Exploration of Remote Didactics at Rural Family Medicine Training Programs.

BACKGROUND AND OBJECTIVES: Distance learning is a feasible and effective method of delivering education, especially in rural settings. Few studies focus on remote learning in graduate medical education. This study explores remote didactic practices of rural family medicine programs in the United States. METHODS: We conducted an electronic survey of rural family medicine residency site directors across the United States. We completed sample analyses through descriptive statistics with an emphasis on descriptions of current didactic practices, facilitators, and challenges to implementation. RESULTS: The overall response rate was 38% (47/124) for all participants from rural residency programs, representing 28 states. About 24% of rural training track (RTT) participants reported no shared remote didactics between urban and rural sites. More than half of RTT participants (52%) reported remote virtual didactics were either not shared between urban and rural site or were shared less than 50% of the time. Top challenges to implementing remote shared didactics were lack of appropriate technology (31%) and lack of training for faculty and residents in delivery of remote didactics (31%). Top facilitators included having technology for the remote connection (54%), a faculty champion (42%), and designated time to develop the curriculum (38%). CONCLUSIONS: There is potential for improving shared remote didactic sessions between rural and urban sites for family medicine RTTs, which may enhance efficiency of curriculum development across sites and maximize opportunities for bidirectional learning between urban and rural sites.

Investigating the Impact of Geographic Location on Colorectal Cancer Stage at Diagnosis: A National Study of the SEER Cancer Registry.

BACKGROUND: Early detection of colorectal cancer (CRC) is associated with decreased mortality and potential avoidance of chemotherapy. CRC screening rates are lower in rural communities and patient outcomes are poorer. This study examines the extent to which United States' rural residents present at a more advanced stage of CRC compared to nonrural residents. METHODS: Using the 2010-2014 Surveillance, Epidemiology and End Results Incidence data, 132,277 patients with CRC were stratified using their county of residence and urban influence codes into 5 categories (metro, adjacent micropolitan, nonadjacent micropolitan, small rural, and remote small rural). Logistic regression was used to investigate the relationship between late stage at diagnosis and county-level characteristics including level of rurality, persistent poverty, low education and low employment, and patient characteristics. RESULTS: In the adjusted analysis the rate of stage 4 CRC at diagnosis differed across geographic classification, with patients living in remote small rural counties having the highest rate of stage 4 disease (range: 19.2% in nonadjacent micropolitan counties to 22.7% in remote small rural counties). Other factors, such as patient characteristics, insurance status, and regional practice variation were also significantly associated with late-stage CRC diagnosis. CONCLUSIONS: Geographic residence is associated with the rate of stage 4 disease at presentation. Additional patient factors are associated with stage 4 CRC disease at diagnosis. Cancer outcomes are worse for rural patients, and late stage at diagnosis may partially account for this disparity. These differences have persisted over time and suggest areas for further research, patient engagement, and education.

Projected Contributions of Nurse Practitioners and Physicians Assistant to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas.

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.

Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update.

PURPOSE: Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier. METHODS: Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012. FINDINGS: The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural). CONCLUSIONS: Overall, MAT access has improved, but rural communities still experience treatment disparities.

Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations from Rural Physicians.

PURPOSE: The United States is in the midst of a severe opioid use disorder epidemic. Buprenorphine is an effective office-based treatment that can be prescribed by physicians, nurse practitioners, and physician assistants with a Drug Enforcement Administration (DEA) waiver. However, many providers report barriers that keep them from either getting a DEA waiver or fully using it. The study team interviewed rural physicians successfully prescribing buprenorphine to identify strategies for overcoming commonly cited barriers for providing this service. METHODS: Interview candidates were randomly selected from a list of rurally located physicians with a DEA waiver to prescribe buprenorphine who reported treating high numbers of patients on a 2016 survey. Forty-three rural physicians, who were prescribing buprenorphine to a high number of patients, were interviewed about how they overcame prescribing barriers previously identified in that survey. FINDINGS: Interviewed physicians reported numerous ways to overcome common barriers to providing buprenorphine treatment in rural areas. Key recommendations included ways to (1) get started and maintain medication-assisted treatment, (2) minimize DEA intrusion and medication diversion, and (3) address the lack of mental health providers and stigma surrounding opioid use disorder (OUD). Overall, physicians found providing this service to be very rewarding. CONCLUSIONS: Despite known barriers, rural physicians around the country have been successful in adding buprenorphine treatment to their practices. Nonprescribing providers can learn from the strategies used by successful prescribers to add this service.