Rural health care providers in the United States

A qualitative study of naturopathy in rural practice: a focus upon naturopaths' experiences and perceptions of rural patients and demands for their services

BACKGROUND

Complementary and alternative medicine (CAM) use--of which naturopathy constitutes a significant proportion--accounts for approximately half of all health consultations and half of out-of-pocket expenditure in Australia. Data also suggest CAM use is highest amongst rural Australians. Unfortunately little is known about the grass-roots reality of naturopathy or other CAM use in rural regions.

METHODS

Semi-structured interviews were conducted with 20 naturopaths practising in the Darling Downs region of South-East Queensland to assess their perceptions and experiences of rural patients and demand for their services.

RESULTS

Naturopaths described strong demand in rural areas for their services and perceived much of this demand as attributable to cultural traits in rural communities that served as pull factors for their naturopathic services. Such perceived traits included a cultural affinity for holistic approaches to health and disease and the preventive philosophy of naturopathy and an appreciation of the core tenet of naturopathic practice to develop closer therapeutic relationships. However, cost and a rural culture of self-reliance were seen as major barriers to naturopathic practice in rural areas.

CONCLUSIONS

Demand for naturopathic services in rural areas may have strong underlying cultural and social drivers. Given the apparent affinity for and increasingly large role played by CAM services, including naturopathic medicine, in rural areas it is imperative that naturopathic medicine and the CAM sector more broadly become a core focus of rural health research.

Recruitment of rural physicians in a diabetes internet intervention study: overcoming challenges and barriers

PURPOSE

This paper highlights a descriptive study of the challenges and lessons learned in the recruitment of rural primary care physicians into a randomized clinical trial using an Internet-based approach.

METHODS

A multidisciplinary/multi-institutional research team used a multilayered recruitment approach, including generalized mailings and personalized strategies such as personal office visits, letters, and faxes to specific contacts. Continuous assessment of recruitment strategies was used throughout study in order to readjust strategies that were not successful.

RESULTS

We recruited 205 primary care physicians from 11 states. The 205 lead physicians who enrolled in the study were randomized, and the overall recruitment yield was 1.8% (205/11231). In addition, 8 physicians from the same practices participated and 12 nonphysicians participated. The earlier participants logged on to the study Web site, the greater yield of participation. Most of the study participants had logged on within 10 weeks of the study.

CONCLUSION

Despite successful recruitment, the 2 major challenges in recruitment in this study included defining a standardized definition of rurality and the high cost of chart abstractions. Because many of the patients of study recruits were African American, the potential implications of this study on the field of health disparities in diabetes are important.

Telehealth ethics

The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.

Quality of care and in-hospital outcomes in patients with coronary heart disease in rural and urban hospitals (from Get With the Guidelines-Coronary Artery Disease Program)

Previous studies have suggested that patients with coronary artery disease (CAD) in rural areas may have worse outcomes due to limited availability of specialists, fewer resources, and less institutional funding. Data were collected from hospitals participating in the Get With the Guidelines-Coronary Artery Disease Program (GWTG-CAD) from January 2000 to December 2008. In-hospital outcomes and quality of care were stratified by care at rural versus urban hospitals. Multivariate logistic regression analysis was used to determine the association of rural locale with in-hospital mortality, length of stay, and compliance with the GWTG-CAD performance measurements including (1) early aspirin use, (2) smoking cessation counseling and discharge prescriptions of (3) aspirin, (4) angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers for left ventricular systolic dysfunction, (5) beta-blockers, and (6) lipid-lowering therapy and a composite of all 6 measurements. Data were collected from 22,096 patients at 71 rural centers and 329,938 patients at 477 urban centers. Unadjusted rates of compliance with performance measurements were lower in rural (range 82.4% to 90.5%) compared to urban (range 81.3% to 95.0%) hospitals including the composite (74.7% vs 80.6%, p <0.0001). In multivariate analysis, rural status was not independently associated with lower compliance with any of the performance measurements. Unadjusted mortality rates were higher in rural versus urban hospitals (5.7% vs 4.4%, p <0.0001), but this was not significant in multivariate analysis (odds ratio 1.05, 95% confidence interval 0.87 to 1.26). In conclusion, within the GWTG-CAD quality improvement initiative, patients with CAD treated at rural hospitals receive similar quality of care and have similar outcomes as those at urban centers.

Perceptions of physical activity and motivational interviewing among rural African-American women with type 2 diabetes

PURPOSE

Motivational interviewing (MI), a patient-centered behavioral counseling style, is a common behavioral intervention strategy. Because intervention outcomes are highly dependent on patient responsiveness to intervention strategy, we evaluated MI perceptions among rural African American women with type 2 diabetes before a physical activity intervention.

METHODS

Four moderator-led focus groups were conducted with patients aged 21-50 years who had never participated in a MI intervention and who receive diabetes care in a rural community health center. Patients were asked to share their perceptions of an MI consultation after viewing a DVD-based example. They were also asked to discuss their physical activity perceptions and readiness. A comprehensive content analysis based on grounded theory was performed by two raters in order to identify main themes.

MAIN FINDINGS

Although patients (n = 31) had an appreciation for physical activity benefits and high levels of physical activity readiness, themes related to physical activity barriers and lack of motivation were pervasive. Patients regarded the MI consultation as an effective health communication but the patient-centeredness of the approach was negatively perceived. Compared with MI, patients agreed that more traditional paternalistic approaches (i.e., physician-led interactions) were more representative of "good counseling" and more familiar to them. Patients shared deeply about personal experiences and provided words of encouragement to one another.

CONCLUSION

Physical activity interventions including rural African-American women should include activities that focus on barrier management and increasing motivation. MI might be an appropriate behavioral counseling model when added to a more traditional cognitive-behavioral physical activity intervention that is group-based and tailored to patients' communication preferences and the clinical setting.

Why doctors choose small towns: a developmental model of rural physician recruitment and retention

Shortages of health care professionals have plagued rural areas of the USA for more than a century. Programs to alleviate them have met with limited success. These programs generally focus on factors that affect recruitment and retention, with the supposition that poor recruitment drives most shortages. The strongest known influence on rural physician recruitment is a "rural upbringing," but little is known about how this childhood experience promotes a return to rural areas, or how non-rural physicians choose rural practice without such an upbringing. Less is known about how rural upbringing affects retention. Through twenty-two in-depth, semi-structured interviews with both rural- and urban-raised physicians in northeastern California and northwestern Nevada, this study investigates practice location choice over the life course, describing a progression of events and experiences important to rural practice choice and retention in both groups. Study results suggest that rural exposure via education, recreation, or upbringing facilitates future rural practice through four major pathways. Desires for familiarity, sense of place, community involvement, and self-actualization were the major motivations for initial and continuing small-town residence choice. A history of strong community or geographic ties, either urban or rural, also encouraged initial rural practice. Finally, prior resilience under adverse circumstances was predictive of continued retention in the face of adversity. Physicians' decisions to stay or leave exhibited a cost-benefit pattern once their basic needs were met. These results support a focus on recruitment of both rural-raised and community-oriented applicants to medical school, residency, and rural practice. Local mentorship and "place-specific education" can support the integration of new rural physicians by promoting self-actualization, community integration, sense of place, and resilience. Health policy efforts to improve the physician workforce must address these complexities in order to support the variety of physicians who choose and remain in rural practice.

Trends in rural and urban deliveries and vaginal births: California 1998-2002

CONTEXT

Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making.

PURPOSE

Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings.

METHODS

Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers.

FINDINGS

Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different.

CONCLUSIONS

Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Access to cancer services for rural colorectal cancer patients

CONTEXT

Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas.

PURPOSE

To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation.

METHODS

Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996.

FINDINGS

Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles.

CONCLUSIONS

Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Interventions for increasing the proportion of health professionals practising in rural and other underserved areas

BACKGROUND

The inequitable distribution of health professionals, within and between countries, poses an important obstacle to the achievement of optimal attainable health for all.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas.

SEARCH STRATEGY

We searched the specialised register of the Cochrane Effective Practice and Organisation of Care Group (up to July 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (up to July 2007), MEDLINE (1966 to July 2007), EMBASE (1988 to July 2007), CINAHL (1982 to July 2007) and LILACS (up to July 2007). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work.

SELECTION CRITERIA

Randomised controlled trials, controlled trials (not strictly randomised), controlled before-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial or regulatory strategies) on the recruitment and/or retention of health professionals in under-served areas.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened titles and abstracts obtained from the search in order to identify potentially relevant studies.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There are no studies in which bias and confounding are minimised to support any of the interventions that have been implemented to address the inequitable distribution of health care professionals. Well-designed studies are needed to confirm or refute findings of various observational studies regarding educational, financial, regulatory and supportive interventions that may influence health care professionals' choice to practice in underserved areas. Governments and educators should ensure that where interventions are implemented this is done within the context of a well-planned study so that the true effects of these measures on recruitment and long term retention can be determined in various settings.

Trends in perinatal and infant health disparities between rural American Indians and Alaska natives and rural Whites

OBJECTIVES

We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time.

METHODS

We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births.

RESULTS

Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985-1987, 36.3%; 1995-1997, 26.3%) and postneonatal death (1985-1987, 7.1 per 1000; 1995-1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985-1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995-1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985-1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995-1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted.

CONCLUSIONS

Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group.

Expanding the role of nurse practitioners: effects on rural access to care for injured workers

CONTEXT

A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician.

PURPOSE

The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing.

METHODS

Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group.

FINDINGS

NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas.

CONCLUSIONS

Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.

United States rural hospital quality in the Hospital Compare database-accounting for hospital characteristics

BACKGROUND

Rural hospitals in the United States have demonstrated lower adherence to evidence based guidelines than their urban counterparts in national public reporting initiatives. We compared the quality of rural hospitals participating in a public reporting initiative to that of their urban counterparts using Hospital Compare, a new national database containing process measures.

METHODS

Cross-sectional analyses of hospitals participating in Hospital Compare in 2005, evaluating percent adherence to guidelines for 10 processes of care for acute myocardial infarction (AMI), heart failure (HF), and community-acquired pneumonia (CAP) using multivariable linear regression analyses.

RESULTS

Participating rural hospitals demonstrated lower adherence to evidence based guidelines in MI and HF quality measures (p<0.05) and higher adherence to prescribing antibiotics in a timely manner in CAP (p<0.05). Differences increased with bed size (F test for linear trend, p<0.05). After adjustment, the trends demonstrating lower adherence persisted in 6 AMI and HF measures and higher adherence in 1 CAP measure in spite of a disproportionate number of drop-outs among lower performing urban hospitals.

CONCLUSIONS

Participating rural hospitals had lower performance than their urban counterparts. As the rural/urban quality gap varies by condition, bed size, and participation, we recommend comparing performance across a wide variety of condition-specific measures to enable targeted quality improvement.

Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication

PURPOSE

To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication.

METHOD

Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed.

RESULTS

Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130).

CONCLUSIONS

All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.

Urban-rural flows of physicians

CONTEXT

Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies.

PURPOSE

To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs.

METHODS

Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003.

FINDINGS

Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003.

CONCLUSIONS

The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population.

Health communications in rural America: lessons learned from an arthritis campaign in rural Arkansas

CONTEXT

Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas.

PURPOSE

To review findings and lessons learned from a rural health communications campaign.

METHODS

The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign.

FINDINGS

Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints.

CONCLUSION

Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.

Differential effects of economic factors on specialist and family physician distribution in Illinois: a county-level analysis

CONTEXT

Uneven distribution of physicians across geographic areas of the United States remains a significant problem that may have implications for health.

PURPOSE

To develop a statistical model of physician distribution in Illinois counties that predicts where specialists and family physicians practice, and to suggest policy strategies for alleviating shortages.

METHODS

Three-stage least squares, an estimation technique, was utilized to create a model where 19 variables suggested by the literature predicted specialist and family physician distribution within geographic areas, specifically counties in Illinois.

FINDINGS

Non-economic quality of life factors seemed to be related to specialist physician practice location (eg, percent graduates and professionals located in the area, public school expenditures, nonpublic teachers per capita, and sufficient hospital beds). In contrast, economic factors were related to family physician practice location (eg, per capita income, total population [an indicator of demand for medical care]).

CONCLUSION

Indicators suggest quality of life factors appear important in specialist location and retention, whereas indicators suggest economic factors appear important to family physician location and retention. Subsidies are suggested to encourage more family physicians to locate and remain in rural areas.

Physician Perceptions of Practice Environment and Professional Satisfaction in California: From Urban to Rural

CONTEXT

Few studies have systematically examined the experience of rural practice from the physician's perspective or included physicians from an array of specialties, particularly non-primary care.

PURPOSE

To better understand differences between rural and urban physicians in perceptions of their practice environment.

METHODS

In 2001-2002, self-administered questionnaires were sent to a probability sample of primary care and specialist physicians identified from the American Medical Association's Physician masterfile in California. Logistic regression was performed to model the effect practice location had on key variables, controlling for physician demographics, specialty, and the insurance profile of the physician's patients.

FINDINGS

Completed questionnaires were obtained from 1,365 of 2,240 eligible urban physicians (61%), and 398 of 632 rural physicians (63%). Among primary care physicians, those in rural areas defined as nonadjacent or small non-metropolitan counties were the least likely to report pressures to see more patients, limit referrals, and limit treatment options. In contrast, among specialists, those in rural areas within metropolitan areas (or in large adjacent non-metropolitan counties) were more likely than urban specialists to report practice pressures. Although rural physicians in both primary care and specialist fields were more likely than urban physicians to report difficulty attracting new physicians to their communities, they perceived their overall practice climate to be better. Physicians in the nonadjacent-or-small non-metropolitan category were the most satisfied, but specialists in the nonadjacent-or-small non-metropolitan category were the least satisfied.

CONCLUSION

Physicians in rural California appear to have maintained a greater sense of clinical autonomy and higher professional satisfaction compared with their urban counterparts.

Gender differences in rural and urban practice location among mid-level health care providers

CONTEXT

Mid-level providers comprise an increasing proportion of the health care workforce and play a key role in providing health services in rural and underserved areas. Although women comprise the majority of mid-level providers, they are less likely to work in a rural area than men. Maldistribution of health providers between urban and rural practices is an important issue influencing health care.

PURPOSE

To gain further insight into this issue, this study examined how mid-level practice location varied by gender.

METHODS

Semistructured interviews were conducted with a purposive sample of 55 nurse practitioners, physician assistants, and nurse anesthetists in New York State and Pennsylvania.

FINDINGS

Results suggest that family and community ties played a key role in influencing practice location. Men were particularly drawn to the broad scope of practice and autonomous nature of rural practice. Women in rural areas enjoyed the more personable environment and greater respect from colleagues and patients. Both male and female rural providers preferred their location because there were fewer turf issues, while some women were concerned about being professionally isolated. Meanwhile, both men and women enjoyed the fast pace, specialization, and greater opportunities urban areas had to offer.

CONCLUSIONS

Recruitment efforts should focus on candidates from rural areas and not underestimate the impact of family in decisions about work location.

Factors in recruiting and retaining health professionals for rural practice

CONTEXT

Rural communities, often with complex health care issues, have difficulty creating and sustaining an adequate health professional workforce.

PURPOSE

To identify factors associated with rural recruitment and retention of graduates from a variety of health professional programs in the southwestern United States.

METHODS

A survey collecting longitudinal data was mailed to graduates from 12 health professional programs in New Mexico. First rural and any rural employment since graduation were outcomes for univariate analyses. Multivariate analysis that controlled for extraneous variables explored factors important to those who took a first rural position, stayed rural, or changed practice locations.

FINDINGS

Of 1,396 surveys delivered, response rate was 59%. Size of childhood town, rural practicum completion, discipline, and age at graduation were associated with rural practice choice (P < .05). Those who first practiced in rural versus urban areas were more likely to view the following factors as important to their practice decision: community need, financial aid, community size, return to hometown, and rural training program participation (P < .05). Those remaining rural versus moving away were more likely to consider community size and return to hometown as important (P < .05). Having enough work available, income potential, professional opportunity, and serving community health needs were important to all groups.

CONCLUSION

Rural background and preference for smaller sized communities are associated with both recruitment and retention. Loan forgiveness and rural training programs appear to support recruitment. Retention efforts must focus on financial incentives, professional opportunity, and desirability of rural locations.

The role of telemedicine in fostering health-care innovations to address problems of access, specialty shortages and changing patient care needs

The integration of advanced technologies into health-care services promises to aid society in its transition to a coordinated, systems approach which is focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality and patient safety. By incorporating such technologies, clinicians will be able to manage the growing volumes of medical information, research and decision support analytical tools. The deployment of advanced technologies will minimize the barriers of distance and geography to enhance access and facilitate the delivery of integrated health care. This will support and enhance the goals of the US federal Healthy People 2010 initiative.

Comparative analysis of urban and rural nursing workforce shortages in Nebraska hospitals

Current workforce models that rely on economic indicators have seriously underestimated the rural RN shortage and its impact on rural hospitals. This cross-sectional study developed an algorithm using the concept of need and applied it to health service demand data in 66 counties of a midwestern state (1993-2002) to determine trends in RN shortages between urban and rural areas. Results showed that rural areas consistently had the largest gap between predicted need for RNs and numbers employed and that the rural RN shortages were significantly greater than in urban areas. This study suggests that adequate and geographically specific targets of RN need are essential, especially for rural areas, because of policy implications for rural hospital staffing and workforce planning. Inadequate workforce targets perpetuate the shortage, especially in rural areas, and exacerbate the very reasons that RNs leave over concerns for patient safety, inadequate staffing, and job dissatisfaction.

Rural residents with disabilities confront substantial barriers to obtaining primary care

OBJECTIVE

To learn about the health care experiences of rural residents with disabilities.

STUDY SETTING

Rural areas in Massachusetts and Virginia.

STUDY DESIGN

Local centers for independent living recruited 35 adults with sensory, physical, or psychiatric disabilities to participate in four focus group interviews.

DATA COLLECTION METHODS

Verbatim transcripts of interviews were reviewed to identify major themes.

PRINCIPAL FINDINGS

Interviewees described the many well-recognized impediments to health care in rural America; disability appears to exacerbate these barriers. Interviewees reported substantial difficulties finding physicians who understand their disabilities and sometimes feel that they must teach their local doctors about their underlying conditions. Interviewees described needing to travel periodically to large medical centers to get necessary specialty care. Many are poor and are either uninsured or have Medicaid coverage, complicating their searches for willing primary care physicians. Because many cannot drive, they face great difficulties getting to their local doctor and especially making long trips to urban centers. Available public transportation often is inaccessible and unreliable. Physicians' offices are sometimes located in old buildings that do not have accessible entrances or equipment. Based on their personal experiences, interviewees perceive that rural areas are generally less sensitive to disability access issues than urban areas.

CONCLUSIONS

Meeting the health care needs of rural residents with disabilities will require interventions beyond health care, involving transportation and access issues more broadly.

The use of insulin declines as patients live farther from their source of care: results of a survey of adults with type 2 diabetes

Background

Although most diabetic patients do not achieve good physiologic control, patients who live closer to their source of primary care tend to have better glycemic control than those who live farther away. We sought to assess the role of travel burden as a barrier to the use of insulin in adults with diabetes

Methods

781 adults receiving primary care for type 2 diabetes were recruited from the Vermont Diabetes Information System. They completed postal surveys and were interviewed at home. Travel burden was estimated as the shortest possible driving distance from the patient's home to the site of primary care. Medication use, age, sex, race, marital status, education, health insurance, duration of diabetes, and frequency of care were self-reported. Body mass index was measured by a trained field interviewer. Glycemic control was measured by the glycosolated hemoglobin A1C assay.

Results

Driving distance was significantly associated with insulin use, controlling for the covariates and potential confounders. The odds ratio for using insulin associated with each kilometer of driving distance was 0.97 (95% confidence interval 0.95, 0.99; P = 0.01). The odds ratio for using insulin for those living within 10 km (compared to those with greater driving distances) was 2.29 (1.35, 3.88; P = 0.02).

Discussion

Adults with type 2 diabetes who live farther from their source of primary care are significantly less likely to use insulin. This association is not due to confounding by age, sex, race, education, income, health insurance, body mass index, duration of diabetes, use of oral agents, glycemic control, or frequency of care, and may be responsible for the poorer physiologic control noted among patients with greater travel burdens.

Surgery in rural America

Despite recent increased attention to ailing health-care systems in rural America, policy makers have paid relatively little attention to the status of rural surgery. This paucity of attention is rooted in a combination of poor communication and incomplete knowledge. Unfortunately, the scarce dialogue between advocates of rural surgery and policy makers has been driven largely by anecdotes and generalizations. What is needed as a foundation for productive discourse is evidence-based objective observations regarding important issues and concerns related to rural surgical practice. This article reviews our current understanding of several of these issues; namely, the adequacy of the current and future surgical workforce, preparation for rural practice, professional isolation, rural surgical quality, and the critical interplay between rural surgeons and local systems of care in which they function. The intent of this article is to stimulate further inquiry that will create a foundation for meaningful dialogue between rural surgeons, surgical leaders, and health-care policy makers.

Technology, job satisfaction, and retention: rural mental health practitioners

CONTEXT

Job satisfaction as it relates to retention of mental health professionals is a major problem in rural areas. Several authors have suggested that technology can positively influence job satisfaction and thus improve retention.

OBJECTIVES

This study examined technology use and technology expertise in relationship to job satisfaction. It is based on a theoretical framework that asserts as technology use increases, communication among providers and access to educational and consultative resources increase as well, resulting in a boost in professional support and a reduction in isolation.

METHODS

Surveys were sent to 320 providers in rural southeast Ohio; 163 returned usable surveys.

FINDINGS

There was a statistically significant relationship between the combination of technology use and expertise and job satisfaction. Use alone, however, was not significant. Despite the fact that over 90% of respondents had access to both a computer and the Internet, just 45% used technology to communicate with peers and nearly 96% indicated that they never or rarely used the Internet for educational programs.

CONCLUSIONS

The results challenge the assertion that technology plays a major role in job satisfaction and rural retention since access and perceived expertise did not guarantee technology usage. Decisions to stay or leave a rural practice involve a complex array of factors. Technology, with its ability to link providers to resources outside the geographic bounds of an individual's practice, may play a role, but since its adoption can be costly in both time and money, future studies need to determine its place in the retention model.

Practice locations of graduates of family physician residency and nurse practitioner programs: considerations within the context of institutional culture and curricular innovation through Titles VII and VIII

BACKGROUND

Studies have described the aggregate results of federal funding for health professions education at the national level, but analysis of the long-term impact of institutional participation in these programs has been limited.

PURPOSE

To describe and assess federally supported curricular innovations at East Tennessee State University designed to promote family medicine and nurse practitioner graduate interest in rural and underserved populations.

METHODS

Descriptive analysis of a survey to determine practice locations of nurse practitioner graduates (1992-2002) and graduates of 3 family medicine residencies (1978-2002). Graduates' (N = 656) practice locations were documented using specific federal designations relating to health professions shortages and rurality.

RESULTS

Overall, 83% of family medicine residency and 80% of nurse practitioner graduates selected practice locations in areas with medically underserved or health professions shortage designations; 48% of family physicians and 38% of nurse practitioners were in rural areas.

CONCLUSIONS

Graduates who study in an educational setting with a mission-driven commitment to rural and community health and who participate in curricular activities designed to increase their experience with rural and underserved populations choose, in high numbers, to care for these populations in their professional practice.

Advances in rural medical education in three countries: Canada, the United States and Australia

INTRODUCTION

This article documents a number of rural medical education initiatives in Australia, Canada and the United States. A typology is created reflecting the centrality the rural mandate and characterizing different features of each school's program. Interviews with school officials are drawn on to reflect the challenges these schools face.

METHOD

Seven schools noted for their rural programs were selected from the three countries and interviews were conducted with senior officials. The interview data was supplemented by published material on the schools.

RESULTS

The Typology: Three kinds of school are distinguished: Mixed Urban/Rural Schools (University of Washington, US, the University of British Columbia, Canada and Flinders University, Australia); DeFacto Rural Schools (University of New Mexico, US and Memorial University, Canada) and Stand Alone Rural Schools (James Cook University, Australia and the Northern Ontario School of Medicine, Canada). The Pipeline Approach: All of the schools adopted in varying degrees a pipeline approach to meeting the need for rural doctors focusing on: (a) early recruitment; (b) admissions; (c) locating clinical education in rural settings; (d) rural health focus to curriculum; and (e) support for rural practice.

CONCLUSION

The analysis does not strongly favor one model over others, although the Stand-Alone Rural schools had more opportunities to adopt innovative curricula reflecting rural health issues and to foster positive views of rural practice. Government funding targeting rural health needs will remain critical in the development of all these programs.

Rural definitions for health policy and research

The term "rural" suggests many things to many people, such as agricultural landscapes, isolation, small towns, and low population density.However, defining "rural" for health policy and research purposes requires researchers and policy analysts to specify which aspects of rurality are most relevant to the topic at hand and then select an appropriate definition. Rural and urban taxonomies often do not discuss important demographic, cultural, and economic differences across rural places-differences that have major implications for policy and research. Factors such as geographic scale and region also must be considered. Several useful rural taxonomies are discussed and compared in this article. Careful attention to the definition of "rural" is required for effectively targeting policy and research aimed at improving the health of rural Americans.

The impact on rural New Mexico of a family medicine residency

PURPOSE

To determine the impact on rural New Mexico of the large, decentralized University of New Mexico (UNM) family medicine residency.

METHOD

A cross-sectional study was conducted of all 317 residency's graduates from 1974 to 2004. Location of current practice was correlated with the residents' gender, ethnicity, medical school of origin, and whether most training took place in the urban program or one of three rural programs. The residency's impact on rural communities was assessed.

RESULTS

There was no significant gender difference between graduates who went into urban or rural practice. Compared with non-minority graduates, a significantly greater percentage of ethnic minority graduates were in rural and urban New Mexico practices and fewer in out-of-state practices. A greater percentage of graduates who had been medical students in New Mexico practiced in both rural and urban New Mexico areas compared with graduates of out of state medical schools. Finally, a greater percentage of graduates from the three rural family medicine residencies remained in the state and practiced in rural areas compared with graduates from the urban program. The graduates' contributions to the school of medicine and to rural New Mexico are described.

CONCLUSIONS

Graduates of UNM's family medicine residency have contributed significantly to the state's rural health workforce. Ethnic minority status, graduation from New Mexico's medical school, and training in one of the three rurally based residencies favored in-state and rural retention, while gender had no significant effect. The rural orientation of the residencies offered rural communities economic benefits.

An evaluation of the Rural Medical Education Program of the State University Of New York Upstate Medical University, 1990-2003

PURPOSE

The Rural Medical Education Program (RMED) of the State University of New York (SUNY) Upstate Medical University is a 36-week clinical experience in rural communities for medical students that began in 1989. The authors sought to assess RMED's success in providing a valuable educational experience for students that assists rural communities recruit physicians.

METHOD

In 2004, the authors used the Physician Masterfiles of the American Medical Association to compare practice locations of SUNY Upstate graduates who completed RMED with those who did not; surveyed former RMED students to assess their satisfaction with their practice location and the importance of RMED in helping them choose a location; interviewed hospital administrators in communities that have hosted RMED students to understand the impact of RMED on host communities; and compared United States Medical Licensing Examination Step 2 scores of RMED students with those of non-RMED students to evaluate educational attainment.

RESULTS

A greater percentage of former RMED students practiced in rural locations [22/86 (26%)] than did non-RMED students [95/1,307 (7%)]. Ninety-one percent (69/76) of former RMED students were satisfied with their location, and 84% (64/76) believed that RMED was important in helping them choose a location. Hospital administrators viewed the program highly because it helped them recruit physicians and benefitted their medical staff. RMED students had higher adjusted mean Step 2 scores than did non-RMED students (212.3 versus 199.1).

CONCLUSION

The RMED program has successfully met its goals of providing a valuable educational experience for medical students and assisting rural communities recruit physicians.

Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?

CONTEXT

Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades.

METHODS

This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival.

FINDINGS

Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns.

CONCLUSIONS

At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Perceived barriers to nurse practitioner practice in rural settings

CONTEXT

Rural residents experience the same incidence of acute illness as urban populations and have higher levels of chronic illness. Overall, access to adequate rural health care is limited. Nurse practitioners (NPs) have been identified as safe, cost-effective providers in meeting these challenges in rural settings.

PURPOSE

This replication study was conducted to examine NP perceptions of barriers to rural practice in Minnesota. Findings were compared to earlier studies to examine issues that have persisted over time.

METHODS

A Barriers to Practice checklist was mailed to NPs from the database of the Board of Nursing of a midwestern state. Rural NPs (n = 191) identified and described barriers to practice and rated the overall restrictiveness of their practice.

FINDINGS

Barriers to practice were perceived to be prevalent. Persisting barriers continued to stand in the way of full utilization of NP roles. Lack of understanding of NP roles on the part of the public and other health professionals has been particularly problematic over time. Key issues in 2001 were low salaries, lack of adequate office space, and a limited peer network. Perceived restrictiveness of the practice climate, gauged as somewhat restrictive, remained unchanged between 1996 and 2001.

CONCLUSIONS

NPs have an excellent history of meeting rural primary health care needs. Enhancing the NP work environment could prove instrumental to retaining these professionals in the work force and thereby contribute to improved access and quality of care in underserved rural communities.

Recruitment of rural health care providers: a regional recruiter strategy

CONTEXT

Access to care in rural areas is a major problem. Despite more than 20% of the US population residing in these areas, only 9% of physicians practice there. Extensive research has documented multiple issues that affect where physicians decide to locate and maintain practices. Creative strategies have been used to influence these recruitment and retention decisions. An emerging strategy, borne out of the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), effectively uses a targeted regional approach to assist rural communities and health care facilities in assessing health care needs and recruiting primary care providers.

PURPOSE

This article examines the issues surrounding recruitment and retention of primary care providers to rural areas and describes the experiences of the regional recruitment strategy in several states and in particular in the Mississippi Delta region of Arkansas.

METHODS

A case study approach is used to examine the targeted regional recruiter strategy in the Mississippi Delta region of Arkansas.

FINDINGS

The regional recruiter strategy, which combines traditional recruitment efforts with community development activities, has been successful in recruiting health care providers to rural communities. The cost-effective strategy can be easily replicated in other rural states.

CONCLUSIONS

Community factors affect provider decisions on practice locations. Addressing community factors in recruitment efforts through community development activities may increase their success.

Using the theory of reasoned action to model retention in rural primary care physicians

CONTEXT

Much research attention has focused on medical students', residents', and physicians' decisions to join a rural practice, but far fewer studies have examined retention of rural primary care physicians.

PURPOSE

The current review uses Fishbein and Ajzen's Theory of Reasoned Action (TRA) to organize the literature on the predictors and correlates of retention of rural practicing physicians. TRA suggests turnover behavior is directly predicted by one's turnover intentions, which are, in turn, predicted by one's attitudes about rural practice and perceptions of salient others' (eg, spouse's) attitudes about rural practice and rural living.

METHODS

Narrative literature review of scholarship in predicting and understanding predictors and correlates of rural physician retention.

FINDINGS

The TRA model provides a useful conceptual model to organize the literature on rural physician retention. Physicians' subjective norms regarding rural practice are an important source of influence in the decision to remain or leave one's position, and this relation should be more fully examined in future research.

The future supply of family physicians: implications for rural America

Throughout the past century rural health care has been dependent upon general practitioners (GPs) and their successors, family physicians (FPs). Only FPs and GPs have practiced in rural areas in proportion to the population, then and now. As specialization occurred, numbers of GPs declined and physician shortages developed in rural areas. The creation of family practice residencies in the 1970s halted this decline, but rural shortages persist today. During the 1990s the number of allopathic and osteopathic FP residency graduates rose 54 percent. At the same time, the percentage of women enrolled in these residencies increased to 46 percent, and women have been less likely than men to select rural practice. We project that if current numbers of graduates continue, the nonmetropolitan FP/GP-to-population ratio will increase 17 percent by the year 2020. However, today, medical students' interest in primary care residencies (including family practice) is declining precipitously. If numbers of FP graduates return to 1993 levels, the density of FPs in rural America and in the nation as a whole will decline after 2010.