Standardizing post-cardiac arrest care across rural-urban settings - qualitative findings on proposed post-cardiac arrest learning community intervention.

BACKGROUND: Standardization of post-cardiac arrest care between emergency department arrival and intensive care unit admission can be challenging, particularly for rural centers, which can experience significant delays in interfacility transfer. One approach to addressing this issue is to form a post-cardiac arrest learning community (P-CALC) consisting of emergency department (ED) and intensive care unit (ICU) physicians and nurses who use data, shared resources, and collaboration to improve post-cardiac arrest care. MaineHealth, the largest regional health system in Maine, launched its P-CALC in 2022. OBJECTIVE: To explore P-CALC participants' perspectives on current post-cardiac arrest care, attitudes toward implementing a P-CALC intervention, perceived barriers and facilitators to intervention implementation, and implementation strategies. METHODS: We conducted semi-structured, individual, qualitative interviews with 16 staff from seven system EDs spanning the rural-urban spectrum. Directed content analysis was used to discern key themes in transcribed interviews. RESULTS: Participants highlighted site- and system-level factors influencing current post-cardiac arrest care. They expressed both positive attitudes and concerns about the P-CALC intervention. Multiple facilitators and barriers were identified in regard to the intervention implementation. Five proposed implementation strategies emerged as important factors to move the intervention forward. CONCLUSIONS: Implementation of a P-CALC intervention to effect system-wide improvements in post-cardiac arrest care is complex. Understanding providers' perspectives on current care practices, feasibility of quality improvement, and potential intervention impacts is essential for program development.

Rural-Urban Differences in the Decline of Adolescent Cigarette Smoking.

OBJECTIVES: To examine change over time in cigarette smoking among rural and urban adolescents and to test whether rates of change differ by rural versus urban residence. METHODS: We used the 2008 through 2010 and 2014 through 2016 US National Survey of Drug Use and Health to estimate prevalence and adjusted odds of current cigarette smoking among rural and urban adolescents aged 12 to 17 years in each period. To test for rural-urban differences in the change between periods, we included an interaction between residence and time. RESULTS: Between 2008 to 2010 and 2014 to 2016, cigarette smoking rates declined for rural and urban adolescents; however, rural reductions lagged behind urban reductions. Controlling for socioeconomic characteristics, rural versus urban odds of cigarette smoking did not differ in 2008 through 2010; however, in 2014 through 2016, rural youths had 50% higher odds of smoking than did their urban peers. CONCLUSIONS: Differential reductions in rural youth cigarette smoking have widened the rural-urban gap in current smoking rates for adolescents. Public Health Implications. To continue gains in adolescent cigarette abstinence and reduce rural-urban disparities, prevention efforts should target rural adolescents.

Federal telehealth policy changes during the COVID-19 public health emergency: Associations with telemental health use among rural and urban Medicare beneficiaries.

PURPOSE: The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted. METHODS: In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use. FINDINGS: From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p < 0.0001) and from 1.1% to 61.3% (p < 0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR = 18.10, p < 0.001) and nearly 120-fold for their urban counterparts (OR = 119.75, p < 0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age. CONCLUSIONS: TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities.

Engaging At-Risk Rural Residents in Secondary Lung Cancer Prevention.

INTRODUCTION: Rural residents are at elevated risk for lung cancer and related mortality, yet limited research has explored their perspectives on cancer risk or prevention options, including tobacco treatment and lung cancer screening with low-dose computed tomography (LDCT). This qualitative study examined attitudes and beliefs among rural adults who reported either current or former tobacco use, as well as disengagement from the health care system. METHODS: We conducted 6 focus groups with rural Maine residents at risk for lung cancer based on age and smoking history (n = 50). Semistructured interviews explored participants' knowledge, perceptions, and attitudes regarding lung cancer risk, LDCT screening, and patient provider relationships. Inductive qualitative analysis of interview transcripts was conducted to identify key themes. RESULTS: Participants were cognizant of their elevated lung cancer risk, yet few were aware of LDCT screening. When informed about LDCT, most participants indicated a willingness to undergo screening, although a substantial minority indicated reluctance related to fear and fatalism. Participants generally expressed the belief that relationships with a primary care provider could support their health and identified several provider factors that influence these relationships, including attention and time for patient concerns; respect and non-judgmental, nonstigmatizing attitudes; treating patients as individuals; and provider empathy and emotional support. CONCLUSIONS: Rural residents at risk for lung cancer report limited knowledge and substantial ambivalence regarding LDCT screening, but identify provider behaviors that may promote patient-provider relationships and greater engagement with their health. More research is needed to confirm these findings and understand how to help rural residents and healthcare providers work together to reduce lung cancer risk.

Use of electronic health records to manage tobacco screening and treatment in rural primary care.

PURPOSE: Electronic health records (EHRs) can facilitate primary care providers' (PCPs) use of best practices in addressing tobacco dependence. It is unknown whether rural PCPs reap the same benefits as their urban counterparts when employing EHRs for this purpose. Our study examines this issue. METHODS: This cross-sectional investigation based on the 2012-2015 National Ambulatory Medical Care Survey used chi-square tests and adjusted logistic regression models to explore how rurality and use of tobacco-related EHR functions were related to smoking status documentation (SSD) and cessation treatment at adult primary care visits. FINDINGS: SSD rates were similar in visits to rural- and urban-based PCPs (88.2% rural-based vs 81.1% urban-based, P = .5819). Use of EHRs for SSD was associated with higher SSD odds at visits to both rural- and urban-based PCPs, but this increase was greater for visits to rural-based PCPs (428% vs 220% urban-based, P = .0443). Rates of cessation treatment at smokers' visits were low in rural and urban contexts (19.3% rural vs 19.6% urban, P = .9430). Odds of cessation treatment were 68% higher where EHRs were used to remind PCPs of treatment guidelines (P = .001), with no rural-urban difference in the size of the increase. Access to EHRs with tobacco-related functions was similar across rural and urban practices. CONCLUSIONS: Rural-based PCPs were at least as successful as urban-based PCPs in leveraging EHRs to enhance tobacco-related services. Even where EHRs are used, opportunities exist to expand cessation treatment in rural primary care.

Recalled Coparenting Conflict, Paralysis of Initiative, and Sensitivity to Conflict during Late Adolescence.

During late adolescence, interpersonal acuity and decisiveness are facilitative of transitions to emerging adulthood. Disruptions in these capacities may be traceable to phenomena evoked by origin family coparental conflict - paralysis of initiative and hypersensitivity to conflict. Documenting such connections can lead to more beneficial interventions for adolescents transitioning into adulthood. The aims of this study were to examine relationships between college freshmen's reports of coparenting conflict in their origin families and (a) their immobility and indecision when faced with calls to action and (b) their hypersensitivity to signs of inter-adult conflict. Thirty-four freshmen (25 women and 9 men) rated their own coparents' conflict dynamics and completed (a) a timed perceptual-motor challenge in which quick and deft action was essential to avoid failure; (b) the Rorschach inkblot test; and (c) a judgement task requiring ratings of and predictions about the interpersonal dynamics between unfamiliar adults portrayed in videos coparenting small children. Even controlling for the effects of self-reported depressive symptoms, significant links emerged between greater recalled coparenting conflict in the origin family and longer delays in initiating action in the perceptual-motor challenge; lower active-to-passive responses on the Rorschach; and attributions of more dissonant coparenting behavior in the videotaped family interactions. Results suggest that origin family coparental conflict may show ties to hypersensitivity to conflict and to indecisiveness in the face of calls to action. Implications for theory, research and practice are discussed.

Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas.

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.

Patterns of Telehealth Use Among Rural Medicaid Beneficiaries.

PURPOSE: Few studies have examined telehealth use among rural Medicaid beneficiaries. This study produced a descriptive overview of telehealth use in 2011, including the prevalence of telehealth use among rural and urban Medicaid beneficiaries, characteristics of telehealth users, types of telehealth services provided, and diagnoses associated with telehealth use. METHODS: Using data from the 2011 Medicaid Analytic eXtract (MAX), we conducted bivariate analyses to test the associations between rurality and prevalence and patterns of telehealth use among Medicaid beneficiaries. FINDINGS: Rural Medicaid beneficiaries were more likely to use telehealth services than their urban counterparts, but absolute rates of telehealth use were low-0.26% of rural nondual Medicaid beneficiaries used telehealth in 2011. Psychotropic medication management was the most prevalent use of telehealth for both rural and urban Medicaid beneficiaries, but the proportion of users who accessed nonbehavioral health services through telehealth was significantly greater as rurality increased. Regardless of telehealth users' residence, mood disorders were the most common reason for obtaining telehealth services. As rurality increased, significantly higher proportions of telehealth users received services to address attention-deficit/hyperactivity disorder (ADHD) and other behavioral health problems usually diagnosed in childhood. CONCLUSIONS: These findings provide a baseline for further policy-relevant investigations including examinations of changes in telehealth use rates in Medicaid since 2011. Reimbursement policies and unique rural service needs may account for the observed differences in rural-urban Medicaid telehealth use rates.

Mental Health First Aid in Rural Communities: Appropriateness and Outcomes.

PURPOSE: Mental Health First Aid (MHFA), an early intervention training program for general audiences, has been promoted as a means for improving population-level behavioral health (BH) in rural communities by encouraging treatment-seeking. This study examined MHFA's appropriateness and impacts in rural contexts. METHODS: We used a mixed-methods approach to study MHFA trainings conducted from November 2012 through September 2013 in rural communities across the country. DATA SOURCES: (a) posttraining questionnaires completed by 44,273 MHFA participants at 2,651 rural and urban trainings in 50 US states; (b) administrative data on these trainings; and (c) interviews with 16 key informants who had taught, sponsored, or participated in rural MHFA. Measure of Rurality: Rural-Urban Commuting Area Codes. ANALYSES: Chi-square tests were conducted on questionnaire data. Structural, descriptive, and pattern coding techniques were used to analyze interview data. FINDINGS: MHFA appears aligned with some key rural needs. MHFA may help to reduce unmet need for BH treatment in rural communities by raising awareness of BH issues and mitigating stigma, thereby promoting appropriate treatment-seeking. However, rural infrastructure deficits may limit some communities' ability to meet new demand generated by MHFA. MHFA may help motivate rural communities to develop initiatives for strengthening infrastructure, but additional tools and consultation may be needed. CONCLUSIONS: This study provides preliminary evidence that MHFA holds promise for improving rural BH. MHFA alone cannot compensate for weaknesses in rural BH infrastructure.

Rural considerations in establishing network adequacy standards for qualified health plans in state and regional health insurance exchanges.

PURPOSE: The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access. METHOD: This policy analysis reviews ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models. We analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. Finally, we propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers. FINDINGS: A traditional approach to safeguarding rural access is to impose strict network adequacy standards on plans in rural areas. However, if strict standards prove difficult to meet due to rural provider scarcity, they might diminish QHPs' willingness to serve rural areas. Thus, they could exacerbate rather than alleviate rural access problems. CONCLUSIONS: To benefit rural communities, network adequacy standards must be strong enough to provide real protections for beneficiaries, yet flexible enough to accommodate rural delivery system constraints and remain attainable for QHPs. Useful strategies to achieve this balance might include: adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.

Sharing the Love: Prebirth Adult Attachment Status and Coparenting Adjustment During Early Infancy.

OBJECTIVE: The purpose of this study to consider whether attachment security in mothers and fathers promotes more successful early coparenting adjustment, to assess the role of marital quality in amplifying or diminishing any such effects, and to examine interactive effects of maternal and paternal attachment status on coparenting. DESIGN: Eighty-five couples transitioning to new parenthood completed Main and Goldwyn's Adult Attachment Interview (AAI) and a multimethod marital evaluation during the pregnancy's third trimester and participated in comprehensive assessments of coparenting conflict and cohesion at 3 months postpartum. RESULTS: Maternal Insecure attachment status predicted higher levels of coparental conflict, as did father Secure status. Families with Insecure fathers exhibited lower coparental cohesion on the whole. Maternal attachment status moderated the relation between paternal attachment status and cohesion, with Insecure father/Secure mother dyads exhibiting the lowest levels of cohesion, and Secure/Secure dyads showing the highest levels. Prenatal marital quality predicted 3-month coparenting cohesion, but not conflict. Prenatal marital quality did not interact with parental attachment status in the prediction of coparenting, but relations between parents' attachment status and coparenting maintained after controlling for marital quality. CONCLUSION: Prenatally assessed attachment status in both mothers and fathers predicts dimensions of coparenting early in the family life cycle. The impact of attachment status differs in important ways as a function of parent gender, and security in some cases exacerbated rather than buffered the negative impact of partner insecurity on coparental functioning. Effects of parental attachment security on coparenting cannot be properly estimated without reference to contextual factors.

Individual Parental Adjustment Moderates the Relationship Between Marital and Coparenting Quality.

Contemporary family research studies have devoted surprisingly little effort to elucidating the interplay between adults' individual adjustment and the dynamics of their coparental relationship. In this study, we assessed two particularly relevant "trait" variables, parental flexibility and self-control, and traced links between these characteristics and the nature of the coparents' interactions together with their infants. It was hypothesized that parental flexibility and self-control would not only explain significant variance in coparenting quality, but also act as moderators attenuating anticipated relationships between marital functioning and coparental process. Participants were 50 heterosexual, married couples and their 12-month-old infants. Multiple regression analyses indicated that even after controlling for marital quality, paternal flexibility and maternal self-control continued to make independent contributions to coparenting harmony. As anticipated, paternal flexibility attenuated the association between marital quality and coparenting negativity. Contrary to predictions, maternal flexibility and self-control did not dampen, but actually heightened the extent to which coparenting harmony declined in the face of lower marital quality.

Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse.

This study examined whether shame-proneness is associated with dissociation among abused women. Participants were 99 hospitalized women with and without reported histories of childhood sexual abuse. Hypotheses were that childhood sexual abuse and shame-proneness would each be associated with dissociation, and that the relationship between sexual abuse and dissociation would be greater among women with higher shame-proneness. Multiple regression analysis indicated that shame-proneness was independently related to dissociation, but childhood sexual abuse was not. As predicted, the combination of shame-proneness and childhood sexual abuse was associated with dissociation.