than in non-rural areas. Results generalize across both Alaska and New Mexico with few differences. Conclusions: We obtained evidence for disparity in care for patients/ clients who were minority group members, and clear evidence of disparity for people residing in rural compared to non-rural areas of 2 states with large rural areas.     

Health Care Markets, the Safety Net, and Utilization of Care among the Uninsured

Objective. To quantify the relationship between utilization of care among the uninsured and the structure of the local health care market and safety net.
Data Sources/Study Setting. Nationally representative data from the 1996 to 2000 waves of the Medical Expenditure Panel Survey (MEPS) linked to data from multiple secondary sources.
Study Design. We separately analyze outpatient care utilization and whether an individual incurred any medical expenditure among uninsured adults living in urban and rural areas. Safety net measures include distances between each individual and the nearest safety net providers as well as a measure of capacity based on local government and hospital health expenditures. Other covariates include the managed care presence in the local health care market, the percentage of individuals who are uninsured in the area, and local primary care physician supply. We simulate utilization using standardized predictions.
Principal Findings. Distances between the rural uninsured and safety net providers are significantly associated with utilization. In urban areas, we find that the percentage of individuals in the area who are uninsured, the pervasiveness and competitiveness of managed care, the primary care physician supply, and safety net capacity have a significant relationship with health care utilization.
Conclusions. Facilitating transport to safety net providers and increasing the number of such providers are likely to increase utilization of care among the rural uninsured. Our findings for urban areas suggest that the uninsured living in areas where managed care presence is substantial, and especially where managed care competition is limited, could be a target for policies to improve the ability of the uninsured to obtain care. Policies oriented toward enhancing funding for the safety net and increasing the capacity of safety net providers are likely to be important to ensuring the urban uninsured are able to obtain health care.     

2000-2018年我国城乡居民医疗保健支出公平性变化研究

目的:了解我国城乡及地区间医疗保健支出现状及差异性,分析我国城乡居民医疗保健支出的公平性,为我国医药卫生体制改革提供科学参考。方法:收集2000—2018年城乡医疗保健支出、人均可支配收入及人均纯收入等相关数据,采用集中指数和集中曲线对我国城乡医疗保健支出进行公平性分析。结果:2010—2018年城镇居民人均医疗保健支出(实际值)年平均增长速度为3.55%,农村居民人均医疗保健支出(实际值)年平均增长速度为10.00%。2000—2017年我国城镇居民人均医疗保健支出集中指数呈下降趋势,其中2006年出现最大值为0.1332,除2015—2017年外,其余年份差异均具有统计学意义(P<0.05);2000—2017年我国农村居民人均医疗保健支出集中指数呈下降趋势,2004年出现最大值为0.2522,差异均具有统计学意义(P<0.05)。结论:我国城乡人均医疗保健支出逐年增加,全国和各地区城乡人均医疗保健支出差距较大。我国城乡人均医疗保健支出存在不公平性,城镇人均医疗保健支出优于农村人均医疗保健支出,公平性逐渐趋好。     

建设覆盖城乡居民的基本卫生保健制度的思考

从现实和理论的角度,采用综合分析的方法,提出了建设覆盖城乡居民的基本卫生保健制度的内涵、内容、方法和建议。新时期建设覆盖城乡居民的基本卫生保健制度,应高度坚持我国卫生事业发展的经验,合理借鉴国际通行的做法,强化政府主导,理顺管理职能,完善卫生经济政策,注重综合配套改革,提供适应经济社会发展水平的适宜技术,依法保障人人享有基本卫生保健服务。     

The growing importance of dental services in rural America

As the science of medicine progresses, associations between good oral health and improved health status are being documented. However, the data would suggest that individuals in America's rural communities are experiencing dramatic health problems because they are not receiving dental treatment. This article addresses the importance of dental services in rural communities and highlights the importance of cooperation among hospitals, individual clinical providers, community health care organizations, and governmental entities. It will also discuss why there is a shortage in these rural areas and how the shortage is affecting rural communities and will address some strategies for solving this crisis. This research on the availability of dental care in rural communities will provide a framework for community leaders, elected officials, and health care providers to collect and analyze data to support future decision making in response to community health care needs. Such decisions increase the quality and efficiency of health care services, thereby safeguarding the health status of the population. This study found that the capability for hospital-based dental care services is greater in urban communities, whereas rural communities have significantly less capability for hospital dental care. This would support the premise that the availability of dental services is inconsistent across the United States and that dental care resources could be allocated to provide a consistent level of services across the population. It also emphasizes the importance of building innovative partnerships among local, state, and national organizations to ensure that an appropriate level of dental care is available in rural America. The study has managerial implications on meeting the demand for dental care in rural communities and policy implications on future resource allocation.     

Rural Policy Development: An NRHA and PACE Association Collaborative Model

The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model of comprehensive care for frail, elderly people. To date, all of the PACE programs have been located in urban areas. Rural advocates and policymakers, however, believe the program may hold great promise for use in rural areas, which have higher percentages of elderly residents than urban areas. In 2002, the National Rural Health Association and the National PACE Association convened a meeting that brought together PACE experts, policymakers, and rural health care providers to examine PACE and its applicability for rural communities. The meeting participants concluded that there were many rural communities where the PACE model might not only be appropriate but also highly successful in caring for rural, frail, elderly people. This article examines the notion of expanding the PACE model to rural communities, including some of the barriers and some of the possible solutions that might make PACE a viable part of the rural health care delivery system.     

Emergency Medical Services in Rural Areas: The Supporting Role of State EMS Agencies

CONTEXT: EMS is an integral part of health care and is especially important in less densely populated areas. What is known about EMS in rural areas is limited because of fragmentation in the system and rudimentary data collection efforts. PURPOSE: The goal of this study is to identify important issues faced by rural EMS systems and describe the support of rural EMS providers by state EMS agencies. METHODS: A telephone survey of state EMS directors (response rate 95.7%) asked questions regarding issues in medical direction, programs, and initiatives by state EMS agencies that target rural and volunteer EMS providers, integration initiatives, and anticipated effects of the new Medicare fee schedule. FINDINGS: Medical direction in rural EMS was identified as a major issue for a majority of states. Integration in EMS is seen as a possible solution but does not occur very commonly. The survey found substantial variation in the state approach to EMS issues. Less than a third of the states in the study have a statewide EMS plan. State EMS agencies address rural EMS provider needs in a limited manner. EMS state agencies focus on regulation and funding of EMS providers, with only approximately a third providing technical assistance to EMS providers. CONCLUSIONS: The range in approaches to EMS issues at the state level will need to be taken into account in formulating national EMS policy. The limited provision of technical assistance leaves a void that may be addressed by other agencies and organizations in some states. In the absence of major federal funding initiatives, the development of EMS has become a state and local issue. A new national initiative may help address EMS issues and stimulate the development of EMS as a system beyond its current fragmented state.     

Access to Health Care: Urban-Rural Comparisons from a Midwestern Agricultural State

Lack of access to quality health care for a large number of Americans, particularly those living in rural areas, is a major health care problem. Differences in access between rural and urban areas are caused by obstacles to providing adequate care, such as hospital closures and physician shortages, and low income and/or employment that does not provide health insurance as an employee benefit. This study, based on a random sample of 6,000 households in Nebraska, finds that access to health care is better for residents of rural than urban areas. The relationship holds with controls for health status and health insurance. The pattern in Nebraska reflects an absence of differences in income, health insurance, and health status that produce differences in access between rural and urban areas nationwide. The findings suggest that any serious proposal to reform health care delivery should involve the states and use established patterns of seeking care among state residents.     

Service Use of Rural and Urban Medicaid Beneficiaries Suffering From Depression: The Role of Supply

Despite the prevalence and consequence of depression in rural areas, the literature on treating depression in rural areas is relatively scarce and inconclusive. The use of mental health services by rural people suffering from depression and the role that supply may play in explaining these differences are not well understood. Understanding these issues for rural Medicaid beneficiaries is important as Medicaid managed carefor physical and behavioral health care is expanded to rural areas. This study compares the mental health service use of rural and urban Medicaid beneficiaries, ages 18 to 64, in Maine suffering from depression and examines what influence mental health and primary care supply have in explaining observed differences. Two models are used to estimate the use of ambulatory mental health services: (1) a logit likelihood estimate of whether a beneficiary uses any outpatient mental health services for depression; (2) an ordinary least squares regression estimating the number of annualized ambulatory mental health care visits among users. Rural beneficiaries suffering from depression have lower utilization than urban beneficiaries. Rural and urban Aid for Families with Dependent Children (AFDC)--and Supplemental Security Income (SSI)--beneficiaries suffering from depression rely more on mental health than on general health care providers to receive ambulatory mental health care. Rural beneficiaries (AFDC and SSI) rely relatively more on general health care providers than urban beneficiaries. Multivariate analysis suggests that mental health supply and patient-level factors, but not primary care supply, account for utilization differences. This article describes the need to better understand factors limiting participation of primary care providers and to study the role of supply across multiple states.     

Rural-Urban Differences in Health Risks, Resource Use and Expenditures Within Three State Medicaid Programs: Implications for Medicaid Managed Care

This study uses Medicaid claims data for income-eligible enrollees in California, Georgia and Mississippi to compare expenditures, resource usage and health risks between residents of rural and urban areas of the states. Resource use is measured using the Resource Based Relative Value Scale (RBRVS) system for professional services, hospital days and outpatient facility visits; it also is valued at private insurance reimbursement rates for the states. Health risks are measured using the diagnosis-based Adjusted Clinical Group system. Resource use is compared on a risk-adjusted basis with the use of urban Medicaid enrollees as the benchmark. We find that actual expenditures for rural care users are lower than for urban care users. However, because the proportion of Medicaid enrollees who use care is higher in rural than in urban areas in all three states, expenditures per rural enrollee are not consistently lower. Case mix is more resource intensive for rural compared to urban residents in all three states. Although resource usage is not systematically lower overall for rural enrollees, on a risk-adjusted basis they tend to use less hospital resources than urban enrollees. Capitation rates based on historical per enrollee expenditures would not appear to under-reimburse managed care organizations for the care of rural as opposed to urban residents in the study states.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

Rural Residence and Poor Birth Outcome in Washington State

It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome.