Journal of Rural Health最新文献

Purpose: To evaluate rural-urban disparities over time in the association of ACO participation and diabetes-related quality measures among health clinics.

Methods: We used data from the Wisconsin Collaborative for Healthcare Quality all-patient all-payer electronic health records data system between 2011 and 2018, for patients 18-75 years. Difference-in-differences regression models estimated the association between ACO participation and eight diabetes quality measures among populations in rural and urban areas, separately. Triple-difference models were also estimated to assess urban-rural disparities.

Findings: Considering the two measures used in ACO performance evaluation, patients in ACO clinics were less likely to receive tobacco cessation advice relative to those in non-ACO clinics (rural: marginal effect estimate (MEE) = -0.025, p = 0.033; urban: MEE = -0.231, p < 0.001). The triple difference across rurality was not statistically significant (MEE = -0.007 p = 0.56). For the remaining six ACO-non-incentivized measures, rural patients at ACO clinics performed better relative to their non-ACO counterparts on kidney function monitored, and diabetes all-or-none optimal testing and control.

Conclusions: ACO participation appeared to be more favorable for rural versus urban patients with diabetes. ACOs have potential to contribute to reducing existing rural-urban disparities in diabetes process measures.

Purpose: The role of telehealth use in primary care among rural Medicare Advantage (MA) beneficiaries following Medicare's expanded telehealth coverage during COVID-19 is not well understood. With increasing evidence that provider characteristics influence patient access to telehealth, this study compared receipt of telehealth primary care between rural and nonrural MA beneficiaries by providers' level of telehealth delivery.

Methods: Using claims for MA beneficiaries from January 2021 to June 2024, we compared the proportion of primary care visits that were delivered via telehealth between rural and nonrural beneficiaries. We then categorized primary care physician (PCP) groups into quartiles based on the provision of telehealth as a share of total primary care visits. We conducted visit-level generalized linear regression analyses to assess whether differences in telehealth primary care receipt between rural and nonrural beneficiaries varied by PCP telehealth quartile.

Findings: PCPs delivering the highest rates of telehealth were significantly more likely to provide primary care via telehealth to rural MA beneficiaries than nonrural ones (4th quartile odds ratio: 1.12, 95% confidence interval: 1.02, 1.22). This finding differed from the overall disparity in telehealth use between rural and nonrural populations, in which rural beneficiaries used less telehealth.

Conclusions: Results showing increased telehealth use among rural MA beneficiaries receiving care from PCPs delivering the highest rates of telehealth may partly stem from unique capabilities among these providers, who are potentially better equipped with tools for implementing telehealth. As such, we provide insight on provider-oriented factors that can bolster telehealth access for rural MA populations.

Purpose: Cost structure, the proportion of fixed-to-total costs, plays a central role in rural hospital financial viability. Rural hospitals face unique challenges due to low volumes and limited flexibility in reducing fixed costs. This study evaluated variation in cost structures across rural hospital categories and assessed whether fixed-to-total cost ratios are associated with financial distress and closure.

Methods: We analyzed 2394 rural hospitals using the CMS Healthcare Cost Report Information System data from 2011-2023. Hospitals included 1200 Critical Access Hospitals (CAHs), 870 rural Prospective Payment System (PPS) hospitals, and 224 Rural Referral Center (RRC) hospitals. Fixed-to-total cost ratios were estimated using a mixed-effects regression framework and examined by hospital category, Financial Distress Index (FDI) category, and closure status.

Findings: Rural hospital categories exhibited substantial variation in cost structures. CAHs had the highest average fixed-to-total cost ratios (80.6%), followed by rural PPS hospitals (73.6%), and RRC hospitals (58.2%). Higher ratios consistently aligned with a higher risk of financial distress. Hospitals in the highest-risk FDI category and those that closed had higher fixed-to-total cost ratios than other rural hospitals. Differences were most pronounced between rural PPS and RRC hospitals.

Conclusions: Cost structure is a strong indicator of rural hospital vulnerability. Hospitals with heavier fixed cost burdens are less able to adapt to declining volumes, making them more susceptible to financial distress and closure. Regular monitoring of fixed-to-total cost ratios can support policymakers and health system leaders in designing payment models and interventions that strengthen the stability of rural hospitals.

Purpose: Rural older Veterans have limited access to specialty care. In the Veterans Health Administration (VHA), tele-geriatric mental health (tele-GMH) services provide mental health care to older Veterans through regional telehealth hubs. However, older Veterans may still face gaps in access to geriatric medicine and specialty services, exacerbating unmet needs at the intersection of mental and physical health. We assessed unmet needs for geriatric medicine and related specialty services for rural older Veterans served by tele-GMH.

Methods: We surveyed 32 clinicians in 6 VHA geographic regions who referred Veterans to tele-GMH services in fiscal year 2023, 25 of whom served rural Veterans. We also conducted semi-structured interviews with 11 tele-GMH clinicians. Survey data were summarized using descriptive statistics, and interviews were analyzed utilizing rapid qualitative analysis. We also described workflows of tele-GMH clinicians as they align with the "4Ms" of age-friendly care (Mentation, Medications, Mobility, What Matters).

Findings: Referring clinicians serving rural Veterans reported lower access to geriatricians than those serving both rural and nonrural Veterans (14.3% vs 36.4%, respectively). Reported access to additional specialty services, as well as local aging services, was also limited. Based on interviews, facilitators for connecting Veterans to services included tele-GMH clinicians' knowledge of local resources. Tele-GMH clinicians reported barriers including high demand, geography, and frequent staff turnover. Tele-GMH clinicians highlighted the utility of the 4Ms to enhance quality of care.

Conclusions: Integrating geriatric medicine into tele-GMH programs supports the delivery of high-quality, age-friendly health care, optimizing VHA workforce capacity and improving care coordination within VHA and non-VHA systems.

Introduction: The advent of curative direct acting antiviral (DAA) drugs to treat those actively infected with the hepatitis C virus (HCV) has allowed for discussion around HCV elimination. Restrictive state-by-state policies for the coverage of DAAs for Medicaid recipients may hamper elimination efforts in the United States by limiting access to these curative treatments.

Methods: The purpose of the current analysis was to examine the sociodemographic, drug use and clinical characteristics of participants in the Kentucky Viral Hepatitis C Treatment (KeY Treat) study in the context of Medicaid policies in the United States. The goal of KeY Treat was to reduce barriers to accessing curative DAAs by providing screening and treatment free of charge.

Results: Results suggest that fewer than one in five KeY Treat participants would be eligible for HCV treatment in states without Medicaid expansion. A third of KeY Treat participants were actively injecting drugs and 40% indicated recent drug use, which would negatively impact their ability to easily access treatment in seven US states. More than 85% of KeY Treat participants started treatment the same day as screening. However, same-day test and treat models would not be possible in almost half of US states because of preauthorization requirements that limit the ability of providers to employ innovative point-of-care RNA screening.

Conclusions: As an elimination plan takes shape in the United States, it is clear that it will be necessary to remove all restrictions for accessing treatment to allow for meaningful increases in HCV treatment uptake and cure.

Purpose: Rural-residing children with medical complexity (CMC) may receive fragmented care given clinician shortages in rural communities. This study characterized differences in continuity of care between rural- and urban-residing CMC, applying novel measures of geographic care continuity and assessing associations between continuity, neighborhood social disadvantage, and unplanned hospital utilization.

Methods: This retrospective cohort study analyzed 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire. After identifying CMC using validated algorithms, we calculated three continuity measures: (i) primary care continuity using the Bice-Boxerman Continuity of Care Index (CoCi), (ii) geographic continuity applying the CoCi at the county-level, and (iii) proportion of clinic visits within one's home county. We specified regression models to estimate rural-urban differences and interactions between rurality and neighborhood disadvantage, and to model associations between care continuity and unplanned hospital utilization.

Findings: Among 93,948 CMC, those who were rural-residing had higher mean primary care CoCi (50.6 [95% CI: 49.6-51.6] vs. 46.9 [95% CI: 46.6-47.2] for urban-residing), lower mean county-level CoCi (66.8 [95% CI: 66.1-67.5] vs. 70.4 [95% CI: 70.2-70.6]) and a lower local care continuity (53.5% [95% CI: 52.5%-54.5% vs. 60.3% [95% CI: 60.0%-60.5%]). Neighborhood social disadvantage was a significant effect modifier of the relationship between rurality and all continuity measures. Higher care continuity was associated with lower risk of unplanned hospitalization and emergency department visits.

Conclusion: Rural-residing CMC had higher primary care continuity than their urban-residing peers but lower geographic continuity. Several associations between rurality and care continuity were moderated by neighborhood social disadvantage, highlighting the importance of considering area-level characteristics when implementing programs and policies to support this population.

Purpose: This review aims to assess interventions connecting providers of perinatal care in rural areas to other providers or training. The main questions we assessed were: (1) what programs are in the academic or gray literature that connect rural providers with other providers regarding perinatal care using telehealth, (2) what are the purposes/goals of these interventions and to what extent are they intended to support provider retention or address gaps in care due to shortages of obstetrics providers in rural areas, and (3) what program evaluation has been done to examine the effectiveness of these interventions?

Methods: We searched PubMed, Web of Science, Embase, Gender Watch, and Sociological Abstracts from January 2002 to November 2024 and included relevant articles. The search produced a total of 12,790 citations, and 62 additional articles were identified through gray literature and citation searching. After screening, 56 articles met the inclusion criteria.

Findings: The 56 included articles described 21 interventions in the USA, Canada, and Australia. Programs rarely identified increasing access to care for rural communities as a goal, with many programs stating their scope was much narrower. The full scope of perinatal care is covered, and providers involved were mostly family medicine physicians and obstetricians. Programs used a variety of technologies, but synchronous connections were most common.

Conclusions: Programs show promise, but little is known about the effectiveness of most programs. Gray literature was crucial for finding many programs, which highlights the potential for a lack of awareness of some of these resources.