Primary Care Providers' Experiences Treating Opioid Use Disorder Using Telehealth in the Height of the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic catalyzed a rapid shift in healthcare delivery towards telehealth services, impacting patient care, including opioid use disorder (OUD) treatment. Regulatory changes eliminated the in-person evaluation requirement for buprenorphine treatment, encouraging adoption of telehealth. This study focused on understanding experiences of primary care providers in predominantly rural areas who used telehealth for OUD treatment during the pandemic. METHODS: Semi-structured interviews were conducted with 22 primary care providers. Participants practiced in 13 rural and 9 urban counties in Kentucky and Arkansas. Data were analyzed using conventional content analysis. RESULTS: The pandemic significantly impacted healthcare delivery. While telehealth was integrated for behavioral health counseling, in-person visits remained crucial, especially for urine drug screenings. Telehealth experiences varied, with some facing technology issues, while others found it efficient. Telehealth proved valuable for behavioral health counseling and sustaining relationships with established patients. Patients with OUD faced unique challenges, including housing, internet, transportation, and counseling needs. Stigma surrounding OUD affected clinical relationships. Building strong patient-provider relationships emerged as a central theme, emphasizing the value of face-to-face interactions. Regarding buprenorphine training, most found waiver training helpful but lacked formal education. CONCLUSION: This research offers vital guidance for improving OUD treatment services, especially in rural areas during crises like the COVID-19 pandemic. It highlights telehealth's value as a tool while acknowledging its limitations. The study underscores the significance of strong patient-provider relationships, the importance of reducing stigma, and the potential for training programs to elevate quality of care in OUD treatment.

Satisfaction With Care Among Cancer Survivors With Medicare Coverage: Are There Rural Versus Urban Inequities?

INTRODUCTION: Rural cancer survivors often face greater barriers to treatment, which may translate into worse satisfaction with health care. OBJECTIVE: To examine rural versus urban differences in satisfaction with health care among Medicare cancer survivors. METHODS: Data are from the 2020 Medicare Current Beneficiary Survey (MCBS). Rao-Scott chi-square analyses were conducted to examine rural versus urban inequities in satisfaction with 9 dimensions of health care (health professionals' concern for health, information about what was wrong, ease/convenience from home, ease of obtaining answers over telephone, getting needs taken care of at same location, availability of specialists, overall quality, and out-of-pocket costs, and availability of care at night/on weekends). Multiple logistic regression analyses were conducted to test for rural/urban differences while adjusting for race/ethnicity, gender, marital status, educational attainment, health insurance (traditional Medicare, Medicare Advantage, dual Medicaid coverage, employer, or self-purchased insurance), and self-rated overall health. RESULTS: Rural cancer survivors were less satisfied with the ease/convenience of getting to health professionals (93.35% rural and 96.87% urban) and less satisfied with getting all health care needs taken care of at the same location (88.32% rural and 92.22% urban). These rural/urban differences persisted when adjusting for other factors. CONCLUSIONS: Health care providers serving rural areas may need to consider new strategies to satisfy some of the unique needs of rural cancer survivors, such as better organizing services at single clinic sites and utilizing telehealth when feasible to reduce the need to travel for in-person services.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. METHODS: Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. RESULTS: Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. CONCLUSIONS: Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Comparing the Demographic Characteristics of Victims of Sexual Assault in Rural Versus Urban Areas.

BACKGROUND: In 2019, over 459,000 persons in the United States survived sexual assault, and 21%-26% sought medical treatment. Ideally, trained medical professionals who understand the unique physical and mental health needs of this patient population, such as forensic nurses, would provide care. Yet, the care that forensic nurses and other healthcare providers can offer to sexual violence/abuse survivors is hindered by the lack of understanding of the demographics of those who seek care. With the delineation of highly affected demographic groups, barriers to care can be addressed. PURPOSE: This study compared rates, demographic characteristics, acuity, and codes for sexual violence/abuse encounters experienced by those patients residing in rural versus urban counties of Kentucky (KY). This included encounters before and after SARS-CoV-2. METHODS: Deidentified claims data were extracted for patient encounters billed with the International Classification of Diseases, 10th Revision, Clinical Modification for sexual violence/abuse seen at a university healthcare center serving the Northeastern, Southeastern, and Central regions of KY from October 2015 to February 2021. Analysis comprised descriptive statistics, independent samples t tests, and chi-square tests of association. RESULTS: Significant demographic differences were identified between the two groups. The mean age of those residing in rural areas was significantly younger than those living in urban areas. Similarly, the percentage of male survivors was significantly higher in the rural population. The racial composition also differed, with higher percentages of survivors being Black and Hispanic in the urban population, relative to rural dwellers. CONCLUSION: Findings suggest that rural youth (especially boys aged 10 years and younger) and urban minorities are at a higher risk for sexual violence/abuse in KY when compared with their counterparts (i.e., urban youth and rural minorities).

Suicide mortality rates in farm-related occupations and the agriculture industry in the United States.

BACKGROUND: Studies suggest that agricultural workers and rural residents may have an elevated suicide risk. However, suicide is relatively rare, and rural and farming populations have significantly declined, limiting their representation in national surveys. Many studies have inadequate samples for meaningful analysis. METHODS: We pooled 29 years of data from the Mortality-Linked National Health Interview Survey, 1986-2014, then measured suicide mortality in groups including agriculture workers, and variation in suicide across rural and urban areas. Exposure variables indicated whether participants worked in a farm-related occupation or industry, or lived in a rural area. We used survey-weighted Poisson regression to estimate suicide mortality rates and rate ratios. RESULTS: Age-adjusted suicide mortality rate per 100,000 was: 22.3 for farmers and farm managers; 21.6 for farmworkers; 28.7 in farming, forestry, and fishing; 15.3 across all other occupations; 16.1 among rural residents. Among farmworkers, age-adjusted rates were 28.3 in rural areas, 17.1 in urban areas (not significantly different). The age-adjusted suicide mortality rate ratio (RR) comparing workers in the agriculture, forestry, and fishery industries to those in all other industries was 1.34 (95% confidence interval, [CI]: 1.05-1.72) (not statistically significant after further adjustment for demographic characteristics). Age-adjusted results were consistent with a higher suicide risk for workers in forestry and fishing than in all other occupations (RR: 1.88, 95% CI: 0.79-4.46). CONCLUSION: Workers in agriculture, forestry, and fishing may have an elevated suicide risk. National surveys should consider oversampling of rural residents, who have increased morbidity and mortality risks.

Ethics and Economics of the COVID-19 Pandemic in the United States.

The Covid-19 experience provides a natural experiment in personal and social ethics. Difficult decisions are routinely made to optimize lives and livelihoods. This commentary provides background and insight into the ethical and economic foundations underpinning dilemmas of this historic pandemic.

Practice Predictors of Buprenorphine Prescribing by Family Physicians.

INTRODUCTION: Both opioid use disorder and mortality for opioid overdoses are increasing. Family physicians (FPs) can treat opioid use disorder if they are waivered to prescribe buprenorphine. Our objective was to determine personal, practice, and community characteristics associated with FPs prescribing buprenorphine. METHODS: We used data from the 2017 and 2018 American Board of Family Medicine examination registration questionnaire. The questionnaire asked about current prescribing of buprenorphine, as well as about practice size, organization, and location. Logistic regression was used to determine associations between buprenorphine treatment and individual, practice, and county characteristics. RESULTS: The questionnaire had a 100% response rate. After excluding FPs in noncontinuity practices and those who could not be linked to a US county, our final sample was 2726. Only 161 (5.9%) prescribed buprenorphine. Practice in a Federal Qualified Health Center (adjusted Odds Ratio [aOR] = 1.98 (95% CI, 1.08, 3.63)), in solo practice (aOR = 2.60 (1.38, 4.92)), or with a mental health professional (aOR = 2.70 (1.73, 4.22)) were positively associated with prescribing buprenorphine. Practice in a rural county or in a whole county mental health professional shortage area were not associated with buprenorphine prescribing. DISCUSSION: Few FPs prescribed buprenorphine, but those in practice settings with supporting mental health services were more likely to prescribe. With their training in the biopsychosocial model and a more even distribution across the rural continuum, FPs are perfectly situated to meet the increasing need for medication-assisted treatment. However, ensuring they have supporting mental health services will be central to having more FPs provide medication-assisted treatment.

What Is Rural? Challenges And Implications Of Definitions That Inadequately Encompass Rural People And Places.

Monitoring and improving rural health is challenging because of varied and conflicting concepts of just what rural means. Federal, state, and local agencies and data resources use different definitions, which may lead to confusion and inequity in the distribution of resources depending on the definition used. This article highlights how inconsistent definitions of rural may lead to measurement bias in research, the interpretation of research outcomes, and differential eligibility for rural-focused grants and other funding. We conclude by making specific recommendations on how policy makers and researchers could use these definitions more appropriately, along with definitions we propose, to better serve rural residents. We also describe concepts that may improve the definition of and frame the concept of rurality.

Trends In Buprenorphine Prescribing By Physician Specialty.

Office-based visits involving a buprenorphine prescription increased significantly among primary care and specialist physicians from 2006 to 2014. The growing involvement of nonpsychiatry physicians in buprenorphine prescribing has the potential to provide better access to care for people with opioid use disorders.

Impact of Medicaid Expansion on Medicaid-covered Utilization of Buprenorphine for Opioid Use Disorder Treatment.

BACKGROUND: Buprenorphine has been proven effective in treating opioid use disorder. However, the high cost of buprenorphine and the limited prescribing capacity may restrict access to this effective medication-assisted treatment for opioid use disorder. OBJECTIVE: To examine whether Medicaid expansion and physician prescribing capacity may have impacted buprenorphine utilization covered by Medicaid. RESEARCH DESIGN: We used a quasi experimental difference-in-differences design to compare the pre-post changes in Medicaid-covered buprenorphine prescriptions and buprenorphine spending between the 26 states that implemented Medicaid expansions under the Affordable Care Act in 2014 and those that did not. SUBJECTS: All Medicaid enrollees in the expansion states and the nonexpansion and late-expansion states. MEASURES: Quarterly Medicaid prescriptions for buprenorphine and spending on buprenorphine from the Centers for Medicare and Medicaid Services Medicaid Drug Utilization files 2011 to 2014. RESULTS: State implementation of Medicaid expansions in 2014 was associated with a 70% increase (P<0.05) in Medicaid-covered buprenorphine prescriptions and a 50% increase (P<0.05) in buprenorphine spending. Physician prescribing capacity was also associated with increased buprenorphine utilization. CONCLUSIONS: Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment of opioid use disorder. Active physician participation in the provision of buprenorphine is needed for ensuring that Medicaid expansion achieves its full potential in improving treatment access.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine.

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.