Local factors affecting the tendency to bypass local hospitals for inpatient mental health care: an exploratory analysis

American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference?

PURPOSE

Rural bypass for elective surgical procedures is a challenge for critical access hospitals, yet there are opportunities for rural hospitals to improve local retention of surgical candidates through alternative approaches to developing surgery lines of business. In this study we examine the effect of visiting surgical specialists on the odds of rural bypass.

METHODS

Discharge data from the 2011 State Inpatient Databases and State Ambulatory Surgery Databases for Iowa were linked to outreach data from the Office of Statewide Clinical Education Programs and Iowa Physician Information System to model the effect of surgeon specialist supply on rural patients' decision to bypass rural critical access hospitals.

FINDINGS

Patients in rural communities with a local general surgeon were more likely to be retained in a community than to bypass. Those in communities with visiting general surgeons were more likely to bypass, as were those in communities with visiting urologists and obstetricians. Patients in communities with visiting ophthalmologists and orthopedic surgeons were at higher odds of being retained for their elective surgeries.

CONCLUSION

In addition to known patient and local hospital factors that have an influence on bypass behavior among rural patients seeking elective surgery, availability of surgeon specialists also plays an important role in whether patients bypass or not. Visiting ophthalmologists and orthopedic surgeons were associated with less bypass, as was having local general surgeons. Visiting general surgeons, urologists, and obstetricians were associated with greater odds of bypass.

Factors contributing towards patient's choice of a hospital clinic from the patients' and managers' perspective

Introduction

Given the competitive nature of the health market and the multiplicity of factors that may contribute towards patient’s choices of a hospital, patients’ needs and preferences for a hospital must be considered in the planning and decision making of hospitals and health care organizations. This study aimed to identify the factors that contribute to patient’s choices of a clinic and the importance of each factor.

Methods

A mixed-method approach was used to collect quantitative and qualitative data in two phases. The study was conducted in a hospital clinic in 2014. Qualitative data were collected by face-to-face semi-structured interviews of a sample of 22 managers and heads of outpatient wards. The self-administered questionnaire designed for this study collected quantitative data from a stratified random sample of 381 patients referred to this clinic. The qualitative data were analyzed by a system of coding, while parametrical statistical analyses were conducted to analyze the quantitative data using the independent-samples t-test and ANOVA in SPSS software, version 21.0.

Results

The qualitative data indicated that there were 21 factors that may contribute to patient’s choices of a clinic, and these factors were classified into six categories, i.e., facilities and physical assets, physicians and employees, location and place, services, price, and promotion. Among the 16 questions studied in the quantitative questionnaire, the highest and lowest means were related to “appropriate clinic environment” (2.47 ± 0.58) and “advertising through TV and radio, the Internet, newspapers, etc.” (1.77 ± 0.75), respectively. There were significant associations between “having experienced and responsive personnel, including physicians and employees” and the patient’s gender and frequency of referrals, between “belonging to the Armed Forces” and the patient’s age and frequency of referrals, between “advertising through TV and radio, the Internet, newspapers, etc.” and shifts and frequency of referrals, between “inadequate facilities and poor quality of services provided in other health care organizations of the Armed Forces” and “adornment and good behavior of staff” and shifts (p < 0.05).

Conclusion

The most significant contributing factors to attract patients were the “physicians and employees,” and “the clinic’s environment.” Therefore, it is essential for clinic managers and heads of outpatient wards to focus on and strengthen these two factors. Also, since the means of the factors were better in the morning shift, the employees should perform their duties properly and consistently in all shifts.

Patient choice of a hospital: implications for health policy and management

PURPOSE

The purpose of this study was to identify the most important influencing factors in choosing a hospital by a patient.

DESIGN/METHODOLOGY/APPROACH

This study involved a mixed research design. Focus groups and in-depth individual interviews were conducted with patients to explore reasons for choosing a hospital. In addition, this study involved survey-based research on the patient choice.

FINDINGS

Type of the hospital, type of the service, word of mouth, cost of services, the health insurance programme, location, physical environment, facilities, providers' expertise and interpersonal behaviour, and reputation of the hospital influenced patients' choice of a hospital. Doctor recommendations and health insurance programme were the main reasons for choosing a hospital for inpatients and outpatients respectively.

PRACTICAL IMPLICATIONS

Identifying and understanding key factors that influence a patient choice of a healthcare setting helps managers and policy makers invest their resources in those critical areas and improve those aspects of their services to attract more patients.

ORIGINALITY/VALUE

This article contributes to healthcare theory and practice by developing a conceptual framework for understanding the factors that influence a patient choice of a healthcare setting.

Determinants of hospital choice of rural hospital patients: the impact of networks, service scopes, and market competition

Among 10,384 rural Colorado female patients who received MDC 14 (obstetric services) from 2000 to 2003, 6,615 (63.7%) were admitted to their local rural hospitals; 1,654 (15.9%) were admitted to other rural hospitals; and 2,115 (20.4%) traveled to urban hospitals for inpatient services. This study is to examine how network participation, service scopes, and market competition influences rural women's choice of hospital for their obstetric care. A conditional logistic regression analysis was used. The network participation (p < 0.01), the number of services offered (p < 0.05), and the hospital market competition had a positive and significant relationship with patients' choice to receive obstetric care. That is, rural patients prefer to receive care from a hospital that participates in a network, that provides more number of services, and that has a greater market share (i.e., a lower level of market competition) in their locality. Rural hospitals could actively increase their competitiveness and market share by increasing the number of health care services provided and seeking to network with other hospitals.

Bypass of local primary care in rural counties: effect of patient and community characteristics

PURPOSE

This national study sought information from rural patients (1) to assess the prevalence of bypass, a pattern of seeking health care outside the local community; (2) to examine the impact of locally available primary care physicians (PCPs) and hospital size on the odds of bypass; and (3) to identify patient demographic and geographic factors associated with bypass. This study also ascertained the reasons patients give for bypass and their suggestions for how hospitals can retain patients locally.

METHODS

We analyzed data from a 2005 telephone survey of 1,264 adults, aged 18 years or older, who lived within 20 miles of 25 randomly selected Critical Access Hospitals and were linked with a Health Professional Shortage Area and 2004 census data. Respondents were asked about demographic characteristics, travel time and distance to local hospitals, and insurance status, as well as for suggestions of what local hospitals could do to retain patients.

RESULTS

Overall, 32% of respondents bypassed local primary care; the rate ranged from 9% to 66% across the Critical Access Hospital service areas. Factors associated with bypass included age, education, marital status, satisfaction with the local hospital, admission to a hospital in the past 12 months, hospital size, and local density of PCPs. Compared with residents in areas with a higher density of PCPs (=3,500 residents per PCP), residents in areas with a low density (>4,500 residents per PCP) were more likely to bypass local care (odds ratio, 1.58; 95% confidence interval, 1.02-2.46). Lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed local hospitals.

CONCLUSIONS

The sizable variation in bypass rates among this sample of Critical Access Hospital service areas suggests that strategies to reduce bypass behavior should be directed at the local community or facility level. Changing rural residents' perception of their local care, helping them gain a better understanding of the function of primary care, and increasing the number of PCPs might help hospitals retain patients and rural communities stay healthy.

Patient bypass behavior and critical access hospitals: implications for patient retention

PURPOSE

To assess the extent of bypass for inpatient care among patients living in Critical Access Hospital (CAH) service areas, and to determine factors associated with bypass, the reasons for bypass, and what CAHs can do to retain patients locally.

METHODS

Six hundred and forty-seven subjects, aged 18 years and older, who had been admitted to a hospital for inpatient care in the past 12 months and lived within 15-20 miles of 25 randomly selected CAHs were surveyed by phone during the period from early February through late July 2005. Survey questions included demographic characteristics, general health status, travel time/distance to health care, questions on satisfaction with local health services, bypass behavior, and solicited suggestions on how local hospitals could retain patients locally.

FINDINGS

About 60% of surveyed patients bypassed their local CAHs for inpatient care including 16% who were referred to another facility by the local CAH/health care providers and would use the local hospital if needed services were available. Bypass rates ranged from 16% to 70% across the sampled CAHs. Factors associated with bypass included age, income, satisfaction with the local hospital, and traveling distance/time. Lack of specialty care, limited services, and the quality/reputation of local services/doctors were most frequently mentioned as reasons why patients bypass local CAHs.

CONCLUSIONS

The bypass rate for sampled CAHs is considerably higher than the 20%-50% bypass rates documented in the literature for all hospitals in general using discharge/administrative data. The sizeable variation in bypass rates across CAHs suggests that the appropriate response/fix should come from the facility/community levels.

Understanding rural hospital bypass behavior

CONTEXT

Though many rural hospitals offer a broad array of services, local residents may choose more distant facilities for inpatient care services. Depending on the extent of the bypass phenomenon, hospitals may experience financial distress, reduced service offerings, or closure.

PURPOSE

This study provides a descriptive analysis of rural hospital bypass behavior in 7 states.

METHODS

We examine hospital discharge data for calendar years 1991 and 1996 to determine the extent to which patients admitted from rural areas are bypassing local facilities. We also assess whether there are trends in bypass patterns over time. Our primary specification of bypass is defined as a discharge from a hospital between 15 and 1000 miles from the closest facility.

FINDINGS

We found an overall bypass rate of 30%. This overall rate changed little between 1991 and 1996. Subgroups of patients, defined by payer and diagnosis, had differing propensities to bypass local rural facilities. Patients with managed care or commercial insurance had higher bypass rates compared to patients who relied on other payer sources. Medicare and uninsured (self-pay) patients had lower bypass rates. Payer type differences persisted when cases were divided into emergent and scheduled categories. Patients seeking general medical or obstetrical care had lower bypass rates than patients discharged with a diagnosis related group (DRG) related to complex medical, general surgery, or specialty surgery services. With the exception of normal delivery, DRG codes frequently associated with bypass discharges involved procedures or surgery that may not be offered by smaller rural facilities.

CONCLUSIONS

Our results indicate that rural patients, or their admitting physicians, perceive local rural hospitals as a viable option for many inpatient care services but prefer other facilities for treatments beyond the scope of general medical or surgical treatment.

Characteristics of rural elderly people who bypass local pharmacies

CONTEXT

The bypassing of local pharmacies by consumers is an indicator of limited accessibility and, possibly, compromised quality of rural pharmacy services.

PURPOSE

The objective of this study was to identify the characteristics of rural consumers who bypassed local pharmacies for their medication needs.

METHODS

The sample was derived from the Texas Tech 5000, a longitudinal survey in West Texas, and pharmacy data from the Texas State Board of Pharmacy. The sample included 1062 people aged 65 or older who lived in rural counties and had at least one community pharmacy in town. Bivariate and multivariate analyses were performed to investigate the demographic, financial, nonfinancial, prescription and over-the-counter drug use, and health characteristics that were associated with the probabilities of the subjects' using local community pharmacies, nonlocal community pharmacies, and mail-order pharmacies.

FINDINGS

In the sample, 70.8%, 13.7%, and 15.5% of elderly people primarily used local pharmacies, nonlocal pharmacies, and mail-order pharmacies, respectively. The oldest subjects, women subjects, subjects with no employer-provided or other federal insurance, subjects who had a regular doctor, and subjects living within city limits and in areas with a higher density of community pharmacies had lower probabilities of choosing nonlocal pharmacies over local pharmacies. Insurance coverage for prescriptions was one of the most important determinants in choosing mail-order pharmacies over local community pharmacies.

CONCLUSIONS

Additional research is warranted to further understand the choices made by older people, as well as by younger people who use medications. In particular, further investigation of the potential differences between services provided by rural-community, urban-community, and mail-order pharmacies is needed to identify other reasons for bypassing local pharmacies.

Rural residence and migration for specialty physician care

This article describes why rural residents migrate or travel outside their local market area for specialty physician care. Data were collected through a random mail survey of persons residing in Iowa's rural counties. The results imply that migration for specialty care is not simply a function of a low perceived availability of local specialty physicians. Managers of rural and urban health care systems may need to rethink the extent to which specialty physician services should be distributed across rural markets.

Why rural residents migrate for family physician care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.

Networks and the fiscal performance of rural hospitals in Oklahoma: are they associated?

This paper uses regression analysis to explore the relation of network membership to the financial performance of rural hospitals in Oklahoma during fiscal year 1995. After adjusting for the scope of service, as measured by the number of facilities or services offered by the hospital, indicators of fiscal status are (1) the cash receipts derived from net patient revenue; (2) the cash disbursements related to operating costs, net of interest and depreciation expense, labor costs and nonlabor costs; and (3) net cash flow, defined as the difference between cash receipts and disbursements. Controlling for the effects of the hospital's structural attributes, operating characteristics and market conditions, the results indicate that members of a network reported lower net operating costs, labor costs and nonlabor expenses per service than nonmembers. Hence, the analysis seems to suggest that the membership of rural hospitals in a network is associated with lower cash disbursements and an improved net cash flow, outcomes that may preserve their fiscal viability and the access of the population at risk to service.