Impact of Institution of a Stroke Program Upon Referral Bias at a Rural Academic Medical Center

ABSTRACT: Context: Referral bias reflecting the preferential hospital transfer of patients with intracerebral hemorrhage (ICH) has been demonstrated as the major contributing factor for an observed high nonrisk-adjusted in-hospital crude acute stroke mortality rate at a rural academic medical center. Purpose: This study was done to assess the impact of a clinical acute stroke program upon referral bias in August 2000. Methods: A chart review of acute stroke (DRG 14) discharges during 2001 from a rural academic medical center was compared with the same data from 1999. Results: The odds ratio of ICH in hospital-transfer patients compared with nonhospital-transfer patients decreased from 11.7 in 1999 to 3.2 in 2001 (P<.035). Conclusions: This study demonstrated the rapid magnitude and significance that clinical programs can have upon referral bias. Changes in referral bias may be more rapid at rural academic medical centers because of the relative lack of health care delivery competition.     

Physicians for Rural America: The Role of Institutional Commitment Within Academic Medical Centers

CONTEXT: Prior study suggests that contextual characteristics of medical schools (e.g., state demographics, public vs private, NIH research effort) predict output of rural physicians without also considering the effects of the medical schools' own policies and programs. PURPOSE: This study examines medical school commitment to rural policies and programs and its relationship to contextual characteristics and rural physician output. METHODS: A survey of 122 U.S. allopathic medical schools provided data to construct a 32-item Rural Commitment Index for each medical school. Data for other characteristics were linked from published sources. Correlations, t tests, and multiple regression analysis were used to study the association between variables and percentage of medical school graduates (1988-1996) who were in rural primary care practice in 2000. FINDINGS: Among 90 medical schools (response rate, 73.8%), the Rural Commitment Index correlated with the percentage of the state population that is rural and whether the school is public or private, and it joined percentage state population rural, public vs private, and National Institutes of Health support in correlating with percentage of graduates in rural primary care. In a regression model that explained 48.4% of variation in the percentage of graduates in rural primary care, the Rural Commitment Index explained most variation, followed by percentage state population rural, public vs private, National Institutes of Health support, and the interaction between the Rural Commitment Index and public vs private. CONCLUSIONS: The findings support the proposition that observable institutional commitment affects rural physician output and provide justification for a definitive study to verify that a change in medical school commitment to rural medicine produces a change in rural physician output.     

Update: Health Insurance and Utilization of Care Among Rural Adolescents

CONTEXT: Adolescence is critical for the development of adult health habits. Disparities between rural and urban adolescents and between minority and white youth can have life-long consequences. PURPOSE: To compare health insurance coverage and ambulatory care contacts between rural minority adolescents and white and urban adolescents. METHODS: Cross-sectional design using data from the 1999-2000 National Health Interview Survey, a nationally representative sample of US households. Analysis was restricted to white, black, and Hispanic children aged 12 through 17 (8,503 observations). Outcome measures included health insurance, ambulatory visit within past year, usual source of care (USOC), and well visit within past year. Independent variables included race, residence, demographics, facilitating/enabling characteristics, and need. RESULTS: Across races, rural adolescents were as likely to have insurance (86.8% vs 87.7%) but less likely to report a preventive visit (60.1% vs 65.5%) than urban children; residence did not affect the likelihood of a visit or a USOC. Minority rural adolescents were less likely than whites to be insured, report a visit, or have a USOC. Most race-based differences were not significant in multivariate analysis holding constant living situation, caretaker education, income, and insurance. Low caretaker English fluency, limited almost exclusively to Hispanics, was an impediment to all outcomes. CONCLUSIONS: Most barriers to care among rural and minority youth are attributable to factors originating outside the health care system, such as language, living situation, caretaker education, and income. A combination of outreach activities and programs to enhance rural schools and economic opportunities will be needed to improve coverage and utilization among adolescents.     

Modeling the Emergency Ambulance Pass-By of Small Rural Hospitals in Victoria, Australia

CONTEXT: Many small rural hospitals struggle to attract sufficient numbers of suitable patients. Inadequate patient throughput threatens the viability of these hospitals and, consequently, the financial, physical, and social well-being of the whole community. Anecdotal evidence suggests that many emergency ambulance patients are routinely taken past their local small rural hospital to the area's major receiving hospital. PURPOSE: To quantify the ambulance pass-by of local small rural hospitals and identify the factors that influence its occurrence. METHODS: Data were collected from the ambulance and hospital records of 3 small rural centers in central Victoria, Australia. RESULTS: Ambulances transport a significant number of patients past their local small rural hospitals to the area's major receiving hospital. This takes less time for paramedics than bringing a patient to the local hospital first if the patient is then redirected by that hospital to the larger hospital. There is an inverse relationship between the rate of cases in which the local hospital redirects ambulances to the regional hospital and the rate of ambulance crew decisions to use the local hospital. CONCLUSIONS: If some patients are being transported directly to the major receiving hospital because paramedics are considering their own time commitments when making patient transport decisions, this could have revenue implications for rural hospitals. Attracting appropriate local ambulance patients to the smaller hospitals may provide an income source that is currently lost to the crowded major receiving hospital's emergency department.     

Cancer Incidence in Kentucky, Pennsylvania, and West Virginia: Disparities in Appalachia

CONTEXT: Composed of all or a portion of 13 states, Appalachia is a heterogeneous, economically disadvantaged region of the eastern United States. While mortality from cancer in Appalachia has previously been reported to be elevated, rates of cancer incidence in Appalachia remain unreported. PURPOSE: To estimate Appalachian cancer incidence by stage and site and to determine if incidence was greater than that in the United States. METHODS: Using 1994--1998 data from the central registries of Kentucky, Pennsylvania, and West Virginia, age-adjusted incidence rates were calculated for the rural and nonrural regions of Appalachia. These state rates were compared to rates from the Surveillance, Epidemiology, and End Results (SEER) program for the same years by calculating the adjusted rate ratio (RR) and a 95% confidence interval (CI). FINDINGS: Both the entire and rural Appalachian regions had an adjusted incidence rate for all cancer sites similar to the SEER rate (RR = 1.00 [95% CI, 1.00-1.01] and RR = 0.99 [95% CI, 0.99-1.00], respectively). However, incidence of cancer of the lung/ bronchus, colon, rectum, and cervix in Appalachia was significantly elevated (RR = 1.22 [95% CI, 1.20-1.23], 1.13 [95% CI, 1.11-1.14], 1.19 [95% CI, 1.16-1.22], and 1.12 [95% CI, 1.07-1.17], respectively). Incidence of cancer of the lung/bronchus and cervix in rural Appalachia was even more elevated (RR = 1.34 [95% CI, 1.31-1.36] and 1.29 [95% CI, 1.21-1.38], respectively). Incidence of unstaged disease for all cancer sites in Appalachia (RR = 1.06 [95% CI, 1.05-1.08]), particularly rural Appalachia (RR = 1.28 [95%CI, 1.25-1.301), was elevated. CONCLUSIONS: Cancer incidence in Appalachia was not found to be elevated. However, incidence of cancer of the lung/bronchus, colon, rectum, and cervix was elevated in Appalachia. The rates of unstaged cancer of every examined site were elevated in rural Appalachia, suggesting a lack of access to cancer health care.     

Comparing the Discriminative Validity of Two Generic and One Disease-Specific Health-Related Quality of Life Measures in a Sample of Patients with Dry Eye

OBJECTIVE: The purpose of this study was to compare the discriminative properties of two generic health-related quality of life (QoL) instruments (SF-36 and EQ-5D) and a newly developed disease-specific patient-reported outcomes instrument (Impact of Dry Eye on Everyday Life (IDEEL)) to distinguish between different levels of dry eye severity. METHODS: Assessment of 210 people: 130 with non-Sjogren's Keratoconjunctivitis Sicca (non-SS KCS), 32 with Sj?gren's Syndrome (SS) and 48 controls; comparison of SF-36, EQ-5D, and IDEEL age-adjusted data by dry eye severity levels. Severity was assessed based on diagnosis (non-SS KCS, SS, control), patient-report (none, very mild, mild, moderate, severe, extremely severe) and clinician-report (none, mild, moderate, severe). RESULTS: Discriminative validity results were consistent for all instruments. Significant differences between severity levels were found with most SF-36 scales (P < 0.05), all EQ-5D scales (P < 0.05), and all IDEEL scales (P < 0.0001), except for Treatment Satisfaction. IDEEL scales consistently outperformed the generic QoL measures regardless of the severity criterion used. Most SF-36 scales outperformed the EQ-5D QoL scale, but the EQ-5D visual analog scale outperformed the SF-36 scales, except for General Health Perceptions. CONCLUSIONS: The disease-specific IDEEL scales are better able to discriminate between severity levels than the majority of the generic QoL scales. Preliminary evidence demonstrates that the IDEEL will be sensitive to QoL changes over time, although further testing in controlled longitudinal studies is needed.