Access to outpatient services in rural communities changes after hospital closure

Rural Residence Associated with Receipt of Recommended Postdischarge Chronic Obstructive Pulmonary Disease Care among a Cohort of U.S. Veterans

Rationale: Individuals with chronic obstructive pulmonary disease (COPD) in rural areas experience inequitable access to care. Objectives: To assess whether rural residence is associated with receipt of recommended postdischarge COPD care. Methods: We conducted a cohort study of all U.S. veterans discharged from a Veterans Affairs medical center after COPD hospitalization from 2010 to 2019. Rural residence was defined by rural-urban commuting area classification. Our primary outcome was the proportion of recommended care received within 90 days of hospital discharge, including smoking cessation therapy, appropriate management of supplemental oxygen, appropriate prescription of inhaled therapy, and pulmonary rehabilitation. We conducted multivariable linear regression between rural residence and the proportion of recommended care received, adjusting for age, sex, race, ethnicity, comorbidities, and primary care facility type. We tested multivariable linear probability models for each of the recommended therapies. Results: Of 67,649 patients, 7,370 (10.8%) resided in rural areas and 2,000 (3.0%) in highly rural areas. Overall, the proportion of recommended COPD treatments received was low (mean, 15.0%; standard deviation, 21.0%). Compared with urban residence, patients with rural and highly rural residence received fewer recommended COPD care treatments (rural estimate [adjusted percentage difference (95% confidence interval)], -1.1 [-1.6, -0.6]; highly rural estimate, -1.2 [-2.1, -0.3]). Rural and highly rural residence were associated with lower likelihood of receiving appropriate inhaled therapy escalation (rural estimate, -4.0 [-5.1, -3.0]; highly rural estimate, -3.0 [-5.0, -1.1]) and pulmonary rehabilitation referral (rural estimate, -1.2 [-1.6, -0.9]; highly rural estimate, -2.1 [-2.7, -1.4]) but a higher likelihood of receiving smoking cessation therapy (rural estimate, 5.4 [3.3, 7.5]; highly rural estimate, 7.2 [3.3, 11.2]). There was no significant difference in appropriate oxygen management (rural estimate, -1.0 [-2.8, 0.9]; highly rural estimate, 3.1 [-0.7, 6.9]). Conclusions: Patients across the rural-urban spectrum received few recommended postdischarge COPD treatments. Health systems approaches are needed to address widespread underuse of evidence-based COPD care.

Longer travel times to acute hospitals are associated with lower likelihood of cancer screening receipt among rural-dwelling adults in the U.S. South

PURPOSE

Given rural hospitals' role in providing outpatient services, we examined the association between travel burdens and receipt of cancer screening among rural-dwelling adults in the U.S. South region.

METHODS

First, we estimated network travel times and distances to access the nearest and second nearest acute care hospital from each rural census tract in the U.S. South. After appending the Centers for Disease Control's PLACES dataset, we fitted generalized linear mixed models.

RESULTS

Longer distances to the second nearest hospital are negatively associated with breast, colorectal, and cervical cancer screening receipt among eligible rural-dwelling adults. Rural-dwelling women in counties with 1 closure had reduced likelihood of breast cancer screening. Residence in a partial- or whole-county Health Professional Shortage Area (HPSA) was negatively associated with cancer screening receipt. Specialist (OB/GYN and gastroenterologist) supply was positively associated with receipt of cancer screening. Uninsurance was positively associated with cervical and breast cancer screening receipt. Medicaid expansion was associated with increased breast and cervical cancer screening.

CONCLUSIONS

Rural residents in partial-county primary care HPSAs had the lowest rates of breast, cervical, and colorectal cancer screening, compared with whole-county HPSAs and non-shortage areas. These residents also faced the greatest distances to their nearest and second nearest hospital. This is notable because rural residents in the South face greater travel burdens for cancer care compared with residents in other regions. Finally, the positive association between uninsurance and breast and cervical cancer screening may reflect the CDC's National Breast and Cervical Cancer Early Detection Program's effectiveness.

Future practice plans of internal medicine fellowship graduates: a focus on pulmonary and critical care medicine

Background

The practice patterns of pulmonary and critical care medicine (PCCM) graduates are not well described. We aimed to describe the career paths sought by PCCM fellowship graduates entering the workforce.

Methods

Using the Fellowship and Residency Electronic Interactive Database, we examined data on the career paths of trainees graduating from internal medicine fellowship programs for 2022.

Results

Our study found that 712 trainees completed PCCM fellowship during 2022. Approximately 17% of PCCM graduates opted to pursue additional subspecialty training. Among those opting to enter practice, approximately 40% and 39% of PCCM graduates preferred academic practice and private practice, respectively. Among those opting for private practice, 48% chose group practice. Among all internal medicine subspecialties, there was a trend toward more graduates entering academia compared to historical averages. Notably, only 2.5% of PCCM graduates entering private practice opted to work in a rural setting. A similar trend was noted in other subspecialties. All specialties showed low percentages for practicing in underserved areas.

Conclusion

PCCM fellowship graduates exhibited a preference for academic practice and a reduced likelihood of pursuing further subspecialty training. The percentage of internal medicine subspecialists practicing in underserved areas remains low.

Exploring access to critical health services for older adults in rural America from 1990 to 2020

PURPOSE

Rural America has experienced a rapid loss of hospitals since the turn of the century, making access to high-quality health care the top rural health priority. Coinciding with this hospital decline is the growth of a rural population age 65 years or older. The health needs of older adults can require specialty care to support healthy aging. To date, minimal research has been conducted on trends in aging-related health care services in rural areas beyond hospital closures.

METHODS

This study uses a 30-year lookback of data from the Area Health Resource Files to describe the trends in local access to hospitals and critical health services important for conditions experienced by older adults in rural America. Results are presented across measures of rurality and population age.

FINDINGS

Local aging-related access to services such as chemotherapy, oncology, emergency department, geriatric, and home health agencies have been stagnant or declining over time in rural areas. Concerningly, the most remote communities with the highest percent of older adults have the lowest service access.

CONCLUSION

These findings shed light on the growing need for policies to support healthy aging among the increasingly older rural population.

The Implementation Climate for Integrating Buprenorphine Prescribing into Rural Primary Care

BACKGROUND

Rural communities have been significantly affected by opioid use disorder (OUD) and related harms but have less access to evidence-based medications for opioid use disorder (MOUD), such as buprenorphine. Given the shortage of specialists in these areas, rural primary care is an important setting to expand buprenorphine access, but implementation is limited.

OBJECTIVE

To explore implementation climate factors that support or hinder buprenorphine implementation in rural primary care.

DESIGN

A qualitative study design using in-depth interviews.

PARTICIPANTS

Primary care physicians, nurse practitioners (NPs), and physician associates (PAs) practicing in rural Ohio counties.

APPROACH

Between December 2022 and March 2023, we interviewed participants about their perspectives on buprenorphine prescribing, including using rural primary care as an implementation setting for buprenorphine. Using a deductive, framework-based approach, codes were grouped based on the Consolidated Framework for Implementation Research (CFIR) inner setting factors that contribute to a positive implementation climate for an intervention.

KEY RESULTS

Three implementation climate constructs emerged as decision points for whether to implement buprenorphine in rural primary care: (1) relative priority: the extent to which OUD treatment should be prioritized over other chronic diseases; (2) compatibility: whether buprenorphine prescribing protocols are compatible with the rural primary care setting; (3) tension for change: the extent to which current buprenorphine access shortages in rural communities can be tolerated. Participants expressed mixed perspectives on whether the implementation climate in rural primary care currently supports buprenorphine prescribing.

CONCLUSION

Implementation strategies targeted toward the implementation climate are critical to support buprenorphine prescribing in rural primary care.

Feasibility and efficacy of a novel audiovisual tool to increase colorectal cancer screening among rural Appalachian Kentucky adults

Introduction

Residents of Appalachian regions in Kentucky experience increased colorectal cancer (CRC) incidence and mortality. While population-based screening methods, such as fecal immunochemical tests (FITs), can reduce many screening barriers, written instructions to complete FIT can be challenging for some individuals. We developed a novel audiovisual tool ("talking card") to educate and motivate accurate FIT completion and assessed its feasibility, acceptability, and efficacy.

Materials and methods

We collected data on the talking card via: (1) cross-sectional surveys exploring perceptions of images, messaging, and perceived utility; (2) follow-up focus groups centered on feasibility and acceptability; and (3) efficacy testing in community-based FIT distribution events, where we assessed FIT completion rate, number of positive vs. negative screens, demographic characteristics of participants, and primary drivers of FIT completion.

Results

Across the three study phases, 692 individuals participated. Survey respondents positively identified with the card's sounds and images, found it highly acceptable, and reported high-to-very high self-efficacy and response efficacy for completing FIT, with nearly half noting greater likelihood to complete screening after using the tool. Focus group participants confirmed the acceptability of the individuals featured on the card. Nearly 75% of participants provided a FIT accurately completed it, with most indicating the talking card, either alone or combined with another strategy, helped with completion.

Discussion

To reduce CRC screening disparities among Appalachian Kentuckians, population-based screening using contextually relevant implementation strategies must be used alongside clinic-based education. The talking card represents a novel and promising strategy to promote screening uptake in both clinical and community settings.

Understanding the impacts of rural hospital closures: A scoping review

PURPOSE

Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research.

METHODS

A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction.

FINDINGS

We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings.

CONCLUSIONS

Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.

The impact of rural general hospital closures on communities-A systematic review of the literature

PURPOSE

To compile the literature on the effects of rural hospital closures on the community and summarize the evidence, specifically the health and economic impacts, and identify gaps for future research.

METHODS

A systematic review of the relevant peer-reviewed literature, published from January 2005 through December 2021, included in the EMBASE, CINAHL, PubMed, EconLit, and Business Source Complete databases, as well as "gray" literature published during the same time period. A total of 21 articles were identified for inclusion.

FINDINGS

Over 90% of the included studies were published in the last 8 years, with nearly three-fourths published in the last 4 years. The most common outcomes studied were economic outcomes and employment (76%), emergent, and non-emergent transportation, which includes transport miles and travel time (42.8%), access to and supply of health care providers (38%), and quality of patient outcomes (19%). Eighty-nine percent of the studies that examined economic impacts found unfavorable results, including decreased income, population, and community economic growth, and increased poverty. Between 11 and 15.7 additional minutes were required to transport patients to the nearest emergency facility after closures. A lack of consistency in measures and definition of rurality challenges comparability across studies.

CONCLUSIONS

The comprehensive impact of rural hospital closures on communities has not been well studied. Research shows predominantly negative economic outcomes as well as increased time and distance required to access health care services. Additional research and consistency in the outcome measures and definition of rurality is needed to characterize the downstream impact of rural hospital closures.

Efficiency effects of public hospital closures in the context of public hospital reform: a multistep efficiency analysis

In the wake of hospital reforms introduced in 2011 in Turkey, public hospitals were grouped into associations with joint management and some shared operational and administrative functions, similar in some ways to hospital trusts in the English National Health Service. Reorganization of public hospitals effect hospital and market area characteristics and existence of hospitals. The objective of this study is to examine the effect of closure on competitive hospital performances. Using administrative data from Turkish Public Hospital Statistical Yearbooks for the years 2005 to 2007 and 2014 to 2017, we conducted a three-step efficiency analysis by incorporating data envelopment analysis (DEA) and propensity score matching techniques, followed by a difference-in-differences (DiD) regression. First, we used bootstrapped DEA to calculate the efficiency scores of hospitals that were located near hospitals that had been closed. Second, we used nearest neighbour propensity score matching to form control groups and ensure that any differences between these and the intervention groups could be attributed to being near a hospital that had closed rather than differences in hospital and market area characteristics. Lastly, we employed DiD regression analysis to explore whether being near a closed hospital had an impact on the efficiency of the surviving hospitals while considering the effect of the 2011 hospital reform policies. To shed light on a potential time lag between hospital closure and changes in efficiency, we used various periods for comparison. Our results suggest that the efficiency of public hospitals in Turkey increased in hospitals that were located near hospitals that closed in Turkey from 2011. Hospital closure improves the efficiency of competitive hospitals under hospital market reforms. Future studies may wish to examine the efficiency effects of government and private sector collaboration on competition in the hospital market.

Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown.

OBJECTIVES

This study characterized opportunities for and achievement of heart failure (HF) medication initiation.

METHODS

Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation.

RESULTS

Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10).

CONCLUSIONS

Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.

Rural Communities in the United States Face Persistent Disparities in Access to Orthopaedic Surgical Care

Background

Access to orthopaedic care across the United States (U.S.) remains an important issue, however, no recent study has examined disparities in rural access to orthopaedic care. The goals of the present study were to (1) investigate trends in the proportion of rural orthopaedic surgeons from 2013 to 2018 as well as the proportion of rural U.S. counties with access to such surgeons and (2) analyze characteristics associated with choice of a rural practice setting.

Methods

The study analyzed the Centers for Medicare and Medicaid Services (CMS) Physician Compare National Downloadable File (PC-NDF) for all active orthopaedic surgeons from 2013 to 2018. Rural practice settings were defined using Rural-Urban Commuting Area (RUCA) codes. Linear regression analysis investigated trends in rural orthopaedic surgeon volume. Multivariable logistic regression evaluated the association of surgeon characteristics with rural practice setting.

Results

The total number of orthopaedic surgeons increased 1.9%, from 21,045 (2013) to 21,456 (2018). Meanwhile, the proportion of rural orthopaedic surgeons decreased by roughly 0.9%, from 578 (2013) to 559 (2018). From a per capita perspective, the number of orthopaedic surgeons practicing in a rural setting per 100,000 population ranged from 4.55 orthopaedic surgeons per 100,000 in 2013 and 4.47 per 100,000 in 2018. Meanwhile, the number of orthopaedic surgeons practicing in an urban setting ranged from 6.63 per 100,000 in 2013 and 6.35 per 100,000 in 2018. The surgeon characteristics most associated with decreased odds of practicing orthopaedic surgery in a rural setting included earlier career-stage (OR: 0.80, 95% CI: [0.70-0.91]; p < 0.001) and sub-specialization status (OR: 0.40, 95% CI: [0.36-0.45]; p < 0.001).

Conclusion

Existing rural-urban disparities in musculoskeletal healthcare access have persisted over the past decade and could worsen. Future research should investigate the effects of orthopaedic workforce shortages on travel times, patient cost burden, and disease specific outcomes. Level of Evidence: IV.

Changes in access to community health services among rural areas affected and unaffected by hospital closures between 2006 and 2018: A comparative interrupted time series study

PURPOSE

Recent studies suggest that Federally Qualified Health Centers (FQHC) may be expanding their provision of primary care in rural communities that experience a hospital loss. Whether these trends are different from rural areas not being affected by rural hospital closures is unknown.

METHODS

Data included Centers for Medicare and Medicaid Services Provider of Services files, the Cecil G. Sheps hospital closure database, and American Community Survey estimates. Changes in straight-line distances to the nearest FQHC and rural health clinic (RHC) were compared between areas affected and unaffected by a rural hospital closure in a matched case control study design using an interrupted time series model.

FINDINGS

There was no instantaneous percentage point increase in FQHC (2.41, 95% CI -0.79 to 5.60, P .140) or RHC (3.27, 95% CI -1.12 to 7.67, P .144) access following hospital closures compared to changes in access occurring in other rural areas. On average, rural ZIP codes affected by hospital closures exhibited a 0.84 percentage point increase in FQHC access over time (95% CI 0.40-1.28, P .000), but similar trends were also found within unaffected ZIP codes classified as small rural areas.

CONCLUSIONS

Rural areas impacted by hospital closures did not experience an increase in proximity to FQHCs or RHCs relative to changes in access occurring in other rural areas. Over time, most rural areas are seeing an increase in access to FQHCs and RHCs. Policies are needed to incentivize primary care providers to target geographic areas experiencing a hospital closure.

Trends and Demographic Disparities in Diabetes Hospital Admissions: Analyses of Serial Cross-Sectional National and State Data, 2008-2017

OBJECTIVE

To analyze national and state-specific trends in diabetes-related hospital admissions and determine whether disparities in rates of admission exist between demographic groups and geographically dispersed states.

RESEARCH DESIGN AND METHODS

We conducted serial cross-sectional analyses of the National Inpatient Sample (2008, 2011, 2014, and 2016) and State Inpatient Databases for Arizona, Florida, Kentucky, Iowa, Maryland, Nebraska, New Jersey, New York, North Carolina, Utah, and Vermont for 2008, 2011, 2014, and 2016/2017 among adult patients with type 1 and type 2 diabetes-related ICD codes (ICD-9 [250.XX] or ICD-10 [E10.XXX, E11.XXX, and E13.XXX]. We measured hospitalization rates for people with diabetes (all-cause hospitalizations) and for admissions with a primary diagnosis of diabetes or diabetes-related complications (diabetes-specific hospitalizations) per 10,000 people per year.

RESULTS

Nationally, all-cause and diabetes-specific hospitalizations declined by 3.1% (95% CI -5.5, -0.7) and 19.1% (95% CI -21.6, -16.6), respectively, over 2008 to 2016. The analysis of individual states showed that diabetes-specific admissions in individuals ≥65 years old declined during this time (16.3-48.8% decrease) but increased among patients 18-29 years old (10.5-81.5% increase) and that rural diabetes-specific admissions decreased in just over half of the included states (15.2-69.2% decrease). There were no differences in changes in admission rates among different racial/ethnic groups.

CONCLUSIONS

Overall, rates of diabetes-related hospitalizations decreased over 2008 to 2016/2017, but there were large state-level differences across subgroups of patients. The rise in diabetes hospitalizations among young adults is a cause for concern. These state- and subpopulation-level differences highlight the need for state-level policies and interventions to address disparities in diabetes health care use.