Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals.

BACKGROUND: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited. OBJECTIVE: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs. DESIGN: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals. SUBJECTS: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017). MEASURES: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year. RESULTS: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ. CONCLUSIONS: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Current turnover intention among nurse managers, directors, and executives.

BACKGROUND: Nursing leadership turnover can adversely affect nurse retention and thus quality of care. Little research has examined the way nurses at differing levels of leadership experience their workplace and voluntarily decide to leave. PURPOSE: Our study sought to explore and compare intent to leave and turnover experiences of acute care nurse managers, directors, and executives. METHODS: Data were collected via an online survey. Participants included nurse managers, directors, and executives from 47 states (n = 1880) working in acute care settings. FINDINGS: Over 50% of respondents intend to leave their current positions within the next 5 years with reasons for leaving differing by type of nurse leader. Retirement was a factor for slightly over 30% of those nurse leaders overall and almost 50% of nurse executives. DISCUSSION: Nurse managers, directors, and executives experience turnover and intent to leave differently. Most frequently, voluntary factors for leaving a position include job dissatisfaction and a desire for promotion and advancement.

Freestanding Dialysis Facility Quality Incentive Program Scores and Mortality Among Incident Dialysis Patients in the United States.

RATIONALE & OBJECTIVE: The Centers for Medicare & Medicaid Services introduced the Quality Incentive Program (QIP) along with the bundled payment reform to improve the quality of dialysis care in the United States. The QIP has been criticized for using easily obtained laboratory indicators without patient-centered measures and for a lack of evidence for an association between QIP indicators and patient outcomes. This study examined the association between dialysis facility QIP performance scores and survival among patients after initiation of dialysis. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Study participants included 84,493 patients represented in the US Renal Disease System's patient-level data who had initiated dialysis between January 1, 2013, and December 1, 2013, and who did not, during the first 90 days after dialysis initiation, die, receive a transplant, or become lost to follow-up. Patients were followed up for the study outcome through March 31, 2014. PREDICTOR: Dialysis facility QIP scores. OUTCOME: Mortality. ANALYTICAL APPROACH: Using a unique facility identifier, we linked Medicare freestanding dialysis facility data from 2015 with US Renal Disease System patient-level data. Kaplan-Meier product limit estimator was used to describe the survival of study participants. Cox proportional hazards regression was used to assess the multivariable association between facility performance scores and patient survival. RESULTS: Excluding patients who died during the first 90 days of dialysis, 11.8% of patients died during an average follow-up of 5 months. Facilities with QIP scores<45 (HR, 1.39; 95% CI, 1.15-1.68) and 45 to<60 (HR, 1.21; 95% CI, 1.10-1.33) had higher patient mortality rates than facilities with scores≥90. LIMITATIONS: Because the Centers for Medicare & Medicaid Services have revised QIP criteria each year, the findings may not relate to years other than those studied. CONCLUSIONS: Dialysis facilities characterized by lower QIP scores were associated with higher rates of patient mortality. These findings need to be replicated to assess their consistency over time.

Charity Care Characteristics and Expenditures Among US Tax-Exempt Hospitals in 2016.

Objectives. To examine content of financial assistance polices (FAPs) among US tax-exempt hospitals and determine whether restrictive policies were associated with reduced charity care spending.Methods. Using hospital tax filings with the Internal Revenue Service in 2016 and FAPs obtained from hospital Web sites, we examined characteristics of FAPs and associated expenditures for charity care in a representative sample of 170 tax-exempt hospitals. We identified common eligibility requirements and used them to define restrictiveness of FAPs.Results. FAPs were characterized by various ways to exclude patients, a patchwork of coverage for typical health care services, and wide-ranging discounts. FAP expenditures were lowest among restrictive hospitals in states that expanded Medicaid as part of the Affordable Care Act and highest among nonrestrictive hospitals in nonexpansion states. FAP expenses did not differ by hospital restrictiveness alone.Conclusions. Standardizing common eligibility requirements among FAPs carries potential benefits with regard to optimizing charity care for community benefit and achieving at least some level of equity; however, further policy efforts must account for additional restrictions, charges, and exclusions to be effective.

Rural-Urban Mortality Disparities: Variations Across Causes of Death and Race/Ethnicity, 2013-2017.

Objectives. To examine rural-urban disparities in overall mortality and leading causes of death across Hispanic (any race) and non-Hispanic White, Black, American Indian/Alaska Native (AI/AN), and Asian/Pacific Islander populations.Methods. We performed a retrospective analysis of age-adjusted death rates for all-cause mortality and 5 leading causes of death (cardiovascular, cancer, unintentional injuries, chronic lower respiratory disease, and stroke) by rural versus urban county of residence in the United States and race/ethnicity for the period 2013 to 2017.Results. Rural populations, across all racial/ethnic groups, had higher all-cause mortality rates than did their urban counterparts. Comparisons within causes of death documented rural disparities for all conditions except cancer and stroke among Hispanic individuals; Hispanic rural residents had death rates similar to or lower than urban residents. Rural Black populations experienced the highest mortality for cardiovascular disease, cancer, and stroke. Unintentional injury and chronic lower respiratory disease mortality were highest in rural AI/AN and rural non-Hispanic White populations, respectively.Conclusions. Investigating rural-urban disparities without also considering race/ethnicity leaves minority health disparities unexamined and thus unaddressed. Further research is needed to clarify local factors associated with these disparities and to test appropriate interventions.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis.

AIM: To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis. MATERIALS AND METHODS: NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%. RESULTS: The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group. CONCLUSIONS: Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Factors Associated With Perceived Job Preparedness Among RNs: Results From a National Survey.

This article examines perceived job preparedness by demographic and professional characteristics among practicing RNs who completed a national survey. Rural and male nurses felt less prepared for nursing practice and may benefit from tailored educational experiences to improve perceptions of being prepared for the workforce.

Association between Freestanding Dialysis Facility Size and Medicare Quality Incentive Program Performance Scores.

BACKGROUND: Medicare uses a quality incentive program (QIP) criteria to evaluate care in dialysis facilities and apply monetary penalties on underperforming facilities. Smaller dialysis facilities are likely to be rural and operate on lower profit margin; therefore, such facilities are likely to underperform and face Medicare penalties. The variation in QIP scores by facility size is not yet known. We investigated the association between freestanding dialysis facility size and QIP scores. METHODS: Our cross-sectional analysis compared QIP scores across levels of facility size for 5,193 freestanding dialysis facilities that received QIP scores in 2015. We used Medicare facility data including Dialysis Facility Compare, Performance Scores, Facility-Level Impact, and Area Health Resource and United States Renal Data System files for the payment year 2015. We measured the facility size using the number of dialysis stations per dialysis facility. QIP scores were used to determine the quality of care. A generalized linear model was estimated at an alpha level of 0.05. RESULTS: Facilities operating more than 10 dialysis stations scored higher than those operating fewer. Further, facilities in the South and Northeast, not offering peritoneal dialysis, affiliated with chains (except chain 3) and spending more hours per dialysis achieved higher QIP scores. Facilities reporting a higher proportion of Hispanic patients and of patients with access to pre-end-stage renal disease (ESRD) nephrologist care achieved higher QIP scores. Conversely, facilities with a higher Black patient population and higher patient travel distances scored lower. CONCLUSIONS: The current study provides important finding about the performance of the dialysis facilities with ≤10 dialysis stations. Quality improvement strategies are needed, especially for the dialysis facilities with ≤10 stations, to prevent penalties and eventual closure of such facilities due to financial insolvency. Failure to address these issues will increase further disparities in ESRD care.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina.

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

Determinants of occupational injury for US home health aides reporting one or more work-related injuries.

OBJECTIVES: Home health aides (HHAs) work in a high-risk industry and experience high rates of work-related injury that have been significantly associated with reduction in workers and organisational productivity, quality and performance. The main objective of the study was to examine how worker environment and ergonomic factors affect HHA risk for reporting occupational injuries. METHOD: We used cross-sectional analysis of data from the 2007 National Home Health and Hospice Aide Survey (NHHAS). The study sample consisted of a nationally represented sample of home health aides (n=3.377) with a 76.6% response rate. We used two scales 1 : a Work Environment Scale and 2 an Ergonomic Scale. Univariate and bivariate analyses were conducted to describe HHA work-related injury across individual, job and organisational factors. To measure scale reliability, Cronbach's alphas were calculated. Multivariable logistic regression was used to determine predictors of reported occupational injury. RESULTS: In terms of Work Environment Scale, the injury risk was decreased in HHAs who did not consistently care for the same patients (OR=0.96, 95% CI: 0.53 to 1.73). In terms of Ergonomic Scale, the injury risk was decreased only in HHAs who reported not needing any other devices for job safety (OR=0.30, 95% (CI): 0.15 to 0.61). No other Work Environment or Ergonomic Scale factors were associated with HHAs' risk of injury. CONCLUSION: This study has great implications on a subcategory of the workforce that has a limited amount of published work and studies, as of today, as well as an anticipated large demand for them.

Gender and geographic differences in Medicare service utilization during the last six months of life.

End-of-life issues are important for senior women, particularly rural women, who are more likely than their urban counterparts to live alone. The role of residence as a factor for health-care utilization among Medicare beneficiaries during the last six months of life has yet to be investigated. The purpose of this study is to examine whether service utilization in the last six months of life differs across gender and rurality. The sample was restricted to fee-for-service Medicare beneficiaries who died between July 1, 2013, and December 31, 2013 (n = 39,508). The odds of rural beneficiaries using home health (aOR 0.87; 95% CI 0.81-0.93) and/or hospice (aOR 0.82; 95% CI 0.77-0.87) in the last six months of life were lower than urban beneficiaries. Female beneficiaries were more likely to use support services such as hospice (aOR 1.24; 95% CI 1.18-1.29) and/or home health services (aOR 1.07; 95% CI 1.02-1.13) than male beneficiaries. The odds of female beneficiaries using inpatient (aOR 1.14; 95% CI 1.08-1.20) and/or outpatient (aOR 1.06; 95% CI 1.01-1.12) were higher than male beneficiaries. This research is important as we examine the range of health services used during the last six months of life, by gender and rurality. Future research is needed to understand how access to health services, residential isolation, and age- and disease-related factors relate to women's observed greater use of inpatient, outpatient, hospice, and home health services in the last six months of life.

The Role of the Nurse Executive in Rural Hospital Closure.

Between 2010 and June 2016, 75 rural hospitals closed, and more than 250 more are at risk of closure. Nurse executives need to be prepared for this eventuality. There is a need for formal direction on how to close a highly regulated healthcare facility.

Rural-urban differences in unpaid caregivers of adults.

INTRODUCTION:   Rural–urban differences in the characteristics of unpaid caregivers of adults in the USA were explored. METHODS:   Using 'Caregiving in the U.S. 2015', a survey fielded by the National Alliance for Caregiving and AARP, a national examination of rural caregivers (n=1352) is presented. RESULTS:   Rural caregivers reported lower socioeconomic status than urban caregivers (measured by income, education, and employment), suggesting greater likelihood of caregiver strain. In multivariable analysis adjusting for age, race, educational attainment, and reported caregiver burden, residence was associated with self-reported health status of the caregiver but not with physical, financial or emotional distress. The odds of rural caregivers reporting poor to fair health were significantly lower than their urban counterparts (adjusted odds ratio 0.57; 95% confidence interval, 0.36­0.91). CONCLUSIONS:   These findings may indicate differing cultural values in rural and urban respondents, rather than better health among rural caregivers. Understanding the characteristics of rural caregivers may help policymakers target interventions. .

Household food insecurity and medication "scrimping" among US adults with diabetes.

OBJECTIVE: Our research examined the prevalence of food insecurity among adults with self-reported diabetes and whether food insecurity was associated with cutting back ("scrimping") on prescribed medications because of financial constraints. METHODS: We conducted a cross-sectional analysis of data from the 2011 National Health Interview Survey (NHIS). Adults completing this survey were considered to have diabetes if they reported current use of insulin or "diabetic pills" (n=3,242). Food insecurity was determined with a 10-item scale; respondents were categorized as food secure (FS), marginally food secure (MFS) or food insecure (FI). RESULTS: Approximately one in six adults in NHIS with diabetes reported food insecurity (17.0%), and an additional 8.8% were marginally FS. An individual was considered to be scrimping on medications if he/she gave a "yes" response to at least one of four questions pertaining to reduced, delayed or avoided medication use. Overall, 18.9% of respondents with diabetes reported one or more type of medication scrimping: 11.7% of FS individuals, 27.7% of MFS individuals and 45.6% of FI individuals. In adjusted analyses, marginal food security and food insecurity remained strongly associated with scrimping. CONCLUSIONS: One-quarter of adults with diabetes may have difficulty obtaining foods appropriate for a diabetic diet; a substantial number of these individuals also fail to obtain or take medications. Practitioners may miss either problem unless targeted questions are included in clinical encounters. Clinicians should consider referring FI and MFS diabetic patients to community food resources.

Rural Area Deprivation and Hospitalizations Among Children for Ambulatory Care Sensitive Conditions.

This study examined the intersection of rurality and community area deprivation using a nine-state sample of inpatient hospitalizations among children (<18 years of age) from 2011. One state from each of the nine US census regions with substantial rural representation and varying degrees of community vulnerability was selected. An area deprivation index was constructed and used in conjunction with rurality to examine differences in the rate of ACSC hospitalizations among children in the sample states. A mixed model with both fixed and random effects was used to test influence of rurality and area deprivation on the odds of a pediatric hospitalization due to an ACSC within the sample. Of primary interest was the interaction of rurality and area deprivation. The study found rural counties are disproportionality represented among the most deprived. Within the least deprived counties, the likelihood of an ACSC hospitalization was significantly lower in rural than among their urban counterparts. However, this rural advantage declines as the level of deprivation increases, suggesting the effect of rurality becomes more important as social and economic advantage deteriorates. We also found ACSC hospitalization to be much higher among racial/ethnic minority children and those with Medicaid or self-pay as an anticipated source of payment. These findings further contribute to the existing body of evidence documenting racial/ethnic disparities in important health related outcomes.

Disparities in home health service providers among Medicare beneficiaries with stroke.

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Obesity and obesity-related behaviors among rural and urban adults in the USA.

INTRODUCTION: Previous studies have reported a higher prevalence of obesity among rural Americans. However, it is not clear whether obesity-related behaviors can explain the higher level of obesity among rural adults. The purpose of this study was to examine the differences in obesity-related behaviors across rural-urban adult populations in the USA. METHODS: Data were obtained from the 1999-2006 National Health and Nutrition Examination Survey, restricted to 14 039 participants aged 20 years or more. Body mass index (BMI) was calculated using measured height and weight, and individuals with BMI≥30 kg/m2 were categorized as obese. Physical activity recommendations were used to define participants' physical activity levels: no leisure-time physical activity, less than, meeting, and exceeding the recommended levels. Sedentary behaviors were measured by hours sitting and watching TV or videos or using a computer (outside of work). Dietary intake was assessed by one-day 24 hour dietary recall. Residence was measured at the census tract level using the Rural-Urban Commuting Area Codes. Multiple logistic regression models were used to examine urban-rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. RESULTS: The prevalence of obesity was higher in rural than in urban residents (35.6% vs 30.4%, p<0.01), among both men (37.7% vs. 32.5%, p<0.01) and women (33.4% vs 28.2%, p<0.01). Compared to urban adults, more rural adults reported no leisure-time physical activity (38.8% vs 31.8%, p<0.01) and fewer rural adults met or exceeded physical activity recommendations (41.5% vs 47.2%, p<0.01). Rural adults had lower intake of fiber and fruits and higher intake of sweetened beverages. After adjusting for sociodemographic, health, diet, sedentary behaviors, and physical activity, the odds of being obese among rural adults were 1.19 times higher than that among urban adults (95% confidence interval: 1.06, 1.34). CONCLUSIONS: Higher level of obesity, physical inactivity, and poor diet among rural residents and the persistent higher risk of obesity among rural adults after adjusting for obesity-related behaviors call for more research into 'obesogenic' environments in rural America. Effective programs are needed to help rural residents reduce high risks for obesity and unhealthy lifestyles.

Changes in Positive Childhood Experiences During the COVID-19 Pandemic.

OBJECTIVE: Changes in family life associated with COVID-19 precautions may have reduced children's access to positive childhood experiences (PCEs). The purpose of this study is to examine the prevalence of PCEs before and during the COVID-19 pandemic among school-age children. METHODS: This cross-sectional study used data from the 2018-19 National Survey of Children's Health (NSCH, n = 42,464) and the 2020-21 NSCH (n = 54,256) to examine the pre-pandemic period (June 2018-January 2020) and compared results to information obtained during the early pandemic period (June 2020-January 2022) using bivariate analyses and Z-tests. RESULTS: PCEs declined in four of the seven PCEs measured, from 2018 to 2019-2020-2021: after-school activities, community volunteerism, guiding mentor, and resilient family, with all differences significant by P < .0001. After-school activities decreased from 79.8% to 72.2%, community volunteering decreased from 43.9% to 35.1%, guiding mentor decreased from 88.8% to 86.3%, and resilient family decreased from 92.7% to 84.6%. PCEs increased for safe neighborhood (64.7-67.2%), supportive neighborhood (55.8-57.5%), and connected caregiver (65.3-94.7%). CONCLUSIONS: As children have experienced higher levels of parental stress and disruption during their lives during the COVID-19 pandemic, policymakers and program makers must find ways to increase exposure to PCEs following the pandemic. The quantification of these PCEs is a great start, with further research needed to describe ways that schools and community organizations have found to expose children to PCEs in safe ways.