Busse CE PhD, O'Hanlon K MPH, Kozhimannil KB PhD, Interrante JD PhD
Purpose
This study describes perspectives of rural hospital administrators regarding the financial context for operating obstetric units, including the unique challenges they face and the strategies they have implemented to maintain obstetric services.
Methods
In this mixed-methods study, we used data from a survey we conducted from March to August 2021 of administrators of rural hospitals that had maintained or closed their obstetric units. Key financial outcomes included general finances, size and equipment, payor mix, workforce, and other fixed costs, examined descriptively. We also conducted thematic content analysis of open-ended responses to financial questions.
Findings
Respondents from hospitals that closed obstetric services (n = 40) reported that physician shortages (67%), financial losses (62%), clinical safety (56%), liability insurance costs (51%), and nurse shortages (39%) influenced the decision to close obstetric units. Among hospitals with obstetrics (n = 88), more than half (55%) reported that their hospital was operating with a profit margin, but only 41% said their obstetric unit had more revenue than costs. Of the hospitals with obstetrics who responded about the future of their obstetric units, 77% (61/79) were confident that they would continue providing obstetric care in 10 years; their open-ended responses highlighted the importance of hospital leadership's commitment to maintaining obstetric services in their communities.
Conclusions
Rural hospitals cite clinical workforce challenges, high fixed costs, and declining birth volumes as financial challenges to providing obstetrics. Strategies for maintaining obstetric care in rural communities should account for lower birth volumes in rural facilities and these interrelated challenges.
{"title":"Financial challenges of providing obstetric services at rural US hospitals","authors":"Busse CE PhD, O'Hanlon K MPH, Kozhimannil KB PhD, Interrante JD PhD","doi":"10.1111/jrh.70082","DOIUrl":"10.1111/jrh.70082","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>This study describes perspectives of rural hospital administrators regarding the financial context for operating obstetric units, including the unique challenges they face and the strategies they have implemented to maintain obstetric services.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In this mixed-methods study, we used data from a survey we conducted from March to August 2021 of administrators of rural hospitals that had maintained or closed their obstetric units. Key financial outcomes included general finances, size and equipment, payor mix, workforce, and other fixed costs, examined descriptively. We also conducted thematic content analysis of open-ended responses to financial questions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Respondents from hospitals that closed obstetric services (<i>n</i> = 40) reported that physician shortages (67%), financial losses (62%), clinical safety (56%), liability insurance costs (51%), and nurse shortages (39%) influenced the decision to close obstetric units. Among hospitals with obstetrics (<i>n</i> = 88), more than half (55%) reported that their hospital was operating with a profit margin, but only 41% said their obstetric unit had more revenue than costs. Of the hospitals with obstetrics who responded about the future of their obstetric units, 77% (61/79) were confident that they would continue providing obstetric care in 10 years; their open-ended responses highlighted the importance of hospital leadership's commitment to maintaining obstetric services in their communities.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Rural hospitals cite clinical workforce challenges, high fixed costs, and declining birth volumes as financial challenges to providing obstetrics. Strategies for maintaining obstetric care in rural communities should account for lower birth volumes in rural facilities and these interrelated challenges.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12539383/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145337876","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alexis Swendener PhD, Mariana Tuttle MPH, Ingrid Jacobson MPH, Lisa I. Iezzoni MD, MSc, Robert Barclay MPH, Carrie Henning-Smith PhD, MPH, MSW
Purpose
Access to health care supports both individual and population health. Ample research demonstrates access barriers faced by rural residents and people with disabilities; however, less research has examined access barriers for rural residents by disability status or explored differences across multiple types of access barriers. This brief report addresses this gap by examining 11 financial and nonfinancial barriers to accessing health care among rural adults by disability status.
Methods
Using nationally representative data from the 2022 National Health Interview Survey and focusing on rural adults (n = 4,703), we conducted bivariate and multivariate logistic regression analyses comparing 11 separate access barriers by disability status and generated adjusted predicted probabilities of experiencing these barriers, controlling for sociodemographic characteristics.
Findings
Overall, compared to those without disabilities, rural people with disabilities had significantly higher adjusted predicted probabilities of 8 of the 11 access barriers. These include delaying multiple types of care due to cost, not being able to afford prescriptions, and delaying care due to facility hours, insurance acceptance, transportation, and travel time. Rural people with disabilities were, however, more likely than their nondisabled counterparts to report having a usual place for care.
Conclusions
Rural individuals with disabilities face more barriers to care than their peers without disabilities, including delaying care, which can potentially worsen health outcomes. Our findings provide important information for policymakers to improve access to care at the intersection of rurality and disability.
{"title":"Barriers to health care among rural adults by disability status","authors":"Alexis Swendener PhD, Mariana Tuttle MPH, Ingrid Jacobson MPH, Lisa I. Iezzoni MD, MSc, Robert Barclay MPH, Carrie Henning-Smith PhD, MPH, MSW","doi":"10.1111/jrh.70086","DOIUrl":"10.1111/jrh.70086","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Access to health care supports both individual and population health. Ample research demonstrates access barriers faced by rural residents and people with disabilities; however, less research has examined access barriers for rural residents by disability status or explored differences across multiple types of access barriers. This brief report addresses this gap by examining 11 financial and nonfinancial barriers to accessing health care among rural adults by disability status.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Using nationally representative data from the 2022 National Health Interview Survey and focusing on rural adults (n = 4,703), we conducted bivariate and multivariate logistic regression analyses comparing 11 separate access barriers by disability status and generated adjusted predicted probabilities of experiencing these barriers, controlling for sociodemographic characteristics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Overall, compared to those without disabilities, rural people with disabilities had significantly higher adjusted predicted probabilities of 8 of the 11 access barriers. These include delaying multiple types of care due to cost, not being able to afford prescriptions, and delaying care due to facility hours, insurance acceptance, transportation, and travel time. Rural people with disabilities were, however, more likely than their nondisabled counterparts to report having a usual place for care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Rural individuals with disabilities face more barriers to care than their peers without disabilities, including delaying care, which can potentially worsen health outcomes. Our findings provide important information for policymakers to improve access to care at the intersection of rurality and disability.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-10-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12538111/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145337887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Suzanne B. Daly PhD, Wei You MS, Elizabeth I. Merwin PhD
<p>Rural and urban differences in mortality and morbidity have been persistent.<span><sup>1-6</sup></span> Rural patients have higher rates of acute and chronic health problems such as obesity, diabetes, cardiovascular disease, and cancer.<span><sup>2, 7, 8</sup></span> Rural communities have higher numbers of uninsured individuals, rates of poverty and unemployment, lower rates of education, and greater difficulty accessing reliable transportation.<span><sup>2, 9</sup></span> They also have fewer hospitals and health care providers, and, despite numerous interventions, rural hospitals continue to close at a rapid rate, leaving rural patients facing increased challenges accessing health care.<span><sup>9, 10</sup></span> The combination of these factors has likely contributed to the gap between rural and urban morbidity and mortality that has continued to expand over the last several decades.</p><p>Rural hospitals are often the only source of care in their communities, as well as the largest employer, and closures threaten the health of rural communities.<span><sup>8, 11</sup></span> Medicaid expansion in 40 states and the District of Columbia has helped rural hospitals by providing compensation for care for patients who would otherwise be unable to pay.<span><sup>12, 13</sup></span> As shown in Figure 1, since 2005, 111 rural hospitals have completely closed, leaving many communities without local access to emergency, obstetric, and other medical services.<span><sup>14</sup></span> Over half of these closures have happened since 2014, the year Medicaid expansion coverage was available, with many closures occurring in states that had not or have not opted to expand Medicaid.<span><sup>13, 15</sup></span> Out of the top five states with the highest numbers of rural hospitals at risk of closure, only Oklahoma has chosen to expand Medicaid.<span><sup>12, 16</sup></span></p><p>In December 2020, a new federal payment program—the Rural Emergency Hospital (REH) program—was established by the Consolidated Appropriations Act, 2021<span><sup>17</sup></span> in an effort to provide financial stability for rural hospitals and ensure local access to care for rural residents.<span><sup>10, 18</sup></span> The first hospitals were eligible to convert to a REH on January 1, 2023, with over 1500 hospitals eligible for the new designation.<span><sup>19</sup></span> In 2023, 19 hospitals converted, 18 in 2024, and three so far in 2025, for a total of 40 REHs currently operating.<span><sup>20</sup></span></p><p>Rural communities can ill-afford to lose access to health care. The loss of a hospital is not only the loss of health care services to patients in the community, it is an economic blow for the community with rural communities seeing hospital and non-hospital job losses.<span><sup>15</sup></span> Shuttering inpatient beds and no longer providing that service is not an easy decision for rural hospital executives, and understanding why these decisions are made i
{"title":"The new Rural Emergency Hospital Designation Program: Will it improve access to care for rural Americans?","authors":"Suzanne B. Daly PhD, Wei You MS, Elizabeth I. Merwin PhD","doi":"10.1111/jrh.70079","DOIUrl":"10.1111/jrh.70079","url":null,"abstract":"<p>Rural and urban differences in mortality and morbidity have been persistent.<span><sup>1-6</sup></span> Rural patients have higher rates of acute and chronic health problems such as obesity, diabetes, cardiovascular disease, and cancer.<span><sup>2, 7, 8</sup></span> Rural communities have higher numbers of uninsured individuals, rates of poverty and unemployment, lower rates of education, and greater difficulty accessing reliable transportation.<span><sup>2, 9</sup></span> They also have fewer hospitals and health care providers, and, despite numerous interventions, rural hospitals continue to close at a rapid rate, leaving rural patients facing increased challenges accessing health care.<span><sup>9, 10</sup></span> The combination of these factors has likely contributed to the gap between rural and urban morbidity and mortality that has continued to expand over the last several decades.</p><p>Rural hospitals are often the only source of care in their communities, as well as the largest employer, and closures threaten the health of rural communities.<span><sup>8, 11</sup></span> Medicaid expansion in 40 states and the District of Columbia has helped rural hospitals by providing compensation for care for patients who would otherwise be unable to pay.<span><sup>12, 13</sup></span> As shown in Figure 1, since 2005, 111 rural hospitals have completely closed, leaving many communities without local access to emergency, obstetric, and other medical services.<span><sup>14</sup></span> Over half of these closures have happened since 2014, the year Medicaid expansion coverage was available, with many closures occurring in states that had not or have not opted to expand Medicaid.<span><sup>13, 15</sup></span> Out of the top five states with the highest numbers of rural hospitals at risk of closure, only Oklahoma has chosen to expand Medicaid.<span><sup>12, 16</sup></span></p><p>In December 2020, a new federal payment program—the Rural Emergency Hospital (REH) program—was established by the Consolidated Appropriations Act, 2021<span><sup>17</sup></span> in an effort to provide financial stability for rural hospitals and ensure local access to care for rural residents.<span><sup>10, 18</sup></span> The first hospitals were eligible to convert to a REH on January 1, 2023, with over 1500 hospitals eligible for the new designation.<span><sup>19</sup></span> In 2023, 19 hospitals converted, 18 in 2024, and three so far in 2025, for a total of 40 REHs currently operating.<span><sup>20</sup></span></p><p>Rural communities can ill-afford to lose access to health care. The loss of a hospital is not only the loss of health care services to patients in the community, it is an economic blow for the community with rural communities seeing hospital and non-hospital job losses.<span><sup>15</sup></span> Shuttering inpatient beds and no longer providing that service is not an easy decision for rural hospital executives, and understanding why these decisions are made i","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12521877/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145294289","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alex H. Crisp PhD, Bethany Barone Gibbs PhD, Jacob B. Gallagher PhD, Katrina L. Wilhite PhD, Angela C. B. Trude PhD, Treah Haggerty PhD, Kara M. Whitaker PhD
Purpose
Poor diet during pregnancy compromises maternal–fetal health and may reflect broader environmental and structural inequities. This study investigated differences in dietary intake across pregnancy among rural and urban women in the United States and assessed whether socioeconomic status (SES) modified rural–urban differences.
Methods
In this prospective study, pregnant women (n = 495; 22.4% rural) from three sites (Iowa, Pennsylvania, West Virginia) had dietary intake estimated via the 26-item Dietary Screener Questionnaire (DSQ) during each trimester. Rural was defined as Rural–Urban Commuting Area (RUCA) code ≥ 4. A SES score was derived using Principal Component Analysis of education, annual household income, and insurance type. Adjusted robust linear mixed-effects models (controlled for site, age, minority status, pre-pregnancy BMI) compared dietary intakes between rural and urban participants, with trimester and SES interactions.
Findings
Compared to their urban counterparts, rural participants had higher predicted intakes of added sugars from sugar-sweetened beverages (SSBs) in the first (0.61 tsp eq/day; 95% CI: [0.04, 1.18]) and second trimesters (0.62 tsp eq/day [0.05, 1.21]), and less fiber across all trimesters (ranging from –0.90 g/day [–1.7, –0.1] to –1.2 g/day [–2.0, –0.3]). Women in the high-SES urban group had higher intakes of fiber and calcium, and lower intakes of SSBs compared to their low-SES counterparts in both rural and urban settings.
Conclusions
Although rurality was associated with greater SSBs and lower fiber intake, differences were modest. Low-SES was related to a poorer diet regardless of geography, highlighting the need for targeted interventions for both rural and urban low-SES pregnant women.
{"title":"Rural-urban differences in dietary intake across pregnancy trimesters: A multisite prospective cohort study","authors":"Alex H. Crisp PhD, Bethany Barone Gibbs PhD, Jacob B. Gallagher PhD, Katrina L. Wilhite PhD, Angela C. B. Trude PhD, Treah Haggerty PhD, Kara M. Whitaker PhD","doi":"10.1111/jrh.70085","DOIUrl":"10.1111/jrh.70085","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Poor diet during pregnancy compromises maternal–fetal health and may reflect broader environmental and structural inequities. This study investigated differences in dietary intake across pregnancy among rural and urban women in the United States and assessed whether socioeconomic status (SES) modified rural–urban differences.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>In this prospective study, pregnant women (<i>n</i> = 495; 22.4% rural) from three sites (Iowa, Pennsylvania, West Virginia) had dietary intake estimated via the 26-item Dietary Screener Questionnaire (DSQ) during each trimester. Rural was defined as Rural–Urban Commuting Area (RUCA) code ≥ 4. A SES score was derived using Principal Component Analysis of education, annual household income, and insurance type. Adjusted robust linear mixed-effects models (controlled for site, age, minority status, pre-pregnancy BMI) compared dietary intakes between rural and urban participants, with trimester and SES interactions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Compared to their urban counterparts, rural participants had higher predicted intakes of added sugars from sugar-sweetened beverages (SSBs) in the first (0.61 tsp eq/day; 95% CI: [0.04, 1.18]) and second trimesters (0.62 tsp eq/day [0.05, 1.21]), and less fiber across all trimesters (ranging from –0.90 g/day [–1.7, –0.1] to –1.2 g/day [–2.0, –0.3]). Women in the high-SES urban group had higher intakes of fiber and calcium, and lower intakes of SSBs compared to their low-SES counterparts in both rural and urban settings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Although rurality was associated with greater SSBs and lower fiber intake, differences were modest. Low-SES was related to a poorer diet regardless of geography, highlighting the need for targeted interventions for both rural and urban low-SES pregnant women.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12519541/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145287574","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Robert M. Bohler PhD, Ryan J. Lofaro PhD, Kenneth D. Smith PhD, J. Aaron Johnson PhD, Blerta Shehaj DrPH, Brian Kite CARES, CPS-AD, William A. Mase DrPH
Purpose
Recovery community centers (RCCs) offer a range of non-clinical services for individuals in recovery from substance use disorder (SUD). RCCs may play an important role in addressing rural service gaps. This study aims to increase our understanding of how rural RCCs address SUD, including how they serve individuals receiving medications for opioid use disorder (MOUD).
Methods
We conducted a mixed methods study consisting of pre-interview surveys and semi-structured interviews with 12 RCC directors in rural Georgia. The surveys examined organizational and participant characteristics and MOUD attitudes, and the interviews explored rural challenges, strategies to overcome challenges, and community collaborations. We conducted descriptive analyses of the survey data and analyzed interviews using thematic analysis.
Results
RCCs serviced an average of 41 new members per month and had an annual budget of $225,407. RCCs provided in-house or linked to many services that addressed social determinants of health. Most participants were in early recovery (<1 year), had criminal legal involvement, and lacked a high school education. In the thematic analysis, transportation and housing were commonly reported challenges. Additionally, RCCs provided essential treatment linkage, were the primary naloxone distributor in the area, and provided in-house mutual help organizations representing alternative recovery pathways. Collaboration with MOUD providers was minimal despite RCC efforts. Directors generally had positive attitudes towards MOUD.
Conclusion
Rural RCCs address a range of social determinants of health and may fill gaps in the SUD continuum of care, including harm reduction services, linkage to treatment, and expansion of recovery pathways.
{"title":"Bridging the gaps: Rural recovery community centers and their role in addressing substance use disorders","authors":"Robert M. Bohler PhD, Ryan J. Lofaro PhD, Kenneth D. Smith PhD, J. Aaron Johnson PhD, Blerta Shehaj DrPH, Brian Kite CARES, CPS-AD, William A. Mase DrPH","doi":"10.1111/jrh.70084","DOIUrl":"https://doi.org/10.1111/jrh.70084","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Recovery community centers (RCCs) offer a range of non-clinical services for individuals in recovery from substance use disorder (SUD). RCCs may play an important role in addressing rural service gaps. This study aims to increase our understanding of how rural RCCs address SUD, including how they serve individuals receiving medications for opioid use disorder (MOUD).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a mixed methods study consisting of pre-interview surveys and semi-structured interviews with 12 RCC directors in rural Georgia. The surveys examined organizational and participant characteristics and MOUD attitudes, and the interviews explored rural challenges, strategies to overcome challenges, and community collaborations. We conducted descriptive analyses of the survey data and analyzed interviews using thematic analysis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>RCCs serviced an average of 41 new members per month and had an annual budget of $225,407. RCCs provided in-house or linked to many services that addressed social determinants of health. Most participants were in early recovery (<1 year), had criminal legal involvement, and lacked a high school education. In the thematic analysis, transportation and housing were commonly reported challenges. Additionally, RCCs provided essential treatment linkage, were the primary naloxone distributor in the area, and provided in-house mutual help organizations representing alternative recovery pathways. Collaboration with MOUD providers was minimal despite RCC efforts. Directors generally had positive attitudes towards MOUD.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Rural RCCs address a range of social determinants of health and may fill gaps in the SUD continuum of care, including harm reduction services, linkage to treatment, and expansion of recovery pathways.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145272700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jessica Riley MS, Eileen M. Dryden PhD, Catherine M. P. Dawson MD, Meaghan A. Kennedy MD, MPH, Lauren R. Moo MD, Camilla B. Pimentel PhD, William Hung MD
{"title":"Weaving the rural health safety net: Voices from the field","authors":"Jessica Riley MS, Eileen M. Dryden PhD, Catherine M. P. Dawson MD, Meaghan A. Kennedy MD, MPH, Lauren R. Moo MD, Camilla B. Pimentel PhD, William Hung MD","doi":"10.1111/jrh.70080","DOIUrl":"10.1111/jrh.70080","url":null,"abstract":"","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145187395","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Peiyin Hung PhD, Jiani Yu PhD, Adiba B. Promiti MS, Berry A. Campbell MD, MFM, Nansi S. Boghossian PhD, Anirban Chatterjee MD, Bo Cai PhD, Jihong Liu ScD, the National COVID Cohort Collaborative Consortium
Purpose
To examine how COVID-19 public health emergency (PHE) exposure during pregnancy and telehealth use were associated with rural-urban and racial/ethnic differences in prenatal care initiation timing and frequency.
Methods
This retrospective cohort study of 349,682 pregnancies to birthing individuals who received both prenatal and intrapartum care at the 75 health systems in the United States contributing to the National Clinical Cohort Collaborative (N3C) from 6/1/2018 through 5/31/2022. Outcomes included prenatal care initiation timing and the number of prenatal care visits. Prenatal periods were categorized into 3 PHE exposure groups: (1) never, (2) partially, and (3) fully exposed to the PHE. The full-exposure group was further categorized into telehealth users and those with exclusively in-person care.
Findings
The full-exposure group with telehealth uptake had the earliest prenatal care initiation (median: 9 weeks [interquartile range: 7-13]) and the most visits (19 visits [12-20]). In contrast, the full-exposure group without telehealth use initiated care the latest (11 weeks [8-21]) and had the fewest visits (13 visits [6-22]). Rural-urban disparities persisted; however, telehealth users in both groups had earlier initiation and more visits. Racial and ethnic disparities in timeliness to initiation were most pronounced among the full-exposure group with telehealth (Black-White: adjusted hazard ratio [aHR]: 0.76, 95% CI, 0.70-0.83; Hispanic-White: aHR: 0.62, 95% CI, 0.58-0.68), compared to the full-exposure group with exclusively in-person care (Black-White: 0.95 [0.93-0.94]; Hispanic-White: 0.80 [0.80-0.81]).
Conclusions
Prenatal telehealth care improved early initiation but also exacerbated racial/ethnic disparities in the timeliness of prenatal care access. However, rural-urban disparities persisted.
{"title":"The roles of COVID-19 pandemic exposure and telehealth in prenatal care access for rural and racial minority communities in the United States: A retrospective cohort study","authors":"Peiyin Hung PhD, Jiani Yu PhD, Adiba B. Promiti MS, Berry A. Campbell MD, MFM, Nansi S. Boghossian PhD, Anirban Chatterjee MD, Bo Cai PhD, Jihong Liu ScD, the National COVID Cohort Collaborative Consortium","doi":"10.1111/jrh.70077","DOIUrl":"10.1111/jrh.70077","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>To examine how COVID-19 public health emergency (PHE) exposure during pregnancy and telehealth use were associated with rural-urban and racial/ethnic differences in prenatal care initiation timing and frequency.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective cohort study of 349,682 pregnancies to birthing individuals who received both prenatal and intrapartum care at the 75 health systems in the United States contributing to the National Clinical Cohort Collaborative (N3C) from 6/1/2018 through 5/31/2022. Outcomes included prenatal care initiation timing and the number of prenatal care visits. Prenatal periods were categorized into 3 PHE exposure groups: (1) never, (2) partially, and (3) fully exposed to the PHE. The full-exposure group was further categorized into telehealth users and those with exclusively in-person care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>The full-exposure group with telehealth uptake had the earliest prenatal care initiation (median: 9 weeks [interquartile range: 7-13]) and the most visits (19 visits [12-20]). In contrast, the full-exposure group <i>without</i> telehealth use initiated care the latest (11 weeks [8-21]) and had the fewest visits (13 visits [6-22]). Rural-urban disparities persisted; however, telehealth users in both groups had earlier initiation and more visits. Racial and ethnic disparities in timeliness to initiation were most pronounced among the full-exposure group with telehealth (Black-White: adjusted hazard ratio [aHR]: 0.76, 95% CI, 0.70-0.83; Hispanic-White: aHR: 0.62, 95% CI, 0.58-0.68), compared to the full-exposure group with exclusively in-person care (Black-White: 0.95 [0.93-0.94]; Hispanic-White: 0.80 [0.80-0.81]).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Prenatal telehealth care improved early initiation but also exacerbated racial/ethnic disparities in the timeliness of prenatal care access. However, rural-urban disparities persisted.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12481008/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145193700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Holly A. Andrilla MS, Sara C. Woolcock MPH, Lisa A. Garberson PhD, Janessa M. Graves PhD
Purpose
To compare the time and distance travel burden to access care for rural and urban Medicaid and commercially insured patients with opioid use disorder (OUD), and to understand where they travel for care.
Methods
We used Medicaid and the Health Care Cost Institute commercial insurance administrative claims data from 2019 to examine the travel burden to health care for adults ages 18 years and older with OUD. We calculated the one-way driving distance and travel time between the enrollee's residence and the provider's location. We used the 2013 Urban Influence Codes (UIC) to classify enrollees as either urban (UIC 1–2) or rural (UIC 3–12) based on the patient's residence county.
Findings
The median distance traveled for a visit by a rural Medicaid or rural commercially insured enrollee was more than twice as far as their urban counterparts (rural Medicaid: 45.9 miles, urban Medicaid: 13.9 miles; rural commercially insured: 32.9 miles, urban commercially insured: 12.4 miles). When we imputed zeros for care provided in the same ZIP Code as an enrollee's residence, these differences persisted. Rural Medicaid enrollees carried the largest travel burden spending an average of more than 60 min traveling to care, about 30 min more than rural commercially insured enrollees. Urban enrollees, regardless of insurance type received almost all of their care in an urban location while rural Medicaid and commercially insured patients traveled to an urban location for about half their visits.
Conclusions
Rural and urban Medicaid and commercially insured enrollees experience different time and distance travel burdens.
{"title":"Differences in the travel burden for care between rural and urban patients with opioid use disorder by insurance type","authors":"C. Holly A. Andrilla MS, Sara C. Woolcock MPH, Lisa A. Garberson PhD, Janessa M. Graves PhD","doi":"10.1111/jrh.70078","DOIUrl":"10.1111/jrh.70078","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>To compare the time and distance travel burden to access care for rural and urban Medicaid and commercially insured patients with opioid use disorder (OUD), and to understand where they travel for care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We used Medicaid and the Health Care Cost Institute commercial insurance administrative claims data from 2019 to examine the travel burden to health care for adults ages 18 years and older with OUD. We calculated the one-way driving distance and travel time between the enrollee's residence and the provider's location. We used the 2013 Urban Influence Codes (UIC) to classify enrollees as either urban (UIC 1–2) or rural (UIC 3–12) based on the patient's residence county.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>The median distance traveled for a visit by a rural Medicaid or rural commercially insured enrollee was more than twice as far as their urban counterparts (rural Medicaid: 45.9 miles, urban Medicaid: 13.9 miles; rural commercially insured: 32.9 miles, urban commercially insured: 12.4 miles). When we imputed zeros for care provided in the same ZIP Code as an enrollee's residence, these differences persisted. Rural Medicaid enrollees carried the largest travel burden spending an average of more than 60 min traveling to care, about 30 min more than rural commercially insured enrollees. Urban enrollees, regardless of insurance type received almost all of their care in an urban location while rural Medicaid and commercially insured patients traveled to an urban location for about half their visits.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Rural and urban Medicaid and commercially insured enrollees experience different time and distance travel burdens.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145187373","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rural-residing children have poor access to preventive health care due to geographic and socioeconomic issues, yet the role of adverse childhood experiences (ACEs) in preventive care for rural children has been understudied. It is hypothesized that among rural-residing children, those with ≥1 ACE will have lower utilization of preventive health care, with differences by sex.
Methods
Data for 425 (weighted n = 3,949,102) children (aged 9-17) residing in “nonmetropolitan” (2013 NCHS Urban-Rural Classification) were drawn from the 2022 National Health Interview Survey. Physician visit in the past 12 months (yes/no), dental visit in the past 12 months (yes/no), COVID-19, flu, and HPV vaccination (yes/no) were self-reported. Participants self-reported (yes/no) to 6 ACEs (high ACEs ≥1). Logistic regression estimated odds ratios and 95% confidence intervals for associations between ACEs and preventive health outcomes, adjusted for demographic and health care factors. This manuscript adheres to STROBE guidelines.
Findings
Children with ≥1 ACE were 81% more likely (OR = 1.81, 95% CI 1.04, 3.18) to receive a flu vaccination and 184% (OR = 2.84, 95% CI 1.66, 4.85) more likely to receive an HPV vaccination compared to children with 0 ACEs. No significant associations were found between ACEs and other preventive health care. Boys with ≥1 ACE had decreased odds (OR = 0.34, 95% CI 0.13, 0.94) of visiting a dentist, while girls with ≥1 ACE had increased odds (OR = 3.87, 95% CI 1.56, 9.60) of receiving an HPV vaccination.
Conclusions
Children with ≥1 ACE were more likely to receive a flu vaccination and HPV vaccination. The effect of ACEs on preventive health care may differ by sex among rural residents, yet additional research is warranted to inform prevention efforts in rural communities.
目的由于地理和社会经济问题，农村儿童难以获得预防性保健，但不良童年经历（ace）在农村儿童预防性保健中的作用尚未得到充分研究。假设在农村儿童中，ACE≥1的儿童对预防性保健的利用率较低，且存在性别差异。方法从2022年全国健康访谈调查中抽取425名（加权n = 3,949,102）名居住在“非大都市”（2013年NCHS城乡分类）的儿童（9-17岁）的数据。自我报告过去12个月的医生就诊（是/否）、过去12个月的牙科就诊（是/否）、COVID-19、流感和HPV疫苗接种（是/否）。参与者自我报告（是/否）至6个ace（高ace≥1）。经人口统计学和卫生保健因素调整后，Logistic回归估计了ace与预防性健康结果之间的比值比和95%置信区间。本手稿遵循STROBE指南。与无ACE的儿童相比，ACE≥1的儿童接受流感疫苗接种的可能性增加81% (OR = 1.81, 95% CI 1.04, 3.18)， HPV疫苗接种的可能性增加184% （OR = 2.84, 95% CI 1.66, 4.85）。ace与其他预防性保健之间未发现显著关联。ACE≥1的男孩看牙医的几率降低（OR = 0.34, 95% CI 0.13, 0.94），而ACE≥1的女孩接受HPV疫苗接种的几率增加（OR = 3.87, 95% CI 1.56, 9.60）。结论：ACE≥1的儿童更有可能接种流感疫苗和HPV疫苗。在农村居民中，ace对预防保健的影响可能因性别而异，但需要进一步的研究来为农村社区的预防工作提供信息。
{"title":"Adverse childhood experiences and preventive health care among rural US children: A cross-sectional examination of 2022 National Health Interview Survey data","authors":"Mary Labuhn MPH, Andrew Williams MPH, PhD","doi":"10.1111/jrh.70081","DOIUrl":"https://doi.org/10.1111/jrh.70081","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Rural-residing children have poor access to preventive health care due to geographic and socioeconomic issues, yet the role of adverse childhood experiences (ACEs) in preventive care for rural children has been understudied. It is hypothesized that among rural-residing children, those with ≥1 ACE will have lower utilization of preventive health care, with differences by sex.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Data for 425 (weighted n = 3,949,102) children (aged 9-17) residing in “nonmetropolitan” (2013 NCHS Urban-Rural Classification) were drawn from the 2022 National Health Interview Survey. Physician visit in the past 12 months (yes/no), dental visit in the past 12 months (yes/no), COVID-19, flu, and HPV vaccination (yes/no) were self-reported. Participants self-reported (yes/no) to 6 ACEs (high ACEs ≥1). Logistic regression estimated odds ratios and 95% confidence intervals for associations between ACEs and preventive health outcomes, adjusted for demographic and health care factors. This manuscript adheres to STROBE guidelines.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Findings</h3>\u0000 \u0000 <p>Children with ≥1 ACE were 81% more likely (OR = 1.81, 95% CI 1.04, 3.18) to receive a flu vaccination and 184% (OR = 2.84, 95% CI 1.66, 4.85) more likely to receive an HPV vaccination compared to children with 0 ACEs. No significant associations were found between ACEs and other preventive health care. Boys with ≥1 ACE had decreased odds (OR = 0.34, 95% CI 0.13, 0.94) of visiting a dentist, while girls with ≥1 ACE had increased odds (OR = 3.87, 95% CI 1.56, 9.60) of receiving an HPV vaccination.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Children with ≥1 ACE were more likely to receive a flu vaccination and HPV vaccination. The effect of ACEs on preventive health care may differ by sex among rural residents, yet additional research is warranted to inform prevention efforts in rural communities.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 4","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jrh.70081","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145181585","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This study examines the effect of nurse staffing (skill mix and flexibility) on the financial sustainability, efficiency, and quality of care in Pennsylvania's critical access hospitals (CAHs) from 2000 to 2023.
Methods
This retrospective longitudinal study utilized unbalanced panel data from Pennsylvania's CAHs (n = 357 hospital-year observations). We employed 2-way fixed effects regression models to analyze the relationship between nurse staffing variables (skill mix and flexibility) and hospital performance outcomes (total margin, cost per adjusted discharge [CPAD], cost per adjusted patient day [CPPD], average length of stay [ALOS], and readmission index). We controlled for hospital-specific, socioeconomic, and demographic factors.
Results
A higher registered nurse (RN) skill mix significantly reduced log(winsorized(CPAD)) (β = −0.495, p<0.01) and log(ALOS) (β = −0.571, p<0.01), indicating improved cost efficiency and patient throughput. Increased nurse flexibility significantly increased log(ALOS) (β = 0.315, p<0.05) but reduced the readmission index (β = −0.895, p<0.01). No significant associations were found between skill mix and total margin, CPPD, or readmission index, nor between flexibility and financial metrics.
Discussion
A richer RN skill mix enhances efficiency by reducing costs and length of stay, while increased staffing flexibility reduces readmissions but extends ALOS. These findings emphasize the complex interplay between nurse staffing and CAH performance. Strategic management of RN skill mix and flexibility is crucial for optimizing resource use and improving patient outcomes in rural hospitals.
Conclusions
Policymakers and CAH administrators should strategically balance RN expertise and staffing flexibility to ensure both financial viability and clinical excellence in these essential rural health care institutions.
{"title":"Skill mix versus flexibility: Decoding nurse staffing impacts on critical access hospitals","authors":"Dinesh R. Pai PhD, Esmaeil Bahalkeh PhD","doi":"10.1111/jrh.70075","DOIUrl":"https://doi.org/10.1111/jrh.70075","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>This study examines the effect of nurse staffing (skill mix and flexibility) on the financial sustainability, efficiency, and quality of care in Pennsylvania's critical access hospitals (CAHs) from 2000 to 2023.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective longitudinal study utilized unbalanced panel data from Pennsylvania's CAHs (n = 357 hospital-year observations). We employed 2-way fixed effects regression models to analyze the relationship between nurse staffing variables (skill mix and flexibility) and hospital performance outcomes (total margin, cost per adjusted discharge [CPAD], cost per adjusted patient day [CPPD], average length of stay [ALOS], and readmission index). We controlled for hospital-specific, socioeconomic, and demographic factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A higher registered nurse (RN) skill mix significantly reduced log(winsorized(CPAD)) (<i>β</i> = −0.495, <i>p</i><0.01) and log(ALOS) (<i>β</i> = −0.571, <i>p</i><0.01), indicating improved cost efficiency and patient throughput. Increased nurse flexibility significantly increased log(ALOS) (<i>β</i> = 0.315, <i>p</i><0.05) but reduced the readmission index (<i>β</i> = −0.895, <i>p</i><0.01). No significant associations were found between skill mix and total margin, CPPD, or readmission index, nor between flexibility and financial metrics.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Discussion</h3>\u0000 \u0000 <p>A richer RN skill mix enhances efficiency by reducing costs and length of stay, while increased staffing flexibility reduces readmissions but extends ALOS. These findings emphasize the complex interplay between nurse staffing and CAH performance. Strategic management of RN skill mix and flexibility is crucial for optimizing resource use and improving patient outcomes in rural hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Policymakers and CAH administrators should strategically balance RN expertise and staffing flexibility to ensure both financial viability and clinical excellence in these essential rural health care institutions.</p>\u0000 </section>\u0000 </div>","PeriodicalId":50060,"journal":{"name":"Journal of Rural Health","volume":"41 3","pages":""},"PeriodicalIF":2.7,"publicationDate":"2025-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jrh.70075","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144910186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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