Rural-Urban Disparities in Access to Breast Cancer Screening: A Spatial Clustering Analysis.

PURPOSE: The purpose of this study was to examine rural-urban differences in access to breast cancer screening in a predominantly rural Midwestern state in the United States. METHODS: The study is a retrospective analysis of pooled cross-sectional data for the years 2008 to 2012. We conducted hot spot analyses of the rate of late-stage diagnosis of breast cancer at the census tract level in Nebraska for cases diagnosed between 2008 and 2012, using cancer registry data. We also conducted hot spot analyses of access to mammography facilities (distance to the nearest center) using data on mammography facilities from the US Food and Drug Administration and rates of screening using the National Private Insurance Claims data for year 2013. RESULTS: The spatial clustering analyses found that urban areas in Nebraska had lower distances to mammography centers, higher screening rates and lower rates of late-stage diagnosis of breast cancer. Rural areas had higher distance to the mammography centers and higher rates of late-stage at diagnosis for breast cancer. CONCLUSIONS: The evidence from this study points to geographic disparities in access to screening for breast cancer. Mitigating the access issues that rural women face would require interventions specifically targeted to rural populations.

Risk Factors for In-Hospital Mortality in Heart Failure Patients: Does Rurality, Payer or Admission Source Matter?

PURPOSE: Considering the high prevalence of heart failure and the economic burden of the disease, factors that influence in-hospital mortality are of importance in improving outcomes of care for this patient population. The purpose of this study was to examine the determinants of in-hospital mortality for adult heart failure patients. METHODS: The study design is a retrospective observational study design using the 2010 Nebraska Hospital Discharge data set including 4,319 hospitalizations for 3,521 heart failure patients admitted to 79 hospitals in Nebraska. Hierarchical logistic regression models including patient- and hospital-specific random intercepts were analyzed. Covariates included in the analysis were patient age in years, gender, comorbidity status, length of stay, primary payer, type and source of admission, transfers, and rurality of county of residence. RESULTS: Overall, 3.5% of heart failure patients died during their hospital stay. In logistic regression analysis that adjusted for age, sex, and comorbidities, the odds of dying in hospital for heart failure patients increased with age (OR = 1.03, 95% CI: 1.01-1.04), co-morbidity (OR = 1.15; 95% CI: 1.05-1.25) and length of stay (OR = 1.03, 95% CI: 1.01-1.05). The patient's gender, payer source, rurality of county of residence, source, and type of admission were not risk factors for in-hospital death. CONCLUSION: Increasing age, comorbidity and length of stay were risk factors for in-hospital death for heart failure. An understanding of the risk factors for in-hospital death is critical to improving outcomes of care for heart failure patients.

Mortality following pancreatectomy for elderly rural veterans with pancreatic cancer.

PURPOSE: The objective of this study was to examine rural/urban differences in post-operative mortality for elderly dually eligible Veteran patients with pancreatic cancer treated by surgery with or without adjuvant therapy. MATERIALS AND METHODS: In this retrospective observational study, Medicare claims data were used to identify elderly dually eligible Veteran patients with pancreatic cancer who underwent pancreatectomy with or without adjuvant therapy. Hierarchical logistic regression models adjusted for age, rurality of residence, post-operative complication rate, length of stay, blood transfusion during admission, and co-morbidity were examined to assess differences in mortality between rural and urban Veteran patients. RESULTS: Among 4,686 dually eligible Veteran patients with pancreatic cancer who underwent pancreatectomy between 1997 and 2011, those who lived in a small rural town focused area had significantly higher odds of one-year mortality (Odds Ratio [OR]= 1.50; p<0.01; Confidence Interval [CI]: 1.15-1.95), compared to those who lived in an urban focused area. Surgical or 90-day mortality was not significantly associated with the rurality of the Veterans' residence. Patients who were younger, had fewer comorbidities, and shorter length of stay had lower odds of dying at 90days and one year. CONCLUSIONS: Using a nationally representative database we found that rural and older patients had worse long-term post-operative outcomes than their urban and younger counterparts, while there were no rural/urban differences in early post-operative outcomes. The study adds to evidence pointing to disparities in the quality of care of Veterans based on place of residence.

Postoperative mortality following multi-modality therapy for pancreatic cancer: Analysis of the SEER-Medicare data.

BACKGROUND AND OBJECTIVES: The objective of this study was to examine post-operative mortality for elderly pancreatic cancer patients treated with multi-modality therapy. METHODS: Surveillance Epidemiology and End Results (SEER) Medicare linked data were used to examine differences in mortality between patients who underwent pancreatectomy alone and those who had early (within 12 weeks) and late (after 12 weeks) adjuvant therapy (chemotherapy and/or radiotherapy). RESULTS: Among 4,105 patients who underwent pancreatectomy between 1991 and 2008, 1-year mortality (Odds Ratio [OR] = 0.71; P-value = 0.000; 95% Confidence Interval [CI]: 0.60-0.85) and 6-month mortality (OR = 0.44; P-value = 0.000; 95%CI: 0.35-0.53) following pancreatectomy were significantly lower in the group that underwent pancreatectomy with early adjuvant therapy. Late adjuvant therapy group also had lower 1 year (OR = 0.51; P-value = 0.000; 95%CI: 0.43-0.61) and 6 months (OR = 0.14; P-value = 0.000; 95%CI: 0.10-0.17) mortality, compared to surgery alone. CONCLUSIONS: Post-operative outcomes were better for patients treated with surgery with adjuvant therapy, with the late adjuvant therapy group having the best outcomes (lowest odds of 6 month and 1-year mortality following surgery). J. Surg. Oncol. 2017;115:158-163. © 2017 Wiley Periodicals, Inc.

Needs Assessment for Behavioral Health Workforce: a State-Level Analysis.

This study describes trends in the supply and the need for behavioral health professionals in Nebraska. A state-level health workforce database was used to estimate the behavioral health workforce supply and need. Compared with national estimates, Nebraska has a lower proportion of all categories of behavioral health professionals. The majority of Nebraska counties have unusually high needs for mental health professionals, with rural areas experiencing a decline in the supply of psychiatrists over the last decade. Availability of robust state-level health workforce data can assist in crafting effective policy for successful systems change, particularly for behavioral health.

Readiness for Teledentistry: Validation of a Tool for Oral Health Professionals.

We validated a survey tool to test the readiness of oral health professionals for teledentistry (TD). The survey tool, the University of Calgary Health Telematics Unit's Practitioner Readiness Assessment Tool (PRAT) gathered information about the participants' beliefs, attitudes and readiness for TD before and after a teledentistry training program developed for a rural state in the Mid-Western United States. Ninety-three dental students, oral health and other health professionals participated in the TD training program and responded to the survey. Wilcoxon signed rank test was used to assess statistical differences in the change in the readiness rating before and after the training. Principal Components Analysis identified a three factor structure for the PRAT tool: Attitudes/ Attributes of Personnel; Motivation to Change and Institutional Resources. Overall, the evaluation demonstrated a positive change in all trainees' attitudes following the training sessions, with the majority of trainees acknowledging a positive impact of the training on their readiness for teledentistry.

Impact of Community-Based Dental Education on Attainment of ADEA Competencies: Students' Self-Ratings.

Fourth-year dental students at the College of Dentistry, University of Nebraska Medical Center participate in a community-based dental education (CBDE) program that includes a four-week rotation in rural dental practices and community health clinics across Nebraska and nearby states. The aim of this study was to assess the impact of participation in the CBDE program on the self-rated competencies of these students. A retrospective survey was administered to students who participated in extramural rotations in two academic years. The survey collected demographic data and asked students to rate themselves on a scale from 1=not competent at all to 5=very competent on attainment of the American Dental Education Association (ADEA) Competencies for the New General Dentist for before and after the rotations. A total of 92 responses were obtained: 43 students for 2011-12 and 49 students for 2012-13 (95% response rate for each cohort). The results showed that the students' mean pre-program self-ratings ranged from 3.28 for the competency domain of Practice Management and Informatics to 3.93 for Professionalism. Their mean post-program self-ratings ranged from 3.76 for Practice Management and Informatics to 4.31 for Professionalism. The students showed a statistically significant increase in self-ratings for all six competency domains. The increase was greatest in the domain of Critical Thinking and least in Communication and Interpersonal Skills. Overall, these results suggest that the CBDE program was effective in improving the students' self-perceptions of competence in all six domains and support the idea that a competency-based evaluation of CBDE programs can provide valuable information to dental educators about program effectiveness.

A Performance Analysis of Long-term Acute-Care Hospitals Owned by Large, Multistate Investor-Owned Companies.

This study provides a descriptive assessment of the operating performance of for-profit long-term acute-care hospitals owned by multistate, investor-owned companies (large FP LTCHs) compared with FP LTCHs owned by smaller FP companies (small FP LTCHs) and nonprofit LTCHs (NP LTCHs). The study used the Centers for Medicare & Medicaid Services cost report data for 290 LTCHs from 2010 through 2012 to compare the financial performance of large and small FP LTCHs and NP LTCHs. The study found that the median operating profit margin for large FP LTCHs was 8.06%, which was twice as high as that of the small FP LTCHs and NP LTCHs (4.78% and 2.80%, respectively). Larger size, serving a greater proportion of private pay and more complex patients and incurring lower operating expenses, including salary expenses, may account for the higher operating margin of the large FP LTCHs.

Applying Lean Six Sigma to improve medication management.

PURPOSE: A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA's dual care policy; collect data and describe the current process for co-management of dual care veterans' medications; and draft recommendations to improve the current process for dual care medications co-management. DESIGN/METHODOLOGY/APPROACH: Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process. FINDINGS: A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers. RESEARCH LIMITATIONS/IMPLICATIONS: This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations. PRACTICAL IMPLICATIONS: The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients. ORIGINALITY/VALUE: The findings of this project will be of value to VA providers and policy makers and health care managers who plan to apply Lean Six Sigma techniques in their organizations to improve the quality of care for their patients.

Rural-Urban Differences in Costs of End-of-Life Care for Elderly Cancer Patients in the United States.

PURPOSE: The objective of this study was to examine the rural-urban differences in Medicare expenditures on end-of-life care for elderly cancer patients in the United States. METHODS: We analyzed Medicare claims data for 175,181 elderly adults with lung, colorectal, female breast, or prostate cancer diagnosis who died in 2008. The end-of-life costs were quantified as total Medicare expenditures for the last 12 months of care including inpatient, outpatient, physician services, hospice, home health, skilled nursing facilities (SNF), and durable medical expenditure. Linear regression models were used to estimate rural-urban differences in log-transformed end-of-life costs and logistic regressions were used to estimate probability of service use, adjusting for demographics, socioeconomic status, and comorbidities. FINDINGS: On average, elderly cancer patients cost Medicare $51,273, $50,274, $62,815, and $50,941 in the last year for breast, prostate, colorectal, and lung cancer, respectively. Rural patients cost Medicare about 10%, 6%, 8%, and 4% less on end-of-life care than their urban counterparts for breast, prostate, colorectal, and lung cancer, respectively. Rural cancer patients were less likely to use hospice and home health, more likely to use outpatient and SNF, and they cost Medicare less on inpatient and physician services and more on outpatient care conditional on service use. CONCLUSIONS: The lower Medicare spending on end-of-life care for the rural cancer patients suggests disparities based on place of residence. A future study that delineates the source of the rural-urban difference can help us understand whether it indicates inappropriate level of palliative care and find effective policies to reduce the urban-rural disparities.

Assessing the Education and Training Needs of Nebraska's Public Health Workforce.

INTRODUCTION: In 2012, the Great Plains Public Health Training Center (Grant #UB6HP22821) conducted an online survey of state and local health departments and the American Indian (tribal clinics, tribal health departments, and urban Indian clinic) public health workforce across three professional levels. The objectives of the needs assessment were to determine the competency levels of the state's public health workforce, assess gaps in public health competencies, identify public health training interests, needs, and preferences, and to determine the barriers and motivators to participate in public health training. METHODS: The assessment was developed using the Council on Linkages Between Academia and Public Health Practice, Core Competencies for Public Health Professionals survey (1). The final assessment was created and piloted by numerous individuals representing practice and academia. RESULTS: Respondents identified cultural competency and communication skills as the two most important public health competency domains. Although the public health professionals perceived that they were least proficient in the area of policy development and program planning, participants identified the greatest needs for training in financial planning and management skills and analytical/assessment skills. In general, respondents preferred instructor-led interactive training sessions offered as onsite multi-day workshops or computer-based courses. Respondents identified obesity, health disparities, physical activity, chronic diseases, and diabetes as the top five public health topical areas. CONCLUSION: These priorities align with State and National public health plans. The findings of the needs assessment were used to tailor educational opportunities to build the capacity of Nebraska's public health system. Additionally, the results were used to develop workforce development plans for numerous local health departments throughout Nebraska.

Organizational and environmental correlates of the adoption of a focus strategy in U.S. hospices.

BACKGROUND: The hospice industry has experienced rapid growth in the last decade and has become a prominent component of the U.S. health care delivery system. In recent decades, the number of hospices serving nursing facility residents has increased. However, there is paucity of research on the organizational and environmental determinants of this strategic behavior. PURPOSE: The aim of this study was to empirically identify the factors associated with the adoption of a nursing facility focus strategy in U.S. hospices. A nursing facility focus strategy was defined in this study as a strategic choice to target the provision of hospice services to skilled nursing facility or nursing home residents. METHODOLOGY/APPROACH: This study employed a longitudinal study design with lagged independent variables in answering its research questions. Data for the study's dependent variables are obtained for the years 2005-2008, whereas data for the independent variables are obtained for the years 2004-2007, representing a 1-year lag. Mixed effects regression models were used in the multivariate regression analyses. FINDINGS: Using a resource dependence framework, the findings from this study indicate that organizational size, community wealth, competition, and ownership type are important predictors of the adoption of a nursing facility focus strategy. PRACTICE IMPLICATIONS: Hospices may be adopting a nursing facility focus strategy in response to increasing competition. The decision to focus the provision of care to nursing facility residents may be driven by the need to secure stability in referrals. Further empirical exploration of the performance implications of adopting a nursing facility focus strategy is warranted.

Supervising dentists' perspectives on the effectiveness of community-based dental education.

The Commission on Dental Accreditation recently implemented new predoctoral standards that require dental schools in the United States to provide students with community-based dental education (CBDE) experiences. The objective of this study was to examine the perspectives of supervising dentists (also known as dental preceptors) at rural CBDE sites regarding the University of Nebraska Medical Center program's effectiveness in improving the competencies of dental students. Surveys were sent to all forty-three preceptors in two subsequent years: nineteen responded to all questions in 2012 and sixteen in 2013, for a total of thirty-five participants. These preceptors evaluated the effectiveness of the program based on the American Dental Education Association (ADEA) Competencies for the New General Dentist. Overall, these preceptors rated the CBDE program as effective (excellent or very good) in improving the students' competence in five of the six ADEA domains: Critical Thinking, Professionalism, Communication and Interpersonal Skills, Health Promotion, Patient Care: Assessment, Diagnosis, and Treatment Planning, and Patient Care: Establishment and Maintenance of Oral Health. Practice Management and Informatics was found to be the least effective domain of competence. CBDE provides a unique opportunity to develop a competent dental workforce with an appreciation for the value of community service. Applying a competency-based framework to program evaluation can provide valuable information on program effectiveness to program administrators, educators, and the dental preceptors.

Quality of end-of-life care among rural Medicare beneficiaries with colorectal cancer.

BACKGROUND: Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors. METHODS: Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death. RESULTS: About 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU. CONCLUSIONS: Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.

Improving care for rural veterans: are high dual users different?

BACKGROUND: Rural veterans face considerable barriers to access to care and are likely to seek health care services outside the Veterans Health Administration (VHA), or dual care. OBJECTIVE: The objective of this study was to examine the characteristics of high users of dual care versus occasional and nonusers of dual care, and the determinants of satisfaction with care received by rural veterans. DESIGN: The design was a cross-sectional observational study. PARTICIPANTS: Structured telephone interviews of a random sample of veterans residing in rural Nebraska were conducted in 2011. MAIN MEASURES: Veterans' frequency of use of dual care and satisfaction with care received were assessed using multinomial and ordinal regression models. KEY RESULTS: Veterans who have an established relationship with a VHA provider or a personal doctor or nurse at the VHA and those who were more satisfied with VHA quality of care were less likely to be high users of dual care. Veterans who were Medicare beneficiaries, or had private insurance or chronic illnesses, or were confused about where to seek care were more likely to be users of dual care. Veterans who report being confused about where to seek care, and those who perceive lack of coordination between the VHA and non-VHA systems are less satisfied with care received. CONCLUSIONS: Understanding what motivates veterans to use dual care and influences their satisfaction with care received will enable the VHA to implement policy that improves the quality of care provided to rural veterans.

Disparities in end of life care for elderly lung cancer patients.

The objective of this study was to examine geographic and race/ethnic disparities in access to end of life care among elderly patients with lung cancer. The study sample consisted of 91,039 Medicare beneficiaries with lung cancer who died in 2008. The key outcome measures included the number of emergency room visits, the number of inpatient admissions and the number of intensive care unit (ICU) days in the last 90 days of life, hospice care ever used and hospice enrollment within the last 3 days of life. Medicare beneficiaries with lung cancer residing in rural, remote rural, and micropolitan areas had more ER visits in the last 90 days of life as compared to urban residents. Urban residents however, had more ICU days in the last 90 days of life and were more likely to have ever used hospice as compared to residents of rural, remote rural and micropolitan counties. Racial minority lung cancer patients had more ICU days, ER visits and inpatient days than non-Hispanic White patients, and also were less likely to have ever used hospice care or be enrolled in hospice in the last 3 days of life. Lung cancer patients with very low socioeconomic status (SES) were less likely to ever use hospice or be enrolled in hospice care in the last 3 days of life, as compared to those who had very high SES. Geographic, racial and socioeconomic disparities in end of life care call for targeted efforts to address access barriers for these groups of patients.

Retooling the RN workforce in long-term care: nursing certification as a pathway to quality improvement.

This article describes a project to improve nursing care quality in long-term care (LTC) by retooling registered nurses' (RN) geriatric clinical competence. A continuing education course was developed to prepare LTC RNs (N = 84) for national board certification and improve technological competence. The certification pass-rate was 98.5%. The study used a mixed methods design with retrospective pretests administered to RN participants. Multivariate analysis examined the impact of RN certification on empowerment, job satisfaction, intent to turnover, and clinical competence. Results showed certification significantly improved empowerment, satisfaction, and competence. A fixed effects analysis showed intent to turnover was a function of changes in empowerment, job dissatisfaction, and competency (F = 79.2; p < 0.001). Changes in empowerment (t = 1.63, p = 0.11) and competency (t = -0.04, p = 0.97) did not affect changes in job satisfaction. Findings suggest RN certification can reduce persistently high RN turnover rates that negatively impact patient safety and LTC quality.

Science-based and practice-based innovativeness and performance of substance abuse treatment facilities.

BACKGROUND: The fields of mental health and substance abuse treatment lag significantly behind other health care organizational fields in the adoption, implementation, and dissemination of evidence-based practices. Innovative organizational practices may be science based or practice based. The implementation of innovative practices requires considerable organizational resources. Whether this organizational investment actually pays off in terms of superior performance is unclear. This issue in the context of substance abuse treatment facilities (SATFs) in the United States is examined in this study. PURPOSE: The purpose of this study is to examine the influence of the use of innovative organizational practices, both science based (psychosocial interventions) and practice based, on the organizational performance of SATFs. METHODOLOGY/APPROACH: The study uses cross-sectional data on 13,513 SATFs in the United States, obtained from the National Survey of Substance Abuse Treatment Services 2009 database. FINDINGS: Multinomial logistic regression models find a positive association between the use of science-based innovations and practice-based innovations and organizational performance, that is, the provision of comprehensive (core and wraparound) services. SATFs that were located in metropolitan areas, those accredited by the Commission on Accreditation of Rehabilitation Facilities and Joint Commission, that had a mixed (Substance Abuse and Mental Health) focus or were recipients of earmark funds also had higher organizational performance. PRACTICE IMPLICATIONS: The results signify that substance abuse facilities that are high innovators in terms of implementing science based and practice-based innovative practices have higher organizational performance. Organizations that have institutionalized these practices have invested considerable resources in innovation. The shown higher organizational performance provides justification for the organizational investment in innovation.

Liver transplant center performance profiling: 2005-2011 reports of the Scientific Registry for Transplant Recipients.

CONTEXT-Transplant center performance profiling provides important information for various concerned parties. Comparing a transplant center's performance against the performance of the best-in-class centers may help in understanding the performance thresholds for the underperforming centers. OBJECTIVES-(1) To identify and describe "Centers for Medicare and Medicaid Services (CMS)-red-flag" performers and the "best-in-class" performers and (2) to examine the relationships between a center's performance profile and outcomes such as 1-year observed mortality, 1-month observed mortality, 1-year risk-adjusted mortality, and volume. METHODS-The data for analysis was obtained from the published reports on the Scientific Registry for Transplant Recipients (SRTR) website for adult liver transplant programs compiled for the rolling 2 1/2-year cohorts of patients and included 7 cohorts of liver transplant recipients in the study from January through July 1, 2002, through December 31, 2010. We defined 4 performance profiles: CMS-red-flag, lower-than-expected, higher-than-expected, and best-in-class performers. RESULTS-The current SRTR methods classify approximately 7% of the adult liver centers as CMS-red-flag performers and 6% of the centers as best-in-class performers in every reported period. Neither of the low-volume centers (<30 liver transplants per 2 1/2-year cohort) was profiled as CMS-red-flag until the 2010 reporting period. The transplant center's profile was significantly associated with the 1-year and 1-month observed mortality rates in every reported cohort (P< .001). CONCLUSION-The CMS-red-flag profile can be characterized with the following: (1) the highest observed 1-year mortality, (2) the highest observed 1-month mortality, (3) a very large difference between the observed and adjusted mortality rates, and (4) the center volume greater than 30 liver transplants per 2 1/2-year cohort. The SRTR methods are not sensitive for performance profiling in the centers that perform fewer than 30 orthotopic liver transplants per 2 1/2-year cohort.

Frontier America's health system challenges and population health outcomes.

PURPOSE: The objective of this cross-sectional descriptive study was to examine and compare the county-level characteristics including demographic factors, health system factors, and population health outcomes of frontier and nonfrontier counties in the United States. All counties in the United States were studied using the merged County Health Rankings 2011 and the Area Resource File 2009 databases. Of a total of 3,141 counties in the County Health Rankings 2011 database, 438 were identified as frontier counties using the conventional definition of fewer than 7 persons per square mile. FINDINGS: Frontier counties were found to have a significantly higher proportion of elderly, Hispanic, and Native American residents than nonfrontier counties. Frontier counties have lower household income and lower levels of illiteracy. Frontier counties also have significantly fewer primary care physicians and higher uninsurance rates. Although frontier counties have a lower percentage of ZIP codes with healthy food and recreational facilities, the incidence of obesity is lower in frontier areas. CONCLUSIONS: Empirical literature on the population health outcomes and health system factors of frontier areas is limited. Frontier communities in the United States face significant challenges in terms of having populations with a higher need for primary care such as the elderly and poor. In addition, they face access barriers due to geographic remoteness. The availability of reliable data on population outcomes will enable policy makers to monitor the health status of frontier populations and to design solutions to the access issues that these populations face.