Characteristics of Hospitals by Graduate Medical Education Expense Category: Implications for Rural Residency Program Expansion.

PURPOSE: To describe how the characteristics of the hospitals and communities they serve vary across the 4 hospital graduate medical education (GME) expense categories (according to Section 131 of the Consolidated Appropriations Act of 2021) and identify the rurally located never claimer hospitals that are most similar to teaching hospitals, signaling that they might be good candidates for new rural GME programs. METHOD: Hospital categories and characteristics were gathered from the March 2022 Medicare Cost Reports; 2022 County Health Rankings & Roadmaps data were used for community characteristics. Each acute hospital was classified into 1 of the following 4 mutually exclusive hospital categories: category A, category B, established teaching hospital (ETH), and never claimer. Multinomial logistic regressions were conducted to estimate the adjusted associations of hospital characteristics with hospital categories and to identify the never claimer hospitals in rural locations that have characteristics similar to teaching hospitals (category A, category B, and ETHs). RESULTS: Out of 3,590 hospitals, 2,075 (57.8%) were never claimer hospitals. After adjusting for multiple characteristics, rural hospitals had a similar probability of being in each hospital category as that of urban hospitals. Never claimer hospitals served an older population and were located in communities with more uninsured adults and children and less availability of primary care physicians, dentists, and mental health professionals. CONCLUSIONS: This study demonstrated that most hospitals in every category, but especially teaching hospitals (i.e., category A hospitals, category B hospitals, and ETHs), were concentrated in urban areas. Larger hospitals (measured by net patient revenue) were more likely to report GME expenses (i.e., be a category A hospital, a category B hospital, or an ETH). The study suggests that there are roughly 145 rural never claimer hospitals that might be strong candidates for initiating new residency programs.

Impact of including drug spending in oncology alternative payment models.

OBJECTIVES: To develop a method for determining the effect of including drug costs in alternative payment models (APMs). STUDY DESIGN: Retrospective claims analysis. METHODS: Using the Oncology Care Model as an example, we developed an oncology episode payment model for a commercial payer using historical claims data. We defined 6-month episodes of chemotherapy. Using claims data, we characterized episodes and developed a risk adjustment model. We used bootstrapping to estimate the variation in episode cost with drugs included and without. RESULTS: Episode costs were approximately $100,000. Although absolute cost variation was higher when we included drugs, the percent of total cost represented by variation was lower. Under reasonable assumptions about potential savings from drug and nondrug spending, our results suggest that including drugs in APMs can improve the risk-benefit trade-off faced by provider groups. We introduce a risk-mitigated sharing rate that may enable inclusion of drugs in APMs without substantially increasing downside risk. CONCLUSIONS: We have developed a method to assess whether the inclusion of drug spending in APMs is a good decision for provider groups. Including drug costs in episode payments for oncology patients may be preferable for many provider groups.

The importance of equity in payments to encourage coexistence with large mammals.

Large mammals often impose significant costs such as livestock depredation or crop foraging on rural communities, and this can lead to the retaliatory killing of threatened wildlife populations. One conservation approach-payments to encourage coexistence (PEC)-aims to reduce these costs through financial mechanisms, such as compensation, insurance, revenue sharing, and conservation performance payments. Little is known about the equitability of PEC, however, despite its moral and instrumental importance, prevalence as a conservation approach, and the fact that other financial tools for conservation are often inequitable. We used examples from the literature to examine the capability of PEC-as currently perceived and implemented-to be inequitable. We recommend improving the equitability of current and future schemes through the cooperative design of schemes that promote compensatory equity and greater consideration of conservation performance payments and by changing the international model for funding PEC to reduce global coexistence inequalities. New and existing programs must address issues of equitability across scales to ensure that conservation efforts are not undermined by diminished social legitimacy.

Importancia de la equidad de pago para alentar la coexistencia con mamíferos mayores Resumen Con frecuencia, los grandes mamíferos acarrean costes importantes para las comunidades rurales, como resultado de la depredación del ganado o por daños a cultivos, lo que puede derivar en la caza de cierta fauna amenazada como represalia. Una de las posibles estrategias para la protección de esta fauna-los llamados 'pagos para alentar la coexistencia' (PEC por sus siglas en inglés)-busca reducir estos costes a través de mecanismos financieros como los seguros de compensación, el reparto de ingresos y el 'pago por resultados'. Actualmente se conoce muy poco sobre aspectos relacionados con la equidad en relación a los PECs, a pesar de la importancia moral e instrumental de este asunto, y de la prevalencia de estos instrumentos, especialmente considerando que otras herramientas financieras para la conservación suelen no ser equitativas. En este artículo usamos ejemplos de la literatura para examinar la (in)equidad potencial de los PECs - de acuerdo a como están siendo percibidos e implementados actualmente. En las conclusiones, recomendamos que los programas actuales y futuros sean mejorados mediante diseños cooperativos que promuevan la equidad compensatoria y una mayor consideración del pago por resultados de conservación. Así mismo, debe cambiarse modelo internacional de financiamiento de los PECs para reducir las desigualdades globales en cuanto a la coexistencia con grandes mamíferos. Tanto los programas nuevos como los ya existentes deben abordar los temas de equidad a todas las escalas para asegurar que los esfuerzos de conservación no se vean perjudicados por una legitimidad social disminuida.

The Distribution of Additional Residency Slots to Rural and Underserved Areas.

This study analyzes data from the Centers for Medicare & Medicaid Services to identify whether new residency training slots went to rural and underserved areas with the greatest need.

Patients With Chronic Foot and Ankle Conditions Experience Significant Improvements in Sleep Quality Following Surgical Intervention.

BACKGROUND: Poor sleep quality is associated with metabolic dysregulation and impaired healing. The purpose of the current study was to quantify the prevalence of poor sleep in patients with atraumatic foot and ankle (F&A) conditions and determine whether surgical treatment is associated with sleep quality improvement. METHODS: Patients scheduled for surgical management of atraumatic F&A conditions were enrolled by 4 fellowship-trained orthopaedic F&A surgeons between May 2018 and April 2019. Patients completed the Pittsburgh Sleep Quality Index (PSQI) pre- and postoperatively. The PSQI ranges from 0 to 21, with a score ≥5 indicative of poor sleep quality. Patients also reported their perception of how their current F&A pain influenced their sleep quality on a scale of 0 to 10, where 0 indicated no influence and 10 indicated a strong influence (pain perception score [PPS]). Patients with known sleep disorders, acute surgical trauma, and infection were excluded. RESULTS: A total of 115 patients were enrolled. The mean preoperative PSQI and PPS were 8.1 ± 3.6 (range, 2-19) and 3.1 ± 2.7 (range, 0-10), respectively. Overall, 86.1% of patients had poor sleep quality (PSQI score ≥5). Similarly, 64.3% of patients had a PPS ≥1, indicating the belief that F&A pain contributed to sleep disturbance. A minimum of 6 months of follow-up was collected for 72 (62.6%) patients. On average, these 72 patients experienced significant improvements in sleep quality (mean PSQI decreased from 7.8 ± 3.2 to 5.4 ± 3.1, P < .001). Of these patients, 59.7% continued to experience poor sleep quality (PSQI ≥5), and 55.6% perceived that F&A pain contributed to sleep disturbance (PPS ≥1). CONCLUSION: In this series, 86.1% of patients presenting for management of atraumatic F&A conditions had poor sleep quality at the time of their initial visit, with 64.3% perceiving their F&A conditions to influence their sleep quality. Improvements in sleep quality were observed at 6 months postoperatively, though over half of patients continued to experience poor sleep quality. The location of pathology and procedure performed was not associated with sleep quality. LEVELS OF EVIDENCE: Level IV: Prospective case series.

Bolstering the rural physician workforce in underserved communities: Are Rural Residency Planning and Development Programs finding the sweet spot?

PURPOSE: The purpose of this study is to describe the characteristics of Rural Residency Planning and Development (RRPD) Programs, compare the characteristics of counties with and without RRPD programs, and identify rural places where future RRPD programs could be developed. METHODS: The study sample comprised 67 rural sites training residents in 40 counties in 24 US states. Descriptive statistics were used to describe RRPD programs and logistic regression to predict the probability of a county being an RRPD site as a function of population, primary care physicians (PCP) per 10,000 population, and the social vulnerability index (SVI) compared to a control sample of nonmetro counties without RRPD sites. FINDINGS: Most RRPD grantees (78%) were family medicine programs affiliated with medical schools (97%). RRPD counties were more populous (P<.01), had a higher population density (P<.05), and a higher percent of the non-White or Hispanic population (P = .05) compared to non-RRPD counties. Both higher population (P<.001) and PCP ratio (P = .046) were strong predictors, while SVI (P = .07) was a weak predictor of being an RRPD county. CONCLUSIONS: RRPD sites appear to represent a "sweet spot" of rural counties that have the population and physician supply to support a training program but also are relatively more socially vulnerable with high-need populations. Additional counties fitting this "sweet spot" could be targeted for funding to address health disparities and health workforce maldistribution.

A cerebellar-prepontine circuit for tonic immobility triggered by an inescapable threat.

Sudden changes in the environment are frequently perceived as threats and provoke defensive behavioral states. One such state is tonic immobility, a conserved defensive strategy characterized by powerful suppression of movement and motor reflexes. Tonic immobility has been associated with multiple brainstem regions, but the underlying circuit is unknown. Here, we demonstrate that a strong vibratory stimulus evokes tonic immobility in larval zebrafish defined by suppressed locomotion and sensorimotor responses. Using a circuit-breaking screen and targeted neuron ablations, we show that cerebellar granule cells and a cluster of glutamatergic ventral prepontine neurons (vPPNs) that express key stress-associated neuropeptides are critical components of the circuit that suppresses movement. The complete sensorimotor circuit transmits information from sensory ganglia through the cerebellum to vPPNs to regulate reticulospinal premotor neurons. These results show that cerebellar regulation of a neuropeptide-rich prepontine structure governs a conserved and ancestral defensive behavior that is triggered by an inescapable threat.

Initial Impact of the COVID-19 Pandemic on a US Orthopaedic Foot and Ankle Clinic.

Background: In the United States, the COVID-19 pandemic led to a nationwide quarantine that forced individuals to adjust their daily activities, potentially impacting the burden of foot and ankle disease. The purpose of this study was to compare diagnoses made in an orthopaedic foot and ankle clinic during the shelter-in-place period of the COVID-19 pandemic to diagnoses made during the same months of the previous year. Methods: A retrospective review of new patients presenting to the clinics of 4 fellowship-trained orthopaedic foot and ankle surgeons in a major United States city was performed. Patients in the COVID-19 group presented between March 22 and July 1, 2020, during the peak of the quarantine for this city. Patients in the control group presented during the same period of 2019. Final diagnosis, chronicity of symptoms (acute: ≤1 month), and mechanism of disease were compared between groups. Results: A total of 1409 new patient visits were reviewed with 449 visits in the COVID-19 group and 960 visits in the control group. The COVID-19 group had a significantly higher proportion of ankle fractures (8.7% vs 5.4%, P = .020) and stress fractures (4.2% vs 2.2%, P = .031), but a smaller proportion of Achilles tendon ruptures (0.7% vs 2.5%, P = .019). The COVID-19 group had a higher proportion of acute injuries (35.4% vs 23.5%, P < .001). Conclusion: There was a shift in prevalence of pathology seen in the foot and ankle clinic during the COVID-19 pandemic, which may reflect the adoption of different activities during the quarantine period and reluctance to present for evaluation of non-urgent injuries. Level of Evidence: Level III, retrospective cohort study.

Rural Medicare beneficiaries are increasingly likely to be admitted to urban hospitals.

OBJECTIVE: To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010. DATA SOURCES: We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey. STUDY DESIGN: We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression. DATA COLLECTION: We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey. PRINCIPAL FINDINGS: Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p < 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p < 0.001). CONCLUSIONS: Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.

The Landscape of State Policies Supporting Family Caregivers as Aligned With the National Academy of Medicine Recommendations.

Policy Points In the absence of federal policy, states adopted policies to support family caregivers, but availability and level of support varies. We describe, compare, and rank state policies to support family caregivers as aligned with National Academy of Medicine recommendations. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended, and benefit restrictions hinder accessibility for all types of family caregivers. Implementing policies supporting family caregivers will become more critical over time, as the reliance on family caregivers as essential providers of long-term care is only expected to grow as the population ages. CONTEXT: In the United States in 2020, approximately 26 million individuals provided unpaid care to a family member or friend. On average, 60% of caregivers were employed, and they provided 20.4 hours of care per week on top of employment. Although a handful of patchwork laws exist to aid family caregivers, systematic supports, including comprehensive training, respite, and financial support, remain limited. In the absence of federal supports, states have adopted policies to provide assistance, but they vary in availability and level of support provided. Our objectives were to describe, compare, and rank state policies to support family caregivers over time. METHODS: We used publicly available data from the AARP Long-Term Services and Supports State Scorecard, the National Academy for State Health Policy, and Tax Credits for Workers and Families for all 50 states and the District of Columbia (2015-2019). FINDINGS: We found that states had increased supports to family caregivers over this five-year period, although significant variability in adoption and implementation of policies persists. Approximately 20% of states had enacted policies that exceed the federal Family and Medical Leave Act requirements, and 18% offered paid family leave. However, most states had not improved spousal impoverishment protections for Medicaid beneficiaries. For example, from 2016 to 2019, 24% of states provided fewer or no protections, while 71% of states did not improve spousal impoverishment protections over time. Access to training for caregivers varied based on eligibility criteria (e.g., select populations and/or only co-residing caregivers). CONCLUSIONS: Overall, state approaches to support family caregivers vary by eligibility and scope of services. Substantial gaps in support of caregivers, particularly economic supports, persist. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended by the National Academy of Medicine, and benefit restrictions hinder accessibility for all family caregivers.

Privately protected areas increase global protected area coverage and connectivity.

Privately protected areas (PPAs) are increasing in number and extent. Yet, we know little about their contribution to conservation and how this compares to other forms of protected area (PA). We address this gap by assessing the contribution of 17,561 PPAs to the coverage, complementarity and connectivity of existing PA networks in 15 countries across 5 continents. We find that PPAs (1) are three times more likely to be in biomes with <10% of their area protected than are other PA governance types and twice as likely to be in areas with the greatest human disturbance; (2) that they protect a further 1.2% of key biodiversity areas; (3) that they account for 3.4% of land under protection; and (4) that they increase PA network connectivity by 7.05%. Our results demonstrate the unique and significant contributions that PPAs can make to the conservation estate and that PPAs deserve more attention, recognition and resources for better design and implementation.

The economic effects of rural hospital closures.

OBJECTIVE: To provide an updated analysis of the economic effects of rural hospital closures. STUDY SETTING: Our study sample was national in scope and consisted of nonmetro counties from 2001 to 2018. STUDY DESIGN: We used a difference-in-differences study design to estimate the effect of a hospital closure on county income, population, unemployment, and size of the labor force. Specifically, we compared economic changes over time in nonmetro counties experiencing a hospital closure to changes in a control group of nonmetro counties over the same time period. We also leveraged insight from recent research to control for estimation bias due to heterogeneity in the closure effect over time or across groups defined by when closure was experienced. DATA EXTRACTION: Data on (adjusted gross) annual income (in real dollars), annual population size, and monthly unemployment rate and labor force size were sourced from the Internal Revenue Service, Census Bureau, and Bureau of Labor Statistics, respectively. We used data from the North Carolina Rural Health Research Program to identify counties that experienced a hospital closure. PRINCIPAL FINDINGS: Of the 1759 nonmetro counties in our study sample, 109 experienced a hospital closure during the study period. Relative to the nonclosure counterfactual, closures significantly decreased labor force size, on average, by 1.4% (95% CI: [-2.1%, -0.8%]). Results also suggest that Prospective Payment System (PPS) hospital closures significantly decreased population size, on average, by 1.1% (95% CI: [-1.7%, -0.5%]), relative to the nonclosure counterfactual. CONCLUSIONS: Our analysis suggests that rural hospital closures often have adverse effects on local economic outcomes. Importantly, the negative economic effects of closure appear to be strongest following Prospective Payment System hospital closures and attenuated when the closed hospital is converted to another type of health care facility, allowing for the continued provision of services other than inpatient care.

The contributions of survey-based versus administrative measures of socioeconomic status in predicting type of post-acute care for hospitalized Medicare beneficiaries.

OBJECTIVES: To assess and compare the associations between socioeconomic status (SES) measures from two sources (claims vs. survey data) and the type of post-acute care (PAC) locations following hospital discharge. METHODS: This observational study included Medicare Fee-for-Service (FFS) beneficiaries age 65.5 years or older who participated in the Medicare Current Beneficiary Survey (MCBS) and were hospitalized in 2006-2011. Multiple data sets were used including: Area Deprivation Index; Medicare Cost Reports, Provider of Services files, and Area Health Resource File. Multinomial regression models estimated associations between beneficiary's SES and PAC type. SES measures came from surveys (income and education) and administrative records (dual enrollment and area deprivation). PAC types included home with self-care, home health agency, skilled nursing facility (SNF), or inpatient rehabilitation facility. RESULTS: Low income and dual enrollment were associated with higher SNF use while living in a deprived area was associated with lower SNF use and higher use of home with self-care. Dual enrollment and area deprivation were associated with the largest differences. CONCLUSIONS: If policies to modify payment based on SES are considered, administrative measures (dual enrollment and area deprivation) rather than survey measures (education and income) may be sufficient.

Which Definition of Rurality Should I Use?: The Relative Performance of 8 Federal Rural Definitions in Identifying Rural-Urban Disparities.

BACKGROUND: The federal government uses multiple definitions for identifying rural communities based on various geographies and different elements of rurality. OBJECTIVES: The objectives of this study were to: (1) assess the degree to which rural definitions identify the same areas as rural; and (2) assess rural-urban disparities identified by each definition across socioeconomic, demographic, and health access and outcome measures. RESEARCH DESIGN: We determined the rural status of each census tract and calculated the rural-urban disparity resulting from each definition, as well as across the number of definitions in which tracts were designated as rural (rurality agreement). SUBJECTS: The population in 72,506 census tracts. MEASURES: We used 8 federal rural definitions. Population characteristics included percent with a bachelor's degree, income below 200% poverty, population density, percent with health insurance and whether various health care services were within 30 minutes driving time of the tract centroid. RESULTS: The rural population varied from slightly < 6.9 million people to >75.5 million across definitions. The largest rural-urban disparities were found using Urban Influence Codes. Urbanized Area and Urbanized Cluster tended to generate smaller disparities. Population characteristics such as population density and percent White had notable discontinuities across levels of rurality, while others such as percent with a bachelor's degree and income below 200% poverty varied continuously. CONCLUSIONS: Rural-urban populations and disparities were sensitive to the specific definition and the relative strength of definitions varied across population characteristics. Researchers and policymakers should carefully consider the choice of outcome and region when deciding the most appropriate rural definition.