Hospitalization rates as indicators of access to primary care.

Variations in hospitalization rates for selected conditions are being used as indicators of the effectiveness of primary care in small areas. Are these rates actually sensitive to problems in local primary care systems? This study examines the relationship between ambulatory care sensitive condition (ACSC) hospital admission rates and primary care resources and the economic conditions in primary care market areas in North Carolina in 1994. The data show a high degree of correlation between the rates and income but not primary care resources. The distribution of rates did agree with expert assessments of the location of places with poor access to health services. The data confirm that access to effective primary care reflected in lower rates of ACSC admissions is a function of more than the professional resources available in a market area. The solution to reducing disparities in health status may not lie within the health system.

How many rural doctors do we have?

The number of physicians practicing in the nonmetropolitan areas of the United States in relation to population has increased over the past two decades, but more slowly than the number of physicians in metropolitan counties. During the same period, there was a growing acceptance of the perception that the physician work force in the United States exceeded the number necessary to meet the requirements of an efficient health care system. This has caused policy-makers to consider reforming the incentives for training physicians and restricting the entry of physicians from other countries into the United States. The supply figures on which these assessments of oversupply were made are based on "head counts" of the number of licensed, active physicians. By using more detailed data describing the licensed practicing physicians in the states of North Carolina and Washington, and by using estimates of professional activity collected as part of the Socioeconomic Monitoring System of the American Medical Association, estimates of the number of full-time equivalent physicians actually in practice in the two states and the comparative productivity of those physicians were made. Based on the state-level data, the estimates of actively practicing physicians are approximately 14 percent lower than the head-count number in North Carolina and, by using a more conservative estimation method, are approaching a 10 percent lower number than the head-count number in Washington. Using national productivity data, the effective supply of nonmetropolitan physicians appears to have not grown significantly over the past 10 years, and for family physicians the supply has declined by 9 percent. These estimates of the effective physician supply support long-held claims that rural communities continue to experience a severe undersupply of practitioners. These results suggest that the way in which physicians are counted needs to be re-examined, especially in rural places where the ratios of providers to population are more sensitive to small changes in supply.

The changing nature of rural health care.

The rural health care system has changed dramatically over the past decade because of a general transformation of health care financing, the introduction of new technologies, and the clustering of health services into systems and networks. Despite these changes, resources for rural health systems remain relatively insufficient. Many rural communities continue to experience shortages of physicians, and the proportion of rural hospitals under financial stress is much greater than that of urban hospitals. The health care conditions of selected rural areas compare unfavorably with the rest of the nation. The market and governmental policies have attempted to address some of these disparities by encouraging network development and telemedicine and by changing the rules for Medicare payments to providers. The public health infrastructure in rural America is not well understood but is potentially the most fragile aspect of the rural health care continuum.

The role of physician recommendation in women's mammography use: is it a 2-stage process?

OBJECTIVE: To explore the use of a 2-stage model in explaining the role of physician recommendation in women's use of mammography screening and to provide an integrated framework for understanding the mammography-use process. METHODS: Data on 1,301 women aged > or =52 years from the North Carolina Breast Cancer Screening Program (NC-BCSP) questionnaire were combined with information from 91 of their physicians from the North Carolina Medical Board. A 2-stage system of equations using women's characteristics (demographic, health, access), physicians' characteristics (demographic, practice), women's beliefs, and women's report of a physician recommendation was created and statistically tested. The model was estimated using 2-stage logistic and probit estimation. RESULTS: The 2-stage approach produced different results compared with the single pooled model. In the second-stage mammography-use model, younger age, family history of breast cancer, and a woman's having ever requested a mammogram retained significance (P < or = 0.05) in addition to the predicted value of physician recommendation obtained from the first stage. Women's characteristics significantly associated with physician recommendation in the first stage included some access, health risk, and demographic variables as well as physician age and race (P < or = 0.05). CONCLUSIONS: A 2-stage model for estimating mammography use among women with regular physicians may be more informative than a single model. These results imply that programs designed to increase mammography rates should focus on ensuring appropriate physician recommendations in addition to encouraging women to request screening. Future research should consider using an integrated framework for evaluating utilization of mammography and other preventive services.

Rural breast cancer treatment: evidence from the Reaching Communities for Cancer Care (REACH) project.

BACKGROUND: Research shows that rural populations are more likely than their urban counterparts to be diagnosed with late-stage cancer, but less is known about appropriateness of cancer treatment in rural locations after diagnosis. The objective of this analysis was to assess the degree to which rural breast cancer treatment was received in concordance with national recommendations. METHODS: Data came from 251 stage I and II breast cancer patients residing in rural North Carolina. State-of-the-art care was defined using the National Cancer Institute's (NCI) physician data query (PDQ) database, and cases were categorized into appropriate primary and/or adjuvant treatment. Chi-square and Fishers' exact tests were used to assess changes in appropriate treatment over time (1991-1996) and between stage. Multiple logistic regression was used to determine whether any patient or disease characteristics were associated with receipt of appropriate treatment. RESULTS: Most (81-90%) of the breast cancer cases received the appropriate primary therapy (mastectomy or lumpectomy followed by radiation therapy); of these, the majority received a mastectomy (66-72%). Fewer women received adjuvant therapy as recommended (27-61%), although significantly more stage II than stage I cases did so (p < or = 0.05). Regression showed that stage and estrogen-receptor (ER) status were associated with appropriate therapy. CONCLUSIONS: The findings suggest that there exist deviations from NCI established treatment recommendations among rural breast cancer patients. More research is needed to develop better methods for dissemination of state-of-the-art cancer information to rural physicians and patients, and to understand how treatment decisions are made.

Rural physicians' understanding of the state-of-the-art in breast, colon and rectum cancer treatment.

OBJECTIVES: This study measured the impact of an educational intervention aimed at heightening rural physicians' awareness of state-of-the-art breast and colorectal cancer therapies. METHODS: Pre- and post-intervention mailed surveys were administered to all primary-care physicians and referring physicians in the seven-county intervention region in North Carolina (NC) and a comparison region in South Carolina (SC). RESULTS: The survey revealed few significant changes in physicians' perspectives that could be attributed to the intervention. Physicians erroneously stated that lumpectomy without follow-up radiation was acceptable for treating breast cancer (55%), failed to indicate that adjuvant therapy was an accepted practice for treating Stage I breast cancer (67%), failed to acknowledge chemotherapy as experimental for Dukes' B colon cancer patients (70%), and failed to recognize a combination of surgery, chemotherapy, and radiation as a standard treatment for rectal cancer (25%). CONCLUSIONS: The low levels of awareness of National Cancer Institute guidelines were reflected in low breast-sparing surgery rates for women living in the intervention region. Stronger consensus on appropriate cancer treatments is needed throughout the medical community in order to reduce undesired variation in rural, community-based cancer care.

Proposed changes to designations of medically underserved populations and health professional shortage areas: effects on rural areas.

This paper reports an analysis of the proposed rule to combine medically underserved population (MUP) and health professional shortage area (HPSA) designations, as published by the Bureau of Primary Health Care (BPHC) in the Federal Register on Sept. 1, 1998 (Department of Health and Human Services, 1998). The effects of the proposed rule overall and on rural communities were examined, particularly with respect to current whole county HPSA designations and eligibility for federal assistance programs. National, county-level estimates of primary care provider counts and other measures included in the proposed rule were used. Different primary care provider sources were compared; results were highly dependent on the data source and the inclusions of counts of nurse practitioners and physician assistants. The projections of losses from the proposed rule were higher than those of the BPHC, probably due to the use of different sources for provider counts. Overall, the authors projected that more than 50 percent of current whole-county HPSAs would lose designation using the proposed rule. The proportion of rural counties that lost designation was not significantly greater than the proportion of urban counties, but because there are many more rural counties, more de-designations were projected to occur in rural areas. The researchers also predicted that 58 percent of rural whole-county HPSAs with National Health Service Corps providers would lose their designation, but most rural whole-county HPSAs with Community and Migrant Health Centers or Rural Health Clinics retained their MUP designation using the proposed rule. The proposed rule likely has a larger effect on current designations than originally projected by the BPHC.

The Medicare Critical Access Hospital program: the first year.

The Medicare Critical Access Hospital (CAH) program, part of the Balanced Budget Act of 1997, is a nationwide limited service hospital program. Structured interviews were conducted in August and September 1998 with key people in state offices of rural health, state hospital associations, departments of health or departments of facility licensing in all 50 states to assess their progress in the development of the CAH program. The majority of states expressed interest in the CAH program. Twenty-one states were moving formally toward involvement in the program. States that had developed or were in the process of developing a state plan estimated that between 183 to 227 hospitals would convert to CAHs in the next one to two years. States that were the most successful with plan development appeared to be states that participated in the Essential Access Community Hospital/Rural Primary Care Hospital program, states where there was dialogue about the possibility of a limited service hospital program and states with widespread support in the state. A pressing need for most states is for reliable fiscal consulting or analysis that could be applied to individual hospitals that are considering conversion to CAHs. The CAH program shows promise for successful implementation based on its early results.

Economic impact of hospital closure on small rural counties, 1984 to 1988: demonstration of a comparative analysis approach.

Hospital closure in a rural community may affect the locale's economic prospects as well as the health of its residents. Studies of economic effects have primarily relied on modeling techniques rather than observation of actual change. This study demonstrates the use of a comparative analysis approach for estimating the economic effects of hospital closure on small rural counties. The experiences of 103 small rural counties at which a hospital closed between 1984 and 1988 was compared with a matched group of counties at which no closure took place. "Comparable" counties were selected based on seven scales measuring the similarity between a closure county and potential comparisons. Three scales examined population and economic characteristics in the year before closure; two scales measured change throughout a three-year period preceding closure; and two scales measured change throughout a five-year period preceding closure. Closure effects were measured through a multivariate analysis of the post-closure economic history of closure and comparison counties. The key assumption is that similar counties should have similar experiences over time. If an event occurs within some of these counties but not others, this event should have visible effects. Comparative analysis suggested that earned income in closure counties (excluding farming and mining income) was lower than in comparison counties subsequent to closure and that labor force growth was similarly affected. A comparative analysis approach produces results that parallel those obtained from economic modeling and should be considered for further research.

Do international medical graduates reduce rural physician shortages?

OBJECTIVES: The authors examined whether international medical graduates (IMGs) constitute a greater percentage of the US physician workforce in rural underserved areas than in rural non-underserved areas. Research findings could help policymakers determine whether the role of international medical graduates in compensating for local physician shortages counterbalances international medical graduates' potential for exacerbating a national oversupply. METHODS: This research was based on data from the American Medical Association Physician Masterfile and the Bureau of Health Professions' Area Resource File. The authors calculated the percentage international medical graduates of all US primary care physicians in rural areas, stratified by the Health Professional Shortage Area (HPSA) designation of underservice. RESULTS: The study showed that international medical graduates do constitute a greater percentage of US primary care physicians in rural areas with physician shortages than in rural areas without physician shortages. This finding held true at the national, Census region, and state scales of analysis, but to varying degrees. The finer the scale of analysis, the greater the variation in international medical graduates' practice in rural, underserved areas. There was substantial interstate variation in the extent to which international medical graduates practice in rural underserved areas. CONCLUSIONS: International medical graduates do help reduce rural physician shortages, but interstate variation points to the role of state policies in influencing international medical graduates' distribution in rural, underserved areas. Such variation also can come about from many different causes, so there is a need for further research to determine why international medical graduates help compensate for physician shortages more so in some states than in others.