Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals.

BACKGROUND: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited. OBJECTIVE: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs. DESIGN: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals. SUBJECTS: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017). MEASURES: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year. RESULTS: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ. CONCLUSIONS: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Current turnover intention among nurse managers, directors, and executives.

BACKGROUND: Nursing leadership turnover can adversely affect nurse retention and thus quality of care. Little research has examined the way nurses at differing levels of leadership experience their workplace and voluntarily decide to leave. PURPOSE: Our study sought to explore and compare intent to leave and turnover experiences of acute care nurse managers, directors, and executives. METHODS: Data were collected via an online survey. Participants included nurse managers, directors, and executives from 47 states (n = 1880) working in acute care settings. FINDINGS: Over 50% of respondents intend to leave their current positions within the next 5 years with reasons for leaving differing by type of nurse leader. Retirement was a factor for slightly over 30% of those nurse leaders overall and almost 50% of nurse executives. DISCUSSION: Nurse managers, directors, and executives experience turnover and intent to leave differently. Most frequently, voluntary factors for leaving a position include job dissatisfaction and a desire for promotion and advancement.

Freestanding Dialysis Facility Quality Incentive Program Scores and Mortality Among Incident Dialysis Patients in the United States.

RATIONALE & OBJECTIVE: The Centers for Medicare & Medicaid Services introduced the Quality Incentive Program (QIP) along with the bundled payment reform to improve the quality of dialysis care in the United States. The QIP has been criticized for using easily obtained laboratory indicators without patient-centered measures and for a lack of evidence for an association between QIP indicators and patient outcomes. This study examined the association between dialysis facility QIP performance scores and survival among patients after initiation of dialysis. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Study participants included 84,493 patients represented in the US Renal Disease System's patient-level data who had initiated dialysis between January 1, 2013, and December 1, 2013, and who did not, during the first 90 days after dialysis initiation, die, receive a transplant, or become lost to follow-up. Patients were followed up for the study outcome through March 31, 2014. PREDICTOR: Dialysis facility QIP scores. OUTCOME: Mortality. ANALYTICAL APPROACH: Using a unique facility identifier, we linked Medicare freestanding dialysis facility data from 2015 with US Renal Disease System patient-level data. Kaplan-Meier product limit estimator was used to describe the survival of study participants. Cox proportional hazards regression was used to assess the multivariable association between facility performance scores and patient survival. RESULTS: Excluding patients who died during the first 90 days of dialysis, 11.8% of patients died during an average follow-up of 5 months. Facilities with QIP scores<45 (HR, 1.39; 95% CI, 1.15-1.68) and 45 to<60 (HR, 1.21; 95% CI, 1.10-1.33) had higher patient mortality rates than facilities with scores≥90. LIMITATIONS: Because the Centers for Medicare & Medicaid Services have revised QIP criteria each year, the findings may not relate to years other than those studied. CONCLUSIONS: Dialysis facilities characterized by lower QIP scores were associated with higher rates of patient mortality. These findings need to be replicated to assess their consistency over time.

Charity Care Characteristics and Expenditures Among US Tax-Exempt Hospitals in 2016.

Objectives. To examine content of financial assistance polices (FAPs) among US tax-exempt hospitals and determine whether restrictive policies were associated with reduced charity care spending.Methods. Using hospital tax filings with the Internal Revenue Service in 2016 and FAPs obtained from hospital Web sites, we examined characteristics of FAPs and associated expenditures for charity care in a representative sample of 170 tax-exempt hospitals. We identified common eligibility requirements and used them to define restrictiveness of FAPs.Results. FAPs were characterized by various ways to exclude patients, a patchwork of coverage for typical health care services, and wide-ranging discounts. FAP expenditures were lowest among restrictive hospitals in states that expanded Medicaid as part of the Affordable Care Act and highest among nonrestrictive hospitals in nonexpansion states. FAP expenses did not differ by hospital restrictiveness alone.Conclusions. Standardizing common eligibility requirements among FAPs carries potential benefits with regard to optimizing charity care for community benefit and achieving at least some level of equity; however, further policy efforts must account for additional restrictions, charges, and exclusions to be effective.

Rural-Urban Mortality Disparities: Variations Across Causes of Death and Race/Ethnicity, 2013-2017.

Objectives. To examine rural-urban disparities in overall mortality and leading causes of death across Hispanic (any race) and non-Hispanic White, Black, American Indian/Alaska Native (AI/AN), and Asian/Pacific Islander populations.Methods. We performed a retrospective analysis of age-adjusted death rates for all-cause mortality and 5 leading causes of death (cardiovascular, cancer, unintentional injuries, chronic lower respiratory disease, and stroke) by rural versus urban county of residence in the United States and race/ethnicity for the period 2013 to 2017.Results. Rural populations, across all racial/ethnic groups, had higher all-cause mortality rates than did their urban counterparts. Comparisons within causes of death documented rural disparities for all conditions except cancer and stroke among Hispanic individuals; Hispanic rural residents had death rates similar to or lower than urban residents. Rural Black populations experienced the highest mortality for cardiovascular disease, cancer, and stroke. Unintentional injury and chronic lower respiratory disease mortality were highest in rural AI/AN and rural non-Hispanic White populations, respectively.Conclusions. Investigating rural-urban disparities without also considering race/ethnicity leaves minority health disparities unexamined and thus unaddressed. Further research is needed to clarify local factors associated with these disparities and to test appropriate interventions.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis.

AIM: To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis. MATERIALS AND METHODS: NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%. RESULTS: The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group. CONCLUSIONS: Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Factors Associated With Perceived Job Preparedness Among RNs: Results From a National Survey.

This article examines perceived job preparedness by demographic and professional characteristics among practicing RNs who completed a national survey. Rural and male nurses felt less prepared for nursing practice and may benefit from tailored educational experiences to improve perceptions of being prepared for the workforce.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina.

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

Determinants of occupational injury for US home health aides reporting one or more work-related injuries.

OBJECTIVES: Home health aides (HHAs) work in a high-risk industry and experience high rates of work-related injury that have been significantly associated with reduction in workers and organisational productivity, quality and performance. The main objective of the study was to examine how worker environment and ergonomic factors affect HHA risk for reporting occupational injuries. METHOD: We used cross-sectional analysis of data from the 2007 National Home Health and Hospice Aide Survey (NHHAS). The study sample consisted of a nationally represented sample of home health aides (n=3.377) with a 76.6% response rate. We used two scales 1 : a Work Environment Scale and 2 an Ergonomic Scale. Univariate and bivariate analyses were conducted to describe HHA work-related injury across individual, job and organisational factors. To measure scale reliability, Cronbach's alphas were calculated. Multivariable logistic regression was used to determine predictors of reported occupational injury. RESULTS: In terms of Work Environment Scale, the injury risk was decreased in HHAs who did not consistently care for the same patients (OR=0.96, 95% CI: 0.53 to 1.73). In terms of Ergonomic Scale, the injury risk was decreased only in HHAs who reported not needing any other devices for job safety (OR=0.30, 95% (CI): 0.15 to 0.61). No other Work Environment or Ergonomic Scale factors were associated with HHAs' risk of injury. CONCLUSION: This study has great implications on a subcategory of the workforce that has a limited amount of published work and studies, as of today, as well as an anticipated large demand for them.

The Role of the Nurse Executive in Rural Hospital Closure.

Between 2010 and June 2016, 75 rural hospitals closed, and more than 250 more are at risk of closure. Nurse executives need to be prepared for this eventuality. There is a need for formal direction on how to close a highly regulated healthcare facility.

Household food insecurity and medication "scrimping" among US adults with diabetes.

OBJECTIVE: Our research examined the prevalence of food insecurity among adults with self-reported diabetes and whether food insecurity was associated with cutting back ("scrimping") on prescribed medications because of financial constraints. METHODS: We conducted a cross-sectional analysis of data from the 2011 National Health Interview Survey (NHIS). Adults completing this survey were considered to have diabetes if they reported current use of insulin or "diabetic pills" (n=3,242). Food insecurity was determined with a 10-item scale; respondents were categorized as food secure (FS), marginally food secure (MFS) or food insecure (FI). RESULTS: Approximately one in six adults in NHIS with diabetes reported food insecurity (17.0%), and an additional 8.8% were marginally FS. An individual was considered to be scrimping on medications if he/she gave a "yes" response to at least one of four questions pertaining to reduced, delayed or avoided medication use. Overall, 18.9% of respondents with diabetes reported one or more type of medication scrimping: 11.7% of FS individuals, 27.7% of MFS individuals and 45.6% of FI individuals. In adjusted analyses, marginal food security and food insecurity remained strongly associated with scrimping. CONCLUSIONS: One-quarter of adults with diabetes may have difficulty obtaining foods appropriate for a diabetic diet; a substantial number of these individuals also fail to obtain or take medications. Practitioners may miss either problem unless targeted questions are included in clinical encounters. Clinicians should consider referring FI and MFS diabetic patients to community food resources.

Disparities in home health service providers among Medicare beneficiaries with stroke.

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Integrating maternal depression care at primary private clinics in low-income settings in Pakistan: A secondary analysis.

Introduction: The prevalence of depression among women in Pakistan ranges from 28% to 66%. There is a lack of structured mental healthcare provision at private primary care clinics in low-income urban settings in Pakistan. This study investigated the effectiveness and processes of a facility-based maternal depression intervention at private primary care clinics in low-income settings. Materials and methods: A mixed-methods study was conducted using secondary data from the intervention. Mothers were assessed for depression using the Patient Health Questionnaire-9 (PHQ-9). A total of 1,957 mothers (1,037 and 920 in the intervention and control arms, respectively) were retrieved for outcome measurements after 1 year of being registered. This study estimated the effectiveness of the depression intervention through cluster adjusted differences in the change in PHQ-9 scores between the baseline and the endpoint measurements for the intervention and control arms. Implementation was evaluated through emerging themes and codes from the framework analysis of 18 in-depth interview transcriptions of intervention participants. Results: Intervention mothers had a 3.06-point (95% CI: -3.46 to -2.67) reduction in their PHQ-9 score at the endpoint compared with their control counterparts. The process evaluation revealed that the integration of structured depression care was feasible at primary clinics in poor urban settings. It also revealed gaps in the public-private care linkage system and the need to improve referral systems. Conclusions: Intervening for depression care at primary care clinics can be effective in reducing maternal depression. Clinic assistants can be trained to identify and deliver key depression counseling messages. The study invites policymakers to seize an opportunity to implement a monitoring mechanism toward standard mental health care.

Examining the association between rurality and positive childhood experiences among a national sample.

PURPOSE: The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. METHODS: Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. FINDINGS: Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children. CONCLUSIONS: The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

Rural-Urban Disparities in Quality of Inpatient Psychiatric Care.

OBJECTIVE: Rural residents have higher rates of serious mental illness than urban residents, but little is known about the quality of inpatient psychiatric care available to them locally or how quality may have changed in response to federal initiatives. This study aimed to examine differences and changes in the quality of inpatient psychiatric care in rural and urban hospitals. METHODS: This national retrospective study of 1,644 facilities examined facility-level annual quality-of-care data from the Inpatient Psychiatric Facility Quality Reporting program, 2015-2019. Facility location was categorized as urban, large rural, or small or isolated rural on the basis of zip code-level rural-urban commuting area codes. Generalized regression models were used to assess rural-urban differences in care quality (five continuity-of-care and two patient experience measures) and changes over time. RESULTS: Rural inpatient psychiatric units performed better than urban units in nearly all domains. Improvements in quality of care (excluding follow-up care) were similar in rural and urban units. Rates of 30- and 7-day postdischarge follow-up care decreased in all hospitals but faster in rural units. Timely transmission of transition records was more frequent in small or isolated rural versus urban units (mean marginal difference=22.5, 95% CI=6.3-38.8). Physical restraint or seclusion use was less likely in rural than in urban units (OR=0.6, 95% CI=0.5-0.8). CONCLUSIONS: Rural psychiatric units had better care quality at baseline (better follow-up care, better timely transmission of transition records, and lower rates of physical restraint use) than urban units, but during 2015-2019, follow-up care performance decreased overall and more in rural than urban units.

Availability of hospital-based cancer services before and after rural hospital closure, 2008-2017.

INTRODUCTION: Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs). METHODS: We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs. RESULTS: Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures. DISCUSSION: Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

A qualitative study of ecological and motivational factors to inform weight management interventions for Black men in the rural South of the United States.

RATIONALE AND OBJECTIVE: Black men in the rural South of the United States (US) are underrepresented in weight management behavioral trials. Qualitative research is needed to inform interventions that can reduce obesity and health disparities in this population. We explored how intrapersonal, social, and environmental factors affect motivation and weight-related behaviors and how to culturally adapt behavioral interventions for Black men in the rural South. METHODS: We conducted individual telephone interviews with 23 Black men (mean age 50 ± 14 years) with overweight or obesity living in rural South Carolina communities in 2020 and 2021. Interviews were audio recorded, professionally transcribed, and coded by two men's health researchers who achieved an intercoder reliability of 70%. Content analysis using QSR NVivo 12 was used to generate themes using deductive and inductive approaches. RESULTS: Physical health and health behaviors were perceived as key determinants of overall health. Family, friends, and other social contacts often provided positive social support that increased motivation but also hindered motivation by engaging in behaviors men were trying to avoid. Younger participants had stronger views of rural environments not supporting healthy lifestyles, which compounded personal challenges such as time constraints and lack of motivation. Comfort was discussed as a critical program consideration, and gender concordance among program participants and facilitators was perceived as promoting comfort. Participants noted preferences and benefits of in-person, group programs emphasizing physical activity, and younger participants more strongly endorsed programs that incorporated sports and competition. CONCLUSIONS: Findings from this study provide important evidence to inform the development of weight management interventions for Black men in the rural US South. Based on these findings, an innovative, competitive "football-themed" weight management program promoting peer support and integrating competitive physical activities is being evaluated for younger Black men in the rural South.

Geographic variations in driving time to US mental health care, digital access to technology, and household crowdedness.

Rural residents face significant barriers in accessing mental health care, particularly as the demand for such services grows. Telemedicine has been proposed as an answer to rural gaps, but this service requires both access to appropriate technology and private space in the home to be useful. Our study documented longer travel time to mental health facilities in rural areas and greater barriers to digital devices for telemedicine access in those same areas. However, urban areas demonstrated greater household crowdedness than rural noncore areas when looking at private space within the home. Across ZIP Code Tabulation Areas located more than an estimated 30 minutes from the nearest outpatient care, 675 950 (13.1%) rural households vs 329 950 (6.4%) urban households had no broadband internet. The current Affordable Connectivity Program should target mental health-underserved communities, especially in rural America, where the scarcity of digital access compounds travel burdens to mental health care.