Health care access barriers among metropolitan and nonmetropolitan populations of eight geographically diverse states, 2018.

INTRODUCTION: Nonmetropolitan populations face frequent health care access barriers compared to their metropolitan counterparts, but differences in the number of these barriers across groups are not known. Our objective was to examine the differences in health care access barriers across metropolitan, micropolitan, and noncore populations. METHODS: We used Behavioral Risk Factor Surveillance System data from the optional "Health Care Access" module to perform a cross-sectional analysis examining access barriers across levels of rurality using bivariate analyses and Poisson models. Access barriers were operationalized as a count ranging from 0 to 5, reflective of the number of financial barriers and nonfinancial barriers. RESULTS: Micropolitan and noncore respondents had lower educational attainment, were older, and were less racially/ethnically diverse than metropolitan respondents. They also reported more barriers, including lacking health insurance, medical debt, and foregoing care or medication due to cost. These barriers were most pronounced in non-Hispanic Black, Hispanic, and American Indian/Alaska Native nonmetropolitan populations, compared to their White counterparts. In adjusted analysis, micropolitan respondents reported more barriers compared to metropolitan (prevalence rate ratio = 1.06; 95% confidence interval: 1.02-1.10) as did women, racial/ethnic minority populations, and those with less education. CONCLUSIONS: Micropolitan populations experience more barriers to health care, and nonmetropolitan respondents report more cost-related barriers than their metropolitan counterparts, raising concerns on health care disparities and financial burdens for these underserved populations. This underscores the need to mitigate these barriers, particularly among those in micropolitan areas and minorized populations.

Participation in the CenteringPregnancy Program and Pregnancy-Induced Hypertension.

INTRODUCTION: CenteringPregnancy emphasizes nutrition, learning, and peer support through a group meeting format in contrast to the standard of prenatal care that maximizes a pregnant patient's time with their provider. It was hypothesized that the program may yield a reduced risk of pregnancy-induced hypertension. In this observational study, authors examined the impacts of the CenteringPregnancy program versus those of standard of prenatal care on pregnancy-induced hypertension. METHODS: In 2021, birth certificate data were linked to hospital discharge records of women who delivered in obstetric clinics in the Midlands of South Carolina between 2015 and 2019. Logistic regression models were used to estimate the association between CenteringPregnancy participation (n=547) and any pregnancy-induced hypertension and specific pregnancy-induced hypertension diagnoses (gestational hypertension/unspecified hypertension, mild pre-eclampsia, and severe pre-eclampsia/eclampsia). Propensity score techniques (e.g., inverse probability of treatment weighting) were used to adjust for self-selection into the program versus into standard of prenatal care. RESULTS: CenteringPregnancy participants had higher odds of developing any pregnancy-induced hypertension under all specifications (OR=1.48, 95% CI=1.15, 1.92) and specifically gestational hypertension/unspecified hypertension (OR=1.76, 95% CI=1.28, 2.42) than those in standard of prenatal care. However, CenteringPregnancy participants did not experience significantly higher odds of mild pre-eclampsia (OR=1.06, 95% CI=0.65, 1.78) and severe pre-eclampsia/eclampsia (OR=1.21, 95% CI=0.78, 1.89) compared with standard of prenatal care participants. CONCLUSIONS: Participation in CenteringPregnancy was associated with higher odds of pregnancy-induced hypertension, particularly gestational hypertension, than participation in standard of prenatal care. Additional research is warranted to definitely rule out selection bias and identify contributing factor(s) that increased pregnancy-induced hypertension despite efforts to improve pregnancy-related health outcomes among CenteringPregnancy participants.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States.

INTRODUCTION: The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based). METHODS: We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type. RESULTS: Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic. DISCUSSION: The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

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.

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.

COVID-19 risk mitigation behaviors among rural and urban community-dwelling older adults in summer, 2020.

PURPOSE: Risk mitigation behaviors are important for older adults, who experience increased mortality risk from COVID-19. We examined these reported behaviors among rural and urban community-dwelling adults aged 65 and older. METHODS: We analyzed public use files from the National Health and Aging Trends Study, which fielded a COVID survey from June to October, 2020, restricted to community-dwelling adults (n = 2,982). Eight behaviors were studied: handwashing, avoid touching face, mask wearing, limiting shopping, avoiding restaurants or bars, limiting gatherings, avoiding contact with those outside the household, and distancing. Residence was defined as urban (metropolitan county) or rural (nonmetropolitan county). Difference testing used Chi Square tests, with an alpha level of P = .05. Multivariable logistic regression was used to calculate adjusted odds ratios. RESULTS: Rural residents constituted 18.8% (± Standard Error 3.6%) of the study population. In bivariate comparisons, rural older adults were less likely to report 5 of 8 studied behaviors: keep 6-foot distance (rural: 88.3% ±1.0%, urban 93.2% ±.08%), limit gatherings (rural 87.5% ±1.8%; urban 91.6% ±0.8%), avoid restaurants/bars (rural 85.3% ±1.9%, urban 89.6% ±0.8%), avoid touching face (rural 83.1% ±2.3%, urban 88.6%, 0.8%), and avoid contact with those outside the household (rural 80.4% ±2.4%, urban 86.2% ±1.0%). After adjusting for demographic characteristics, only maintaining a 6-foot distance remained lower among rural older adults (AOR 0.58, 95% CI: 0.42-0.81). CONCLUSIONS: Within older adults, reported compliance with recommended behaviors to limit the spread of COVID-19 was high. Nonetheless, consistent rural shortfalls were noted. Findings highlight the need for rural-specific messaging strategies for future public health emergencies.

Rural-urban differences in educational attainment among registered nurses: Implications for achieving an 80% BSN workforce.

BACKGROUND: Multiple professional organizations and institutes recommend the Bachelor of Science in Nursing (BSN) degree as a minimum standard for registered nurse practice. Achieving this standard may be particularly challenging in rural areas, which tend to be more economically disadvantaged and have fewer opportunities for higher educational attainment compared to urban areas. PURPOSE: Our primary objective was to provide updated information on rural-urban differences in educational attainment. We also examined rural-urban differences in employment type, salary, and demographics among registered nurses in different practice settings. METHODS: Data were obtained from the 2011-2015 American Community Survey (ACS) Public Use Microdata Sample (PUMS). The sample included registered nurses (RN) between the ages of 18-64 years (n = 34,104) from all 50 states. Chi-square tests, t-tests, and multivariable logistic regression were used to examine the relationship between rurality and BSN preparedness and salary across practice settings. RESULTS: Urban nurses were more likely to have a BSN degree than rural nurses (57.9% versus 46.1%, respectively; p < 0.0001), and BSN preparedness varied by state. In adjusted analysis, factors in addition to residence associated with BSN preparation included age, race, and region of the country. Differences in wages were experienced by nurses across practice settings with urban nurses generally earning significantly higher salaries across practice settings (p < 0.0001). CONCLUSIONS: Strategies to advance nursing workforce education are needed in rural areas and may contribute to improved care quality and health outcomes.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States.

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

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.

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.

Geographic disparities in residential proximity to colorectal and cervical cancer care providers.

BACKGROUND: Persistent rural-urban disparities for colorectal and cervical cancers raise concerns regarding access to treatment providers. To the authors knowledge, little is known regarding rural-urban differences in residential proximity to cancer specialists. METHODS: Using the 2018 Physician Compare data concerning physician practice locations and the 2012 to 2016 American Community Survey, the current study estimated the driving distance from each residential zip code tabulation area (ZCTA) centroid to the nearest cancer provider of the following medical specialties involved in treating patients with colorectal and cervical cancer: medical oncology, radiation oncology, surgical oncology, general surgery, gynecological oncology, and colorectal surgery. Using population-weighted multivariable logistic regression, the authors analyzed the associations between ZCTA-level characteristics and driving distances >60 miles to each type of specialist. ZCTA-level residential rurality was defined using rural-urban commuting area codes. RESULTS: Nearly 1 in 5 rural Americans lives >60 miles from a medical oncologist. Rural-urban differences in travel distances to the nearest cancer care provider(s) increased substantially for cancer surgeons; greater than one-half of rural residents were required to travel 60 miles to reach a gynecological oncologist, compared with 8 miles for their urban counterparts. Individuals residing within ZCTAs with a higher poverty rate, those of American Indian/Alaska Native ethnicity, and/or were located in the South and West regions were more likely than their counterparts to be >60 miles away from any of the aforementioned providers. CONCLUSIONS: The substantial travel distances required for rural, low-income residents to reach a cancer specialist should prompt a policy action to increase access to specialized cancer care for millions of rural residents.

Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014.

BACKGROUND: Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes. METHODS: We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions. RESULTS: Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce. CONCLUSIONS: Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.

Supply-Side Differences Only Modestly Associated With Inpatient Hospitalizations Among Medicare Beneficiaries in the Last Six Months of Life.

CONTEXT: Inpatient hospitalizations are a driver of expenditures at the end of life and are a useful proxy for the intensity of care at that time. OBJECTIVES: Our study profiled rural and urban Medicare decedents to examine whether they differed in rates of inpatient hospital admissions in the last six months of life. METHODS: Using a sample of 35,831 beneficiaries from the 2013 Medicare Research Identifiable Files, we examined inpatient hospital utilization patterns for a full six months before death. Supply-side variables included the number of hospital beds, certified skilled nursing facility beds, and hospice beds per 1000 residents, plus primary care provider/population ratios. Patient characteristics included age, sex, race/ethnicity, dual eligibility status, region, and chronic conditions. RESULTS: In both adjusted and unadjusted analysis, rural vs. urban residence was not associated with an increased risk for hospitalization at the end of life among Medicare beneficiaries nor was there a relationship between the supply of hospital, skilled nursing, and hospice services and the rate of hospitalization. Within rural residents alone, modest effects were found for facility supply. Rural residents in a county without a hospital were slightly less likely than other rural decedents to have been hospitalized during their last six months of life but were no less likely to have used skilled nursing facilities or hospice. CONCLUSIONS: The absence of major disparities in utilization suggests that end-of-life care is reasonably equitable for rural Medicare beneficiaries.