Averted Transfers in Rural Emergency Departments Using Telemedicine: Rates and Costs Across Six Networks.

Objective: This analysis identified the rate of transfers and averted transfers and their associated costs across multiple emergency department telemedicine (teleED) networks. Methods: This study is a prospective cohort analysis in six teleED networks operating in 65 hospitals in 11 states across the United States. Each submitted uniform data on all teleED encounters for a 26-month period to a data co-ordinating center. Averted transfers were identified if an encounter met specific criteria. Cost savings from averted transfers were estimated from hospital-specific costs of transferred patients. Results: A total of 4,324 teleED encounters were reported. Excluding patients who died, 1,934 (46.2%) were transferred to another inpatient facility. Records of the remaining 2,248 teleED patients were examined and 882 (39.2% of nontransfers; 20.4% of all teleED cases) teleED patients met the criteria for an averted transfer. Of the averted transfer cases, 53.3% were admitted to the local inpatient facility, and 43.5% were discharged. Patients who averted transfer had lower levels of severity and less billed services than those who were transferred. Transport savings for averted transfers were estimated to total $1,074,663 annually across the six teleED networks. Average estimated transport savings were $2,673 for each averted transfer. Conclusions: In a large cohort of teleED cases, 39% of nontransfer cases were averted transfers (20% of all teleED cases). Importantly, 43% of these patients were routinely discharged rather than being transferred. Averted transfers saved on average $2,673 in avoidable transport costs per patient, with 63.6% of these cost savings accruing to public insurance.

Chiropractic use in the Medicare population: prevalence, patterns, and associations with 1-year changes in health and satisfaction with care.

OBJECTIVE: The purpose of this study was to examine how chiropractic care compares to medical treatments on 1-year changes in self-reported function, health, and satisfaction with care measures in a representative sample of Medicare beneficiaries. METHODS: Logistic regression using generalized estimating equations is used to model the effect of chiropractic relative to medical care on decline in 5 functional measures and 2 measures of self-rated health among 12170 person-year observations. The same method is used to estimate the comparative effect of chiropractic on 6 satisfaction with care measures. Two analytic approaches are used, the first assuming no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models. RESULTS: The unadjusted models show that chiropractic is significantly protective against 1-year decline in activities of daily living, lifting, stooping, walking, self-rated health, and worsening health after 1 year. Persons using chiropractic are more satisfied with their follow-up care and with the information provided to them. In addition to the protective effects of chiropractic in the unadjusted model, the propensity score results indicate a significant protective effect of chiropractic against decline in reaching. CONCLUSION: This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

The comparative effect of episodes of chiropractic and medical treatment on the health of older adults.

OBJECTIVES: The comparative effect of chiropractic vs medical care on health, as used in everyday practice settings by older adults, is not well understood. The purpose of this study is to examine how chiropractic compares to medical treatment in episodes of care for uncomplicated back conditions. Episodes of care patterns between treatment groups are described, and effects on health outcomes among an older group of Medicare beneficiaries over a 2-year period are estimated. METHODS: Survey data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old were linked to participants' Medicare Part B claims under a restricted Data Use Agreement with the Centers for Medicare and Medicaid Services. Logistic regression was used to model the effect of chiropractic use in an episode of care relative to medical treatment on declines in function and well-being among a clinically homogenous older adult population. Two analytic approaches were used, the first assumed no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models. RESULTS: Episodes of care between treatment groups varied in duration and provider visit pattern. Among the unadjusted models, there was no significant difference between chiropractic and medical episodes of care. The propensity score results indicate a significant protective effect of chiropractic against declines in activities of daily living (ADLs), instrumental ADLs, and self-rated health (adjusted odds ratio [AOR], 0.49; AOR, 0.62; and AOR, 0.59, respectively). There was no difference between treatment types on declines in lower body function or depressive symptoms. CONCLUSION: The findings from this study suggest that chiropractic use in episodes of care for uncomplicated back conditions has protective effects against declines in ADLs, instrumental ADLs, and self-rated health for older Medicare beneficiaries over a 2-year period.

Chiropractic use and changes in health among older medicare beneficiaries: a comparative effectiveness observational study.

OBJECTIVE: The purpose of this study was to investigate the effect of chiropractic on 5 outcomes among Medicare beneficiaries: increased difficulties performing activities of daily living (ADLs), instrumental ADLs (IADLs), and lower body functions, as well as lower self-rated health and increased depressive symptoms. METHODS: Among all beneficiaries, we estimated the effect of chiropractic use on changes in health outcomes among those who used chiropractic compared with those who did not, and among beneficiaries with back conditions, we estimated the effect of chiropractic use relative to medical care, both during a 2- to 15-year period. Two analytic approaches were used--one assumed no selection bias, whereas the other adjusted for potential selection bias using propensity score methods. RESULTS: Among all beneficiaries, propensity score analyses indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, and depressive symptoms, although there were increased risks associated with chiropractic for declines in lower body function and self-rated health. Propensity score analyses among beneficiaries with back conditions indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, lower body function, and depressive symptoms, although there was an increased risk associated with chiropractic use for declines in self-rated health. CONCLUSION: The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

Chiropractic episodes and the co-occurrence of chiropractic and health services use among older Medicare beneficiaries.

OBJECTIVE: The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine. METHODS: Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample. RESULTS: There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period. CONCLUSION: Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries.

BACKGROUND: Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines. METHODS: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop. RESULTS: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline. CONCLUSIONS: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

BACKGROUND: It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates. METHODS: Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. RESULTS: We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58). CONCLUSIONS: We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries.

BACKGROUND: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function. METHODS: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests. RESULTS: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status. CONCLUSIONS: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Tele-emergency behavioural health in rural and underserved areas.

INTRODUCTION: Challenges accessing behavioural health services in rural and underserved areas are compounded by severe shortages of behavioural health specialists, and difficulties placing patients. Tele-emergency (tele-ED) behavioural health is a promising solution for enhancing access to specialists and assisting in patient placement. This paper describes two tele-ED behavioural health models in the Midwest delivering mental- and substance use disorder services to rural and underserved adult populations. METHODS: We performed an in-depth examination of two tele-ED behavioural health programmes and their consultation processes. We provide a retrospective case-control analysis of patient characteristics, patient diagnoses, and disposition status for each model. Data were collected from 19 spoke hospitals across the two programmes between November 2015 and December 2017. RESULTS: Tele-ED was activated in 15% of the Avera Health sample and 58% of the Union Hospital sample. This is primarily a reflection of the sample selection process in each model and how each programme is operationalised. Suicide and/or poisoning by drugs were the most frequent diagnoses followed by mood disorders. Rate of transfer to another inpatient facility was much higher for tele-ED cases than controls in both models. DISCUSSION: This paper describes how two distinct tele-ED behavioural health models operating in unique contexts address challenges in access and placement for patients in rural and underserved areas presenting to EDs with behavioural health conditions. The notable difference in disposition rates between cases and controls is indicative of the impact each model is having on care practices and processes.

Paediatric tele-emergency care: A study of two delivery models.

INTRODUCTION: Tele-emergency models have been utilized for decades, with growing evidence of their effectiveness. Due to the variety of tele-emergency department (tele-ED) models used in practice, however, it is challenging to build standardized metrics for ongoing evaluation. This study describes two tele-ED programs, one specialized and one general, that provide care to paediatric populations. Through an examination of model structures and patient populations, we gain insight into how evaluative measures should reflect tele-ED model design and purpose. METHODS: Qualitative descriptions of the two tele-ED models are presented. We show a retrospective cohort analysis describing paediatric patients' key characteristics, reasons for visit, and disposition status by case/control status. Case/control patient encounter data were collected October 2015 through December 2017, from 15 spoke hospitals within each tele-ED program. RESULTS: The two tele-ED models serve distinct paediatric populations, and measures of tele-ED utilization and disposition reflect those differences. In the specialized University of California (UC) Davis Health program, tele-ED was utilized in 36% of paediatric critical care encounters and 78% of those were transferred. In the Avera eCARE program, tele-ED was activated in 1.7% of paediatric encounters and 50.6% of those were transferred. When Avera eCARE paediatric encounters were stratified by severity, measures of tele-ED use and disposition status among high-severity encounters were more similar to UC Davis Health. DISCUSSION: This study describes how design choices of tele-ED models have implications for evaluative measures. Measures of tele-ED model success need to reflect model purpose, populations served, and for whom tele-ED service use is appropriate.

A longitudinal study of chiropractic use among older adults in the United States.

BACKGROUND: Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use. METHODS: We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use. RESULTS: There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined. CONCLUSION: There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

Mobilising cross-sector collaborations to improve population health in US rural communities: a qualitative study.

OBJECTIVES: This study examines types and forms of cross-sector collaborations employed by rural communities to address community health issues and identifies factors facilitating or inhibiting such collaborations. SETTING: We conducted case studies of four rural communities in the US state of Iowa that have demonstrated progress in creating healthier communities. PARTICIPANTS: Key informants from local public health departments, hospitals and other health-promoting organisations and groups participated in this study. Twenty-two key-informant interviews were conducted. Participants were selected based on their organisation's involvement in community health initiatives. RESULTS: Rural communities used different forms of collaborations, including cross-sector partnership, cross-sector interaction and cross-sector exploration, to address community health issues. Stakeholders from public health, healthcare, social services, education and business sectors were involved. Factors facilitating cross-sector collaborations include health-promoting local contexts, seed initiatives that mobilise communities, hospital visions that embrace broad views of health and shared collaboration leadership and governance. Challenges to developing and sustaining cross-sector collaborations include different institutional logics, financial and human resources constraints and geographic dispersion. CONCLUSIONS: Rural communities use cross-sector collaborations to address community health issues in the forms of interaction and exploration, but real and lasting partnerships are rare. The development, operation and sustainment of cross-sector collaborations are influenced by a set of contextual and practical factors. Practical strategies and policy interventions may be used to enhance cross-sector collaborations in rural communities.

Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference?

PURPOSE: Rural bypass for elective surgical procedures is a challenge for critical access hospitals, yet there are opportunities for rural hospitals to improve local retention of surgical candidates through alternative approaches to developing surgery lines of business. In this study we examine the effect of visiting surgical specialists on the odds of rural bypass. METHODS: Discharge data from the 2011 State Inpatient Databases and State Ambulatory Surgery Databases for Iowa were linked to outreach data from the Office of Statewide Clinical Education Programs and Iowa Physician Information System to model the effect of surgeon specialist supply on rural patients' decision to bypass rural critical access hospitals. FINDINGS: Patients in rural communities with a local general surgeon were more likely to be retained in a community than to bypass. Those in communities with visiting general surgeons were more likely to bypass, as were those in communities with visiting urologists and obstetricians. Patients in communities with visiting ophthalmologists and orthopedic surgeons were at higher odds of being retained for their elective surgeries. CONCLUSION: In addition to known patient and local hospital factors that have an influence on bypass behavior among rural patients seeking elective surgery, availability of surgeon specialists also plays an important role in whether patients bypass or not. Visiting ophthalmologists and orthopedic surgeons were associated with less bypass, as was having local general surgeons. Visiting general surgeons, urologists, and obstetricians were associated with greater odds of bypass.

Rural-Urban Enrollment in Part D Prescription Drug Plans: June 2017 Update.

Purpose: Rural enrollment of Medicare beneficiaries in the Medicare Part D prescription drug program has historically lagged urban enrollment. Rural Part D enrollees are overwhelmingly in standalone prescription drug plans (PDPs), whereas urban beneficiaries are more likely to be enrolled in Medicare Advantage with Prescription Drug (MA-PD) plans. This analysis updates prior briefs on the rural-urban enrollment differential in Medicare Part D plans, and highlights state-to-state variation in PDP and MA-PD enrollment by rural-urban residence. Key Findings: (1) As of June 2017, more than 72 percent of eligible Medicare beneficiaries had prescription drug coverage through Medicare Part D plans, a significantly higher proportion than the 55.6 percent in December 2008.  (2) The percentage of rural enrollment in Part D plans still lags that of urban enrollment, despite growth in both rural and urban participation in Part D plans. (3) Rural enrollees continue to have much higher enrollment in stand-alone PDP plans than do urban enrollees, though rural participation in MA-PD plans has almost doubled since December 2008.

Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?

PURPOSE: The aim of the study was to examine whether Critical Access Hospitals (CAHs), the predominant type of hospital in small and isolated rural areas, perform better than, the same as, or worse than Prospective Payment System (PPS) hospitals on measures of quality. METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases and American Hospital Association annual survey data were used for analyses. A total of 35,674 discharges from 136 nonfederal general hospitals with fewer than 50 beds were included in the analyses: 14,296 from 100 CAHs and 21,378 from 36 PPS hospitals. Outcome measures included 6 bivariate indicators of adverse events (including complications) of surgical care developed from the Agency for Healthcare Research and Quality's Patient Safety Indicators. Multiple logistic regression models were developed to examine the relationship between hospital adverse events and CAH status. FINDINGS: Compared with PPS hospitals, CAHs are significantly less likely to have any observed (unadjusted) adverse event on 4 of the 6 indicators. After adjusting for patient mix and hospital characteristics, CAHs perform better on 3 of the 6 indicators. Accounting for the number of discharges eliminated the differences between CAHs and PPS hospitals in the likelihood of adverse events across all indicators except one. CONCLUSIONS: The study suggests there are no differences in surgical patient safety outcomes between CAHs and PPS hospitals of comparable size. This reinforces the central role of CAHs in providing quality surgical care to populations in rural and isolated areas, and underscores the importance of strategies to sustain rural surgery infrastructure.

Rural Bypass for Elective Surgeries.

PURPOSE: Rural bypass of Critical Access Hospitals (CAHs) for elective inpatient and outpatient surgical procedures has not been studied. Residents choosing to have their elective surgeries elsewhere, when the local CAH provides those surgical services, erode their rural hospital's financial base. The purpose of this research is to describe the elective surgical bypass rate, the procedures most commonly bypassed by rural residents, the distribution of volume among CAHs that offer elective surgical services, and factors predictive of bypass. METHODS: A sample of elective surgery discharges was created from the 2011 Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery Databases for Colorado, North Carolina, Vermont, and Wisconsin. Frequencies of procedures bypassed and CAH volume distribution were performed. Logistic regression was used to model factors associated with rural bypass for elective surgical care. FINDINGS: The rural bypass rate for elective surgical procedures is 48.4%. Procedures bypassed most are operations on the musculoskeletal system, eye, and digestive system. Annual volume distribution for elective surgical procedures among CAHs varied widely. Patients who are younger, medically complex, at higher surgical risk, and have private insurance are at higher odds of bypass. Patients are also more likely to bypass low-volume hospitals. CONCLUSION: Rural hospitals should consider developing surgical services that are performed electively and on an outpatient basis that are attractive to a broader rural population. CAHs that already offer elective surgical procedures and yet who are still bypassed must examine the mutable factors that drive bypass behavior.

Variation in Primary Care Service Patterns by Rural-Urban Location.

BACKGROUND: Rural communities have disproportionately faced primary care shortages for decades in spite of policy efforts to prepare and attract primary care health professionals to practice in rural locales. Insight into how primary care physicians' service patterns in rural areas differ from those in less rural places is important to better inform recruitment strategies that target primary care providers and rural communities. OBJECTIVES: The purpose of this research is to describe how primary care physician service patterns vary by rural-urban location for a large, privately insured population. We discuss implications of service pattern variation on policy efforts to attract primary care providers to underserved rural areas. METHODS: Claims data from fully insured commercial health insurance beneficiaries were used to develop service pattern profiles for primary care providers located in 1 of 4 types of rural-urban areas in Iowa in 2009. The 4 area types are metropolitan, micropolitan, noncore area adjacent to a metro area, and noncore/nonadjacent rural area. RESULTS: There were differences in primary care physicians' service patterns by rural-urban area type. Physicians in nonmetropolitan areas provided relatively more care on a per physician basis than those in the metropolitan area type, as well as more surgery, maternity, emergency, and nursing facility services than metropolitan physicians. CONCLUSION: Primary care physicians who value practicing a relatively diverse range of services may find locating in rural areas an appealing choice. Health systems and policy makers seeking to attract primary care physicians to rural areas can incorporate this reality into a recruitment strategy.

Postoperative complications and patient satisfaction: does payer status have an impact?

BACKGROUND: Patient demographics and outcomes may influence patient satisfaction. We aim to investigate the relationship between postoperative complications and survey-based satisfaction in the context of payer status. METHODS: Institutional data were used to identify major complication occurrence and linked to patient satisfaction surveys. The impact of complication occurrence on satisfaction was investigated and stratified by payer status. RESULTS: In all, 1,597 encounters were identified with an 18% major complication rate. Satisfaction scores in specific domains were significantly more likely to be above the median for patients without complications (P < .01) and for payer status Medicaid/low income (P < .05). In sensitivity analyses, we found no significant interactions among payer status, complications, and satisfaction scores. CONCLUSIONS: Significant differences exist for individual satisfaction survey domains between patients with and without major postoperative complications and by payer status. Payer status was not found to have an impact on the intersection of major complications and patient satisfaction.

Surgical Services in Critical Access Hospitals, 2011.

In this policy brief we describe the types and volume of major surgical services provided in the inpatient and outpatient settings of Critical Access Hospitals (CAHs) in 2011. Major surgical services are those procedures that require use of an operating room (OR), regardless of whether the procedure was inpatient or outpatient. Key Findings (1) CAH discharges of patients having a major surgical procedure that required use of an OR were analyzed from four regionally representative states: Colorado, North Carolina, Vermont, and Wisconsin. The average surgical volume among all CAHs in the sample was 624 procedures per CAH per year, and only 6.8 percent of CAHs performed none. (2) The average portion of all surgery volume performed on an outpatient basis in CAHs is 77 percent. Inpatient procedure volume ranged between 20 percent and 24 percent of total surgical volume across the four states. Most of the research literature on surgery in CAHs focus on inpatient procedures only, thus missing a significant portion of the surgery volume that CAHs perform. (3) The high correlation (0.86, p <0.0001) indicates that the 3:1 ratio of outpatient-to-inpatient surgical volume was relatively consistent across CAHs. (4) Operations on the musculoskeletal system, the eye, and the digestive system accounted for 67 percent on average of all surgical procedures in CAHs. Many surgical procedures are performed on an inpatient and outpatient basis, but some are performed exclusively in one setting.

The effect of Medicare payment policy changes on rural primary care practice revenue.

In this policy brief we analyze the effect of Medicare payment adjustments on Medicare-derived revenues to rural primary care providers. Building on prior work in this area, we look at the effect of changes in the Geographic Practice Cost Indices (GPCIs) from 2013 to 2014 as implemented in the Pathway for SGR Reform Act of 2013 and the Protecting Access to Medicare Act. Key Findings. (1) Changes to the GPCIs made between January 1, 2013, and March 31, 2014, resulted in an average 0.12% (median 0.18%) Medicare-derived revenue increase in rural primary care practices. (2) Without the GPCI work floor reinstatement, primary care practices in rural areas would have been disproportionately impacted through lower Medicare-related revenues.