Journal of Rural Health最新文献

Background: Racial health disparities are well documented and pervasive across the United States. Evidence suggests there is a "rural mortality penalty" whereby rural residents experience poorer health outcomes than their urban counterparts. However, whether this penalty is uniform across demographic groups and U.S. regions is unknown.

Objective: To assess how rural-urban differences in mortality differ by race (Black vs. White), U.S. region, poverty status, and how rural-urban status is measured.

Methods: Age-standardized mortality rates (ASMRs)/100,000 by U.S. county (2015-2019) were obtained by race (Black/White) from the CDC Wonder National Vital Statistics System (2015-2019) and were merged with county-level social determinants from the US Census Bureau and County Health Rankings. Multivariable generalized linear models assessed the associations between rurality (index of relative rurality [IRR] decile, rural-urban continuum codes, and population density) and race-specific ASMR, overall, and by Census region and poverty level.

Results: Overall, average ASMR was significantly higher in rural areas than urban areas for both Black (rural ASMR = 949.1 per 100,000 vs. urban ASMR = 857.7 per 100,000) and White (rural ASMR = 903.0 per 100,000 vs. urban ASMR = 791.6 per 100,000) populations. The Black-White difference was substantially higher (p < 0.001) in urban than in rural counties (65.1 per 100,000 vs. 46.1 per 100,000). Black-White differences and patterns in ASMR varied notably by poverty status and U.S. region.

Conclusion: Policies and interventions designed to reduce racial health disparities should consider and address key contextual factors associated with geographic location, including rural-urban status and socioeconomic status.

Purpose: To examine the relationship between living arrangements and discharge disposition, and how this relationship differs by the rural or urban characteristics of the patient's residence among home health care patients with Alzheimer's disease and related dementia (ADRD).

Methods: This retrospective study used the 2019 Outcome and Assessment Information Set and the Master Beneficiary Summary File. Our study was based on 531,269 Medicare fee-for-service patients with ADRD. We used linear probability regression models to examine the relationship between discharge disposition (to the community vs. an institution) and living arrangements, including an interaction term for rural-urban residence.

Findings: Patients in rural areas (19.8%) were more likely to live alone than those in urban areas (15.2%). Our main results show that patients living at home with others (coefficient: -0.02, p-value < 0.001) or alone (coefficient: -0.03, p-value < 0.001) were less likely to be discharged to the community compared to patients who lived in congregate settings. Also, for patients with ADRD who lived in rural areas, living at home with others (rural*home with others; coefficient: -0.02, p-value < 0.001) or living alone (rural*home alone; coefficient: -0.03, p-value<0.001) were associated with additional lower probabilities of being discharged to their communities.

Conclusions: A multidimensional approach considering living arrangements to support home health care patients with ADRD could be critical to achieving better health outcomes. Furthermore, implementing area-specific target interventions could be important for improving the care and health of patients with ADRD as well as reducing rural-urban disparities in discharge disposition.

Purpose: There are significant rural/urban disparities that exist in cancer and chronic disease morbidity and mortality, many of which are attributed to increased tobacco use prevalence in rural populations compared to urban. Understanding differences in rural and urban tobacco use patterns is key to developing targeted interventions.

Methods: Using nationally representative data from Wave 5 of the Population Assessment of Tobacco Use and Health (PATH), we examined weighted frequencies and conducted multivariable logistic regression to examine the use of cessation supports in people who currently smoke with a quit attempt in the last 12 months (recent attempters) by rural and urban status and geographic region. Our second objective was to examine lifetime quitting in rural versus urban people who smoke and by geographic region.

Results: Rural people who recently attempted to quit were less likely to use any FDA-approved cessation aids, less likely to use Nicoctine Replacement Therapy (NRT), and less likely to be exposed to a home smoking ban in the adjusted analysis. The adjusted odds of quitting were lower in the rural Northeast, Midwest, and South compared to the urban regions.

Conclusions: Findings from this data can serve to inform the development of targeted interventions for rural communities.

Purpose: In rural America, the road to obtaining a liver transplant (LTX) often starts at the primary care provider's (PCP's) office. Patients with end-stage liver disease (ESLD) in rural communities experience lower rates of wait-listing and higher mortality. This study identifies issues related to the knowledge and perceptions of ESLD and LTX referral among PCPs in rural Kentucky (KY).

Methods: The study protocol involved relying upon a semistructured outline to explore the knowledge, attitude, and perceptions of PCPs toward ESLD and LTX referral among PCPs in rural KY. Inductive thematic analysis was utilized to identify, analyze, and report themes.

Findings: From the focus group interviews, three themes were identified: medical culture, gaps in knowledge, and bias against those with self-induced causes of ESLD. Each theme illuminated barriers to referral for transplant evaluation.

Conclusions: Knowledge gaps, attitudes in medical culture, and biases surrounding ESLD and LTX referral exist in community medicine practice. This highlights the importance of education, resources, and facilitation of LTX referral processes for PCPs.

Purpose: To examine rural and urban disparities in cardiovascular disease (CVD) death rates by poverty level and region.

Methods: Using 2021 county-level population and mortality data for CVD deaths listed as the underlying cause among adults aged 35-64 years, we calculated age-standardized CVD death rates and rate ratios (RR) for 4 categories of counties: high-poverty rural, high-poverty urban, low-poverty rural, and low-poverty urban (referent). Results are presented nationally and by US Census region.

Findings: Rural and urban disparities in CVD mortality varied markedly by poverty and region. Nationally, the CVD death rate was highest among high-poverty rural areas (191 deaths per 100,000, RR: 1.76, CI: 1.73-1.78). By region, Southern high-poverty rural areas had the highest CVD death rate (256 deaths per 100,000) and largest disparity relative to low-poverty urban areas (RR: 2.05; CI: 2.01-2.09). In the Midwest and West, CVD death rates among high-poverty areas were higher than low-poverty areas, regardless of rural or urban classification.

Conclusions: Results reinforce the importance of prioritizing high-poverty rural areas, especially in the South, in efforts to reduce CVD mortality. These efforts may need to consider socioeconomic conditions and region, in addition to rural and urban disparities.

Purpose: To explore adult community members' perspectives concerning barriers to mental health care that confront rural-dwelling youth.

Methods: Group concept mapping, a participatory community-engaged research method, was used. Adult community members brainstormed and sorted statements describing barriers rural youth encounter in accessing mental health services. Point and cluster maps were created to visualize conceptual similarities between statements. Statements were rated according to their commonness and importance (1: low commonness/importance, 5: high commonness/importance).

Findings: Thirty-five adults sorted and/or rated 71 barriers facing rural youth in accessing mental health services. Seven conceptual clusters were identified: system-level barriers, knowledge and communication, youth concerns, parent/guardian concerns, parent/guardian barriers, costs and convenience, and school-level barriers. Within youth concerns, community members also identified a subcluster focused on stigma. Common and important statements related to limited after-school programs and community mental health support initiatives.

Conclusions: Group concept mapping methodology provides structure for conceptualizing challenges facing rural youth in accessing mental health services. Policies should be informed by rural community concerns and priorities. After-school and support programs may align with mental health needs identified by rural communities.

Introduction: There are long-standing differences in profitability between rural and urban hospitals. Prior to the COVID-19 Public Health Emergency (PHE), rural hospital profitability was decreasing, while urban hospital profitability was increasing. During the PHE, the Federal Government provided billions of dollars of support to hospitals. Given the prepandemic differences in trends in profitability, it is likely that the PHE funding had different effects on rural hospitals and urban hospitals.

Methods: This study uses 2015-2023 Medicare cost report data from acute-care hospitals to assess the impact of COVID-19 PHE funding on hospital profitability. We employ descriptive Kruskal-Wallis and chi-square tests and an interrupted time series analysis to evaluate the effect of PHE funding on operating margins for a stratified sample of rural prospective payment system (PPS), urban PPS, and critical access hospitals (CAHs).

Results: We found that the PHE funding was associated with significant increases in operating margins, with rural PPS hospitals experiencing similar increases compared to urban PPS hospitals, and CAHs surpassing both rural and urban PPS hospitals in their margin values. However, if PHE funding had not been provided, our evidence suggests operating margins for all hospitals in 2022-2023 would have been below prepandemic levels.

Discussion: This preliminary analysis portrays the importance of the PHE government funding in supporting hospitals during the pandemic, and shows declining profitability trends without the funds. Rural PPS hospitals fare the worst suggesting continued need for financial support if the trend continues.

Purpose: Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one-third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality.

Methods: We examined national VA administrative data for 2019-2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received.

Results: Among home health users (n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans' characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72).

Conclusions: Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans' care needs are equitability addressed.

Purpose: The Rural Communities Opioid Response Program (RCORP) was funded to help rural communities improve prevention, treatment, and recovery services for Opioid Use Disorder (OUD), including increasing the supply of clinicians with a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine, which was required before 2023. This research investigates the impact of RCORP funding on the supply of DEA-waivered clinicians in rural communities.

Methods: We used 2017-2022 DEA lists of waivered clinicians to assign clinicians to US counties. Using RCORP service area data, we classified rural counties as either being served by an RCORP grantee or not. We calculated the number of counties in each category with a waivered clinician, clinician-to-population ratios, and treatment slot-to-population ratios.

Findings: In 2017, 3.7% more of RCORP funded counties had a waivered clinician than non-RCORP counties. RCORP counties also had 1.2 more waivered clinicians per 100,000 population and 57.5 more treatment slots per 100,000 population compared to non-RCORP counties. From 2017 to 2022, these differences more than doubled. The supply of waivered clinicians varied across Census Divisions. In most Census Divisions, a greater percentage of RCORP counties had a waivered clinician as well as more waivered clinicians and treatment slots per population, except for the Pacific Census Division, which had more clinicians and treatment slots per population in non-RCORP counties.

Conclusions: Study findings suggest that federal investments to expand rural OUD patients' access to care may have been successful, but only if increases in clinician supply translate into greater provision of OUD treatment.