Widening Disparities In Infant Mortality And Life Expectancy Between Appalachia And The Rest Of The United States, 1990-2013.

Appalachia-a region that stretches from Mississippi to New York-has historically been recognized as a socially and economically disadvantaged part of the United States, and growing evidence suggests that health disparities between it and the rest of the country are widening. We compared infant mortality and life expectancy disparities in Appalachia to those outside the region during the period 1990-2013. We found that infant mortality disparities widened for both whites and blacks, with infant mortality 16 percent higher in Appalachia in 2009-13, and the region's deficit in life expectancy increased from 0.6 years in 1990-92 to 2.4 years in 2009-13. The association between area poverty and life expectancy was stronger in Appalachia than in the rest of the United States. We found wide health disparities, including a thirteen-year gap in life expectancy among black men in high-poverty areas of Appalachia, compared to white women in low-poverty areas elsewhere. Higher mortality in Appalachia from cardiovascular diseases, lung cancer, chronic lower respiratory diseases or chronic obstructive pulmonary disease, diabetes, nephritis or kidney diseases, suicide, unintentional injuries, and drug overdose contributed to lower life expectancy in the region, compared to the rest of the country. Widening health disparities were also due to slower mortality improvements in Appalachia.

Rural and urban differences in children's Medicaid and CHIP participation.

Efforts to increase enrollment in Medicaid and the Children's Health Insurance Program (CHIP) among uninsured children would benefit from an understanding of how program participation varies in rural and urban areas. Using Current Population Survey data from the period 2006-2007, rural participation rates were slightly higher than urban rates in the nation overall. There was no rural-urban difference when comparisons were based on within-state variation, independent of adjustment for individual characteristics. For researchers examining health policy issues strongly influenced by state policies or other state-level factors, this study highlights the challenges presented by national data sets with small or nonexistent samples from geographic areas within some states.

What does the clinical doctorate in physical therapy mean for rural communities?

BACKGROUND AND PURPOSE: The transition to the Doctor of Physical Therapy (DPT) as the entry-level degree for physical therapists in the United States is nearly complete. Little is known about how the transition has affected the characteristics of the physical therapy workforce or the provision of physical therapy services. Effects may be particularly acute in rural communities with persistent health-care provider shortages. The study objectives were to explore the early impact of the DPT on the supply and quality of physical therapy care in rural areas and to identify issues for future research. METHODS: Qualitative and quantitative data were collected through semi-structured telephone interviews. The interview subjects were education programme directors, directors of physical therapy at rural hospitals and presidents of state physical therapy associations. RESULTS: The respondents provided little evidence that the DPT has had a significant impact on the supply or quality of physical therapy in rural areas thus far. There are problems with the supply of physical therapists in rural communities, but few respondents attributed this directly to the DPT. Few respondents believed the DPT has improved the quality of physical therapy care in rural settings, noting that experience was the main factor that contributed to quality of care. However, several respondents believed the DPT may impact the supply and quality of rural physical therapy in the future; about half were concerned about the potential for negative effects on the supply of physical therapists in rural areas. CONCLUSIONS: In general, the respondents did not indicate that the DPT has had large effects on rural health care. However, future research should consider the negative and positive effects that may occur as DPT therapists make up a larger share of the workforce. Further, there are several areas where increased collaboration could be mutually beneficial to physical therapy educators, practitioners and rural communities.

Designated medical directors for emergency medical services: recruitment and roles.

CONTEXT: Emergency medical services (EMS) agencies rely on medical oversight to support Emergency Medical Technicians (EMTs) in the provision of prehospital care. Most states require EMS agencies to have a designated medical director (DMD), who typically is responsible for the many activities of medical oversight. PURPOSE: To assess rural-urban differences in obtaining a DMD and in their responsibilities. METHODS: A national survey of 1,425 local EMS directors, conducted in 2007. FINDINGS: Rural EMS directors were more likely than urban ones to report DMD recruitment problems, but recruitment barriers were similar, with the most commonly reported barrier being an unwillingness of local physicians to serve. Rural EMS directors reported that their DMDs were less likely to be trained in Emergency Medicine, and were less likely to provide educational support functions such as continuing education. Rural agencies were more likely to get on-line medical direction from their DMD, but were less likely to always get the on-line support they needed. Common barriers to on-line support were typical of rural communication barriers. CONCLUSIONS: Existing recommendations for DMD qualifications may be difficult to attain in rural communities. To develop programs that will support medical direction for rural EMS agencies, it is important to learn what physicians identify as the barriers to serving as DMDs, and whether there are alternative and innovative ways to provide an optimal level of medical oversight. Solutions will likely be multi-faceted, as EMS activities and organizational structures are diverse and the responsibilities of the DMD are broad.

Developing financial benchmarks for critical access hospitals.

This study developed and applied benchmarks for five indicators included in the CAH Financial Indicators Report, an annual, hospital-specific report distributed to all critical access hospitals (CAHs). An online survey of Chief Executive Officers and Chief Financial Officers was used to establish benchmarks. Indicator values for 2004, 2005, and 2006 were calculated for 421 CAHs and hospital performance was compared to the benchmarks. Although many hospitals performed better than benchmark on one indicator in 1 year, very few performed better than benchmark on all five indicators in all 3 years. The probability of performing better than benchmark differed among peer groups.

Recruitment and retention in rural and urban EMS: results from a national survey of local EMS directors.

Maintaining an adequate staff is a challenge for rural emergency medical services (EMS) providers. This national survey of local EMS directors finds that rural EMS are more likely to be freestanding, that is, not affiliated with other public services, to employ only emergency medical technician-basics (EMT-Bs), and to be all volunteer. Rural EMS directors are more likely than urban ones to report that they are not currently fully staffed. The most common barriers to recruitment of EMTs in both urban and rural areas include unwillingness of community members to volunteer and lack of certified EMTs in the area. In rural areas, barriers to EMT training were noted more often than in urban areas as was the lack of employer support for employee volunteers. Similar rural training barriers affected retention of staff. Rural respondents reported that they lose staff to burnout and to difficulty in meeting continuing education requirements. Among rural respondents, those who direct all-volunteer EMS were the most likely to report recruitment and retention problems. The results suggest areas for further study including how volunteer EMS agencies can transition to paid agencies, how to bring EMS education to rural areas, and how EMS can work with other agencies to ensure EMS viability.

Variations in financial performance among peer groups of critical access hospitals.

CONTEXT: Among the large number of hospitals with critical access hospital (CAH) designation, there is substantial variation in facility revenue as well as the number and types of services provided. If these variations have material effects on financial indicators, then performance comparisons among all CAHs are problematic. PURPOSE: To investigate whether indicators of financial performance and condition systematically vary among peer groups of CAHs. METHODS: Suggestions from CAH administrators, a literature review, expert panel advice, and statistical analysis were used to create peer groups based on whether a CAH: (1) had less than $5 million, $5-10 million, or over $10 million in net patient revenue; (2) was owned by a government entity; (3) provided long-term care; and (4) operated a provider-based Rural Health Clinic. FINDINGS: Significant differences in financial performance and condition exist among CAH peer groups. CONCLUSIONS: CAHs should ensure that they use appropriate peer comparators when assessing their financial performance and condition. If quality, outcome, safety and access are affected by financial performance and condition, it may also be important for research in these areas to control for peer group differences among CAHs.

Intensive care in critical access hospitals.

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.

Rural/urban differences in barriers to and burden of care for children with special health care needs.

PURPOSE: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children. METHODS: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care. We present both unadjusted and adjusted results to allow consideration of the causes of rural-urban differences. FINDINGS: Rural CSHCN are less likely to be seen by a pediatrician than urban children. They are more likely to have unmet health care needs due to transportation difficulties or because care was not available in the area; there were minimal other differences in barriers to care. Families of rural CSHCN are more likely to report financial difficulties associated with their children's medical needs and more likely to provide care at home for their children. CONCLUSIONS: Examining results from both unadjusted and adjusted odds ratios shows that the burden of care for families of rural CSHCN stems both from socioeconomic differences and health system differences. Policies aimed at achieving equity for rural children will require focusing on both individual factors and the health care infrastructure, including increasing insurance coverage to lessen financial difficulties and addressing the availability of providers in rural areas.

Financial indicators for critical access hospitals.

CONTEXT: There is a growing recognition of the need to measure and report hospital financial performance. However, there exists little comparative financial indicator data specifically for critical access hospitals (CAHs). CAHs differ from other hospitals on a number of dimensions that might affect appropriate indicators of performance, including differences in Medicare reimbursement, limits on bed size and average length of stay, and relaxed staffing rules. PURPOSE: To develop comparative financial indicators specifically designed for CAHs using Medicare cost report data. METHODS: A technical advisory group of individuals with extensive experience in rural hospital finance and operations provided advice to a research team from the University of North Carolina at Chapel Hill. Twenty indicators deemed appropriate for assessment of CAH financial condition were chosen and formulas determined. Issues 1 and 2 of the CAH Financial Indicators Report were mailed to the chief executive officers of 853 CAHs in the summer of 2004 and 1,092 CAHs in the summer of 2005, respectively. Each report included indicator values specifically for their CAH, indicator medians for peer groups, and an evaluation form. FINDINGS: Chief executive officers found the indicators to be useful and the underlying formulas to be appropriate. The multiple years of data provide snapshots of the industry as a whole, rather than trend data for a constant set of hospitals. CONCLUSIONS: The CAH Financial Indicators Report is a useful first step toward comparative financial indicators for CAHs.

The effect of rural hospital closures on community economic health.

OBJECTIVE: To examine the effect of rural hospital closures on the local economy. DATA SOURCES: U.S. Census Bureau, OSCAR, Medicare Cost Reports, and surveys of individuals knowledgeable about local hospital closures. STUDY DESIGN: Economic data at the county level for 1990-2000 were combined with information on hospital closures. The study sample was restricted to rural counties experiencing a closure during the sample period. Longitudinal regression methods were used to estimate the effect of hospital closure on per-capita income, unemployment rate, and other community economic measures. Models included both leading and lagged closure terms allowing a preclosure economic downturn as well as time for the closure to be fully realized by the community. DATA COLLECTION: Information on closures was collected by contacting every state hospital association, reconciling information gathered with that contained in the American Hospital Association file and OIG reports. PRINCIPAL FINDINGS: Results indicate that the closure of the sole hospital in the community reduces per-capita income by 703 dollars (p<0.05) or 4 percent (p<0.05) and increases the unemployment rate by 1.6 percentage points (p<0.01). Closures in communities with alternative sources of hospital care had no long-term economic impact, although income decreased for 2 years following the closure. CONCLUSIONS: The local economic effects of a hospital closure should be considered when regulations that affect hospitals' financial well-being are designed or changed.

The effect of rural residence on dental unmet need for children with special health care needs.

BACKGROUND: Unmet need for dental care is the most prevalent unmet health care need among children with special health care needs (CSHCN), even though these children are at a greater risk for dental problems. The combination of rural residence and special health care needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs. OBJECTIVE: To examine the effects of rural residence on unmet dental need for CSHCN. METHODS: We use the nationally representative National Survey of CSHCN Needs. We performed logistic regression to estimate the independent effects of rural residence on the likelihood of having an unmet dental need, using a measure of unmet need based on professional society recommendations and a measure based on parental report. RESULTS: Using either of the measures, a substantial percentage of CSHCN do not receive all needed dental care. Rural CSHCN are more likely to forgo needed dental care than their urban counterparts. Our results suggest that rural CSHCN have unmet needs for dental care due to both difficulty accessing care and because their parents do not recognize a need. CONCLUSION: Traditional access barriers for rural children, such as inadequate provider supply and lack of insurance, may increase unmet needs both directly and indirectly, through their effects on parents' perceptions of need. Reducing unmet needs for dental care in rural children with special needs will require addressing both access issues and parents' understanding of dental care need.

The effects of rural residence and other social vulnerabilities on subjective measures of unmet need.

To determine whether self-reports of unmet need are biased measures of access to health care, the authors examine the relationship between rural residence and perceived need for physician services. They perform logistic regression analyses to examine the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs. Even after controlling for factors known to be associated with evaluated need, parents of rural children were less likely to report a need for routine or specialty services. Poor children, those whose mothers had less education, and those who were uninsured in the previous year were also less likely to perceive a need for physician services. Findings suggest that rural residence and other social vulnerabilities are associated with decreased perception of need, which may bias subjective measurements of unmet need for these populations.

Understanding the impacts of the Medicare Modernization Act: concerns of congressional staff.

Sweeping changes to the Medicare program embodied in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), including a new prescription drug benefit, changes in payment policies, and reform of the Medicare managed-care program, have major implications for rural health care. The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in September 2004 to identify a set of researchable questions concerning the impact of the MMA on rural health care. This paper presents research questions in the following areas that staff identified as having the highest priority: access to health plans and pharmacy services, beneficiary outreach and enrollment, technology capacity, provider payment policy, and demonstration projects.

How might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 affect the financial viability of rural pharmacies? An analysis of preimplementation prescription volume and payment sources in rural and urban areas.

CONTEXT: Passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) has created interest in how the legislation will affect access to prescription drugs among rural beneficiaries. Policy attention has focused to a much lesser degree on the implications of the MMA for the financial viability of rural pharmacies. PURPOSE: This article presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs urban areas. Together, these data provide a baseline for evaluating how implementation of the MMA may affect the financial viability of rural independent pharmacies. METHODS: Projections of prescriptions dispensed from retail and mail-order pharmacies in 2002 for the total US and a sample of 17 states were obtained from IMS Health. FINDINGS: The volume of mail-order prescriptions is small. Rural providers prescribed fewer retail and mail-order prescriptions per person, but more units per person. Rural areas have a higher percentage of prescriptions paid for by cash (18% vs 13%) and Medicaid (16% vs 10%) and a lower percentage of third-party payers than urban areas. Significant variation in volume and payer type exists between states. CONCLUSIONS: Rural, independent pharmacies may be negatively affected by MMA implementation as business shifts from cash to third-party reimbursement. The high degree of variation between states also has potentially important implications for the implementation of Prescription Drug Plan regions under MMA.

Comparative performance data for critical access hospitals.

CONTEXT: Among small rural hospitals, there is a growing recognition of the need to measure and report on the use of resources and the safety and quality of the services provided. Dashboards, clinical value compasses, and balanced scorecards are approaches to performance measurement that have been adopted by many health care organizations. However, there exists very little comparative performance data specific for critical access hospitals. PURPOSE: To identify how comparative performance data for critical access hospitals (CPD-CAH) might facilitate performance and quality improvement, to assess the potential benefits and drawbacks of such data, and to identify some of the critical issues in the development and implementation of CPD-CAH. METHODS: Assessment of discussions by participants at a rural hospital performance improvement summit and authors' analyses. FINDINGS: CPD-CAH potentially could improve quality of care and patient outcomes, provide comparative data and benchmarks, inform policy development, facilitate collaboration, and enhance community relations. However, CPD-CAH could also impose an unaffordable cost, produce poor information, require complex coordination, induce a negative public reaction, and result in perverse hospital behavior. Development and implementation of CPD-CAH would require including stakeholders' assessment of its desirability and feasibility, setting objectives, establishing guiding principles, developing a method, collecting and analyzing data, and disseminating results. CONCLUSIONS: CPD-CAH could significantly advance CAH performance and quality improvement. However, development and implementation would be a complicated exercise requiring academic expertise and practitioner consultation. The potential value of CPD-CAH should be carefully weighed against its potential cost.

Moving from Medicaid to North Carolina Health Choice: changes in access to dental care for NC children.

OBJECTIVE: The objective of this study is to identify the extent to which access to dental care changes as children move from a public program with low provider reimbursement and a reputation of non-compliant beneficiaries to another public program with higher reimbursement levels and enrollees that may be viewed differently by providers. STUDY DESIGN: The pre- and post-enrollment dental experience of NC Health Choice enrollees who were previously on Medicaid is compared to those who were uninsured prior to NC Health Choice enrollment. DATA SOURCE: Parents of newly-eligible NC Health Choice children were sent a survey within two weeks of enrollment to determine their child's experience prior to program enrollment. Respondents were resurveyed approximately 11 months later regarding their child's experiences after receipt of NC Health Choice. PRINCIPAL FINDINGS: Medicaid recipients were significantly more likely to have had a dental visit within the year before enrolling in NC Health Choice, to report a usual source of care, and have fewer unmet needs than were uninsured children. After enrollment there was improvement for both groups, and differences between the two groups disappeared. CONCLUSIONS: Medicaid coverage appears to improve access to dental services for children who would otherwise be uninsured. Increased access to dental services for Medicaid children after enrolling in NC Health Choice may be due to higher provider reimbursement, but may also result from providers' perception that NC Health Choice beneficiaries are a different population and more likely to keep appointments. RELEVANCE: In a time of fiscal crisis, changes to NC Health Choice should be carefully considered to avoid loss of dental care gains afforded by this public insurance program.

The changing metropolitan designation process and rural America.

In June 2003, the Office of Management and Budget (OMB) released new county-based designations of Core Based Statistical Areas (CBSAs), replacing Metropolitan Statistical Area designations that were last revised in 1990. In this article, the new designations are briefly described, and counties that have changed classifications are identified. The new designations identify 2 categories of counties or county clusters within CBSAs: Metropolitan Statistical Areas and Micropolitan Statistical Areas. Counties designated as neither are simply referred to as "outside Core Based Statistical Areas." Among counties classified as metropolitan in 1999, 94% are still classified as such, 5% are now micropolitan, and 0.7% are outside CBSAs. The majority of counties that were nonmetropolitan in 1999 remain outside CBSAs (60%), while 28% are now classified as micropolitan and 12% have become metropolitan. The percentage of counties classified as metropolitan has increased from 27.2% to 34.7%, and the population identified as residing in these areas increased from 81% of the total US population to 83%. Some interpretation difficulties may arise in the future, as the naming system lends itself to lumping metropolitan and micropolitan together because of their common designation as CBSAs. The central problem to this classification scheme is that it tracks the urban growth of the nation and its tendency toward agglomeration of markets but pays little attention to the places that are outside CBSAs altogether.

Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs.

OBJECTIVE: To assess the prevalence of unmet needs for routine and specialty care among children with special health care needs (CSHCN) and to identify factors associated with the likelihood of having unmet need for medical care. METHODS: Data come from the respondents for 38 866 children interviewed for the National Survey of Children With Special Health Care Needs. Bivariate analyses were used to assess differences in unmet need for medical care by various environmental, predisposing, enabling, and need factors. Logit analyses were used to determine independent effects of these variables on the likelihood of having an unmet need for medical care. RESULTS: Nationally, 74.4% and 51.0% of CSHCN needed routine and subspecialty physician care, respectively. Of those reporting that they needed routine care, 3.2% were unable to obtain these services. Of those reporting a need for specialty care, 7.2% reported not obtaining all needed specialty care. The prevalence of unmet need for specialty care significantly exceeded the prevalence of unmet need for routine care. In logit analyses, African American children and children whose mothers had less than a high-school education faced twice the odds of having an unmet need for routine care. Compared with nonpoor children, children living below the federal poverty level were significantly more likely to have an unmet need for routine (adjusted odds ratio [aOR]: 1.97; 95% confidence interval [CI]: 1.23-3.14) and specialty (aOR: 2.50; 95% CI: 1.49-4.18) care. Near-poor children were also significantly more likely than nonpoor children to have unmet needs for routine and specialty care. Uninsured children were significantly more likely than continuously insured children to report an unmet need for routine (aOR: 7.51; 95% CI: 4.99-11.30) and specialty (aOR: 4.29; 95% CI: 2.99-6.15) care. Our findings also show that higher levels of general pediatrician supply, relative to the pediatric population, are associated with a significantly lower likelihood of having an unmet need for routine care. Likewise, a greater supply of pediatric subspecialists is associated with a decreased likelihood of having an unmet need for specialty care. CONCLUSIONS: Compared with previous reports of the general pediatric population, CSHCN have higher levels of unmet need for medical services. Our regression results emphasize that children vulnerable because of their social circumstances (eg, poverty, etc) have significantly greater odds of having unmet need for routine and specialty physician care. Furthermore, our findings highlight the importance of insurance coverage in ensuring access to needed routine and specialty medical services.

Effect of the North Carolina State Children's Health Insurance Program on Beneficiary Access to Care.

BACKGROUND: In the fall of 1998, North Carolina implemented its State Children Health Insurance Program, North Carolina Health Choice for Children (NCHC). This stand-alone, fee-for-service program quickly enrolled large numbers of children and has been considered one of the State Children Health Insurance Program success stories. OBJECTIVE: To explore the perceptions of parents of children enrolled in NCHC regarding their children's access to health care services before and after enrollment in the NCHC. DESIGN AND SETTING: Qualitative and quantitative data analyses are combined to assess program effectiveness. Two waves of surveys were fielded. A baseline survey asked parents of children newly enrolled in NCHC questions about their child's health experiences before enrollment in NCHC. Parents who responded with baseline data were resurveyed 1 year later to collect information on their child's experiences while insured by NCHC. PARTICIPANTS: Parents of 987 children newly enrolled in NCHC in the summer of 2000, randomly chosen within 3 age group strata. RESULTS: The NCHC has been successful in improving access to health care for low-income children. Parents reported that the program helped make health services financially accessible to their children, enabling them to get needed physician's care, eyeglasses, or prescription drugs. A significantly higher percentage of children received care in the private sector, increasing from 62% to 75% for well-child care visits and 67% to 78% for acute care. The percentage of children with unmet medical needs dropped significantly from 20% to just 2% after enrollment in NCHC. The improvement in access to care is much more striking for the older age groups and for children who were uninsured prior to NCHC enrollment (rather than those who graduated from Medicaid into the program). Despite these gains, there are still substantial numbers of children who are not receiving age-appropriate well-child care. CONCLUSION: The NCHC has successfully improved access to care for its enrollees.