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2003; 19(3): Summer
Community Driven Medical Education: The Rural Component [Commentary]
Robert C Bowman and Byron J Crouse
Participant Satisfaction in an Adult Telehealth Education Program Using Interactive Compressed Video Delivery Methods in Rural Arkansas
Ann B Bynum, Charles O Cranford, Cathy A Irwin, George S Denny
Context: Rural Americans have less access than their urban counterparts to health promotion information. Purpose: To assess differences in program satisfaction associated with age, gender, ethnicity, community size, and education among participants in an Arkansas adult telehealth education program that utilized interactive video technology. Methods: A program evaluation instrument was administered to a convenience sample of 2567 people who participated in the program from 1996 through 1999. Findings: The evaluation instrument demonstrated adequate internal consistency reliability (Cronbach's alpha = 0.85) and construct validity. Older adults, blacks, American Indians, and participants from smaller rural communities and with a high school degree or less had significantly greater satisfaction (P,.001 to P = .03). Conclusions: The findings suggest that socioeconomic and demographic factors can affect satisfaction with telehealth education programs.
Understanding Rural Hospital Bypass Behavior
Tiffany A Radcliff, Michelle Brasure, Ira S Moscovice, Jeffrey T Stensland
Context: Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure. Purpose: This study provides a descriptive analysis of rural hospital bypass behavior in 7 states. Methods: We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility. Findings: We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self-pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty surgery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities. Conclusions: Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment.
Economic Burden of Agricultural Machinery Injuries in Ontario, 1985-1996
Alison R Locker, John L Dorland, Lisa Hartling, William Pickett
Context: Agricultural injuries are an important and understudied category of occupational injuries. Purpose: This study estimated the economic burden of agricultural machinery injuries that occurred in Ontario, Canada's largest province, between 1985 and 1996. Methods: Conventional methodology for estimating economic burden, as embodied in a computer program previously developed for this purpose, was applied to hospitalized, nonhospitalized, and fatal agricultural machinery injuries. Findings: The total economic burden of these injuries over the 12-year study period was estimated to be $228.1 million, or $19.0 million annually (1995 Canadian dollars, 3.0% discount rate). By extrapolation, the economic burden of all farm injuries in Canada is estimated to be between $200 and $300 million
annually. Conclusions: Costing information about agricultural injuries provides support for the prioritization and development of injury-control initiatives.
Rural-Urban Differences in Health Care Benefits of a Community-Based Sample of At-Risk Drinkers
John C Fortney, Brenda M Booth, JoAnn E Kirchner, Xiaotong Han,
Context: Different types of health plan costcontainment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas. Purpose: This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas. Methods: A screening instrument for at-risk drinkingwas administered by phone to approximately 12 000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance andmedical records. Two thirds of the sample (n=294)were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at risk drinkers, representing 113 different health plans and 206 different policies. Findings: Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P =.001), and physical health (P =.031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P =.042), to pay coinsurance for physical health services (P =.002), and to have limits placed on physical health services use (P =.067), but they were less likely to pay copayments for physical health (P =.046). Rural enrollees were less likely to face higher copayments (P =.007) and higher coinsurance (P =.076) for mental health than for physical health, compared to urban enrollees. Conclusions: Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side costcontainment strategies and more on demand-side costcontainment strategies targeting physical health service
use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.
2003; 3(1): Fall
Developing Cultural Competence in Rural Nursing
Lindsay Lake Morgan and Sally J Reel
Preconceptions of rural lifestyle and culture can color the perspective of future health care providers. To encourage Advanced Practice Nurse (ANP) students to think beyond the mythology about a rural place different than where they practice, two nurse educators and universities teamed up to develop a unique curriculum in which students immersed themselves in a new rural experience. In this innovative curriculum design, students visited a rural Appalachian coal-mining community in an immersion experience to conduct a community assessment and worked with local health care providers in community health education projects in collaboration with a nurse educator and ANP who provides health care to the community through a primary care clinic. The students discovered for themselves the distinctions of rural life in rural West Virginia. This project led to experiential learning and heightened attainment of cultural competence on the part of the students and demonstrated how a collegial effort between nurse educators in two universities and long distance collaboration can benefit students who may someday deliver care in rural communities.
A Comparison Study of Urban and Small Rural Hospitals Financial and Economic Performance
Mustafa Z Younis
This study examines the performance of hospitals based on location (geographical region, rural, urban). In this study, recent data has been used to better understand the hospitals performance after the introduction of Prospective Payment System (PPS). The data set used by the study is much comprehensive in its coverage and information on a number of relevant variables. We have included a number of new economic and financial variables in the analysis and examined the effects of conversion of hospitals from not-for-profit to for-profit on hospital performance. Our empirical findings suggest that the size of hospitals, occupancy rate of hospital beds, ownership status, degree of competition faced in the market, teaching status, and measure of financial indebtedness of hospitals are significant determinants of hospital performance holding location constant. The empirical model also suggests that the relationship between hospital efficiency measure and its various determinants is actually non-linear in nature and therefore, it is important to adopt appropriate non-linear econometric models for empirical estimation of the performance function. Finally, our findings show that rural and small hospitals face significant factors that hinder its performance in comparison to urban and larger hospitals such as the lack of (DSH) payments and economy of scale due to their smaller size and lower proportion of Medicaid patients.
2003; 11(2)
Differences in access to health care services among adults in rural America by rural classification categories and age
Ping Zhang, Guoyu Tao, Lynda A Anderson
Objective: To study differences in excess to health care services between different population groups in rural areas of the United States.
Design: Using data from the 1994 National Health Interview Survey and the 1991 Area Resource File, we examined the differences in excess with seven measures: having a regular source of care, having a usual place of care, having health insurance coverage, delaying medical care because of cost for all rural residents; number of doctor visits, number of hospital discharges and length of hospital stay per discharge for those who reported their health as being either poor or fair. Rural residents were classified by ages and grouped into four rural classification categories that were characterised along two dimensions: adjacent to a metropolitan statistical area (MSA) (yes/no) and inclusion of a city of at least 10 000 people (yes/no). Setting: Rural areas. Subjects: Rural populations. Results: Residents aged 18-24 years had the worst access to services and the residents aged 65 years and over had the best access to services when measured by regular source of care, a usual place of care and health insurance status. Compared to those aged 50-64 years, residents aged 25-49 years were less likely to report having health insurance and more likely to report delaying seeking medical care because of costs. Rural residents who lived in a county adjacent to an MSA generally were less limited in access than those who lived in a county not adjacent to an MSA.
Conclusions: Rural America is not a homogeneous entity in many aspects of the access to health care services.
Self-reported patterns of health services utilisation: an urban-rural comparison in South Australia
Paula Dempsey, David Wilson, Anne Taylor, David Wilkinson
Objective:To compare self-reported patterns of health service utilisation among residents of urban and rural South Australia.
Design, setting and main outcome measures:Secondary analysis of data generated by computer-assisted telephone interviews of 7377 adults done in 1995-6. Respondents were asked if they had used each of 18 different health services during the previous 12 months. Residence was classified in three ways: (1) capital city versus rest of the state, (2) by the Rural, Remote and Metropolitan Areas classification (RRMA) and (3) by the Accessibility and Remoteness Index for Australia classification (ARIA). Results:General practitioner services were most frequently used, by approximately 89% of respondents. Only 4% reported not using any service. Comparing capital city with rest of the state, modest but statistically significant differences in utilisation (P < 0.01) were measured for nine services. In eight of these nine, utilisation was higher among rural residents. Analysing by RRMA, eight services were reportedly used differently and seven of these were the same as those identified from the capital city versus rest of state comparison. Across the five ARIA categories, six previously identified services were reported as being used differentially. Overall, rural residents had a higher than expected rate of moderate and high level of health service use. Conclusions:Self-reported use of a range of health services was broadly similar across urban and rural South Australia, with most cases of higher use were reported from rural areas rather than urban areas. Similar results were obtained when residence was classified in the three different ways.
Rural origin medical students: how do they cope with the medical school environment?
Shane R Durkin, Angela Bascomb, Deborah Turnbull, John Marley
Australia suffers from a well documented shortage of rural medical practitioners. In an attempt to increase recruitment, it has emerged that rural origin medical students are more than twice as likely as their urban colleagues to become rural practitioners. This has led to a wide range of programs aimed at increasing the number of rural students who apply for and gain entry into medical school. But how do rural students cope with the medical school environment? This paper was based on the results of a survey of senior medical students and looked at how rural students' fare with the medical school environment compared to their urban counterparts. It was concluded that government initiatives currently supporting rural medical students must be continued into the future and continuously evaluated to ensure that rural students have a positive learning experience in preparation for future rural practice.