Access to transportation and health care utilization in a rural region

Association between residing in municipalities facing population decline and satisfaction with neighboring healthcare infrastructure in older aged adults

BACKGROUND

Many municipalities in rural areas of Korea are facing population decline due to the aging population phenomenon. This study examined the relationship between residing in municipalities facing population decline and satisfaction with nearby healthcare infrastructure in older aged adults.

METHODS

The 2021 Korea Community Health Survey (KCHS) data were used. Municipalities were classified as those not facing population decline, those at risk, and those facing population decline based on the Population Decline Index. The association between residing in municipalities facing population decline and satisfaction with nearby healthcare infrastructure was examined cross-sectionally using a multi-level logistic regression analysis. Satisfaction with available public transportation was concomitantly examined as it is related to accessing healthcare services.

RESULTS

Of the 58,568 individuals aged 65 years or above analyzed, 27,471 (46.9%) adults were residing in municipalities without population decline, 4,640 (7.9%) adults in municipalities at risk of population decline, and 26,457 (45.2%) in municipalities with population decline. Individuals living in municipalities with population decline were more likely to be dissatisfied with nearby healthcare infrastructure (OR 1.76, 95% CI 1.41-2.20). Similar tendencies were found for public transportation infrastructure (OR 1.67, 95% CI 1.38-2.03).

CONCLUSIONS

Individuals residing in municipalities with declining populations are more likely to report dissatisfaction with nearby healthcare infrastructure and public transportation. These findings emphasize the importance of providing adequate medical infrastructure to reduce potential health-related disparities.

Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors

BACKGROUND

It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States.

MATERIALS AND METHODS

County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon.

CONCLUSION

Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 2024;47(4):e204-e210.].

Providers' and survivors' perspectives on the availability and accessibility of surgery in gastrointestinal cancer care

BACKGROUND

Surgery is essential for gastrointestinal (GI) cancer treatment. Many patients lack access to surgical care that optimizes outcomes. Scarce availability and/or low accessibility of appropriate resources may be the reason for this, especially in economically disadvantaged areas. This study aimed to investigate providers' and survivors' perspectives on barriers and facilitators to the availability and accessibility of surgical care.

METHODS

Semistructured interviews informed by surgical disparities and access-to-care conceptual frameworks with purposively selected GI cancer providers and survivors in Alabama and Mississippi were conducted. Survivors were within 3 years of diagnosis of stage I to III esophageal, pancreatic, or colorectal cancer. Transcripts were analyzed using inductive thematic and content analysis techniques. Intercoder agreement was reached at 90 %.

RESULTS

The 27 providers included surgeons (n = 11), medical oncologists (n = 2), radiation oncologists (n = 2), a primary care physician (n = 1), nurses (n = 8), and patient navigators (n = 3). This study included 36 survivors with ages ranging from 44 to 87 years. Of the 36 survivors, 21 (58.3 %) were male, and 11 (30.6 %) identified as Black. Responses were grouped into 3 broad categories: (i) transportation/geographic location, (ii) specialized care/testing, and (iii) patient-/provider-related factors. The barriers included lack and cost of transportation, reluctance to travel because of uneasiness with urban centers, low availability of specialized care, overburdened referral centers, provider-related referral biases, and low health literacy. Facilitators included availability of charitable aid, centralizing multidisciplinary care, and efficient appointment scheduling.

CONCLUSION

In the Deep South, barriers and facilitators to the availability and accessibility of GI surgical cancer care were identified at the health system, provider, and patient levels, especially for rural residents. Our data suggest targets for improving the use of surgery in GI cancer care.

Demographic Disparities in Drive Times to the Nearest Audiologist in the United States

PURPOSE

Audiological services are underused, possibly because patients need to drive long distances to see a provider. In this study, we measured the association of drive times to the nearest audiologist with population density, income, ethnicity, race, and distance to the nearest audiology graduate program.

METHOD

Drive times for each census block group to the nearest audiologist were measured using census data, the National Provider Identifier Registry, and a geographic analyzing tool called ArcGIS for all block groups within the United States. The association between drive times and population density, income, ethnicity, race, and audiology program distance was evaluated with a population density-matched case-control study and multiple linear regression analyses.

RESULTS

Approximately 5.29 million Americans need to drive at least 1 hr to visit their closest audiologist. The 10% most rural-dwelling Americans drive an average of 33.8 min. The population density-matched case-control study demonstrated that percent below poverty, percent identifying as Hispanic, and travel times to the nearest audiology program were all significantly higher in census block groups with high drive times to the nearest audiologist. An average of 7.96% of individuals in census block groups with low drive times identified as Hispanic, but 18.8% identified as Hispanic in high drive time groups. The multiple linear regression showed that the effect of demographics and distance to the nearest audiology program was highest in rural areas. In both analyses, adjusting for poverty did not drastically change the effect of percent identifying as Hispanic on drive times.

CONCLUSIONS

Long drive times restrict access to audiological care for those who live in rural areas. This restriction disproportionately affects those in rural areas who identify as Hispanic or have low income.

A Systematic Review of the Effectiveness of Health Education Programs for Cervical Cancer Prevention in Rural Communities: Implications for Promoting Health Equity

Rural women face an increased risk of cervical cancer diagnosis in comparison to women living in metropolitan areas. This review synthesized and critically evaluated cervical cancer screening interventions that target women living in rural communities in the USA. EBSCO, JSTOR, Medline, PsychINFO, Psychology and Behavioral Sciences Collection, PubMed, and Cochrane Library were searched using keywords related to cervical cancer screening, rural communities, and prevention interventions. Study eligibility included randomized controlled trials or quasi-experimental designs, a psychosocial or educational intervention targeting cervical cancer prevention, and implementation in a rural setting. Eleven articles met criteria for the systematic review and 6 of those included information sufficient for meta-analysis. Cochrane guidelines, CONSORT-Equity 2017, and PROGRESS-Plus were used to assess included studies. The systematic review encompassed 9720 participants who were involved in a variety of intervention types: social media campaigns, faith-based, and patient navigation with lay health advisors. None of the studies met all criteria for the health equity assessment. The meta-analysis found that women in the intervention groups were more likely to participate in cervical cancer screening than women in control groups (OR: 2.43, 95% CI: 1.49 to 3.97). The type of intervention mattered in increasing cervical cancer screening participation for women living in rural communities. Educational interventions in combination with patient navigation saw the most success in promoting cervical cancer screening. Further, health inequities focus is lacking robust consideration. Our results highlight a continued need to develop multicomponent interventions with a health equity focus to address barriers to screening and prevention.

Evaluating variations in the barriers to colorectal cancer screening associated with telehealth use in rural U.S. Pacific Northwest

PURPOSE

The incidence and mortality rates of colorectal cancer (CRC) remain consistently high in rural populations. Telehealth can improve screening uptake by overcoming individual and environmental disadvantages in rural communities. The present study aimed to characterize varying barriers to CRC screening between rural individuals with and without experience in using telehealth.

METHOD

The cross-sectional study surveyed 250 adults aged 45-75 residing in rural U.S. states of Alaska, Idaho, Oregon, and Washington from June to September 2022. The associations between CRC screening and four sets of individual and environmental factors specific to rural populations (i.e., demographic characteristics, accessibility, patient-provider factors, and psychological factors) were assessed among respondents with and without past telehealth adoption.

RESULT

Respondents with past telehealth use were more likely to screen if they were married, had a better health status, had experienced discrimination in health care, and had perceived susceptibility, screening efficacy, and cancer fear, but less likely to screen when they worried about privacy or had feelings of embarrassment, pain, and discomfort. Among respondents without past telehealth use, the odds of CRC screening decreased with busy schedules, travel burden, discrimination in health care, and lower perceived needs.

CONCLUSION

Rural individuals with and without previous telehealth experience face different barriers to CRC screening. The finding suggests the potential efficacy of telehealth in mitigating critical barriers to CRC screening associated with social, health care, and built environments of rural communities.

A Cyclical Model of Barriers to Healthcare for the Hispanic/Latinx Population

As the Hispanic/Latinx population in the United States continues to grow, disparities in health outcomes for this population continue to widen. Worse health outcomes can be attributed to a variety of barriers to healthcare specific to this population, but scant literature exists that presents the connections among them. Many of these barriers to healthcare stem from institutional racism, disparities in socioeconomic status, and xenophobia. To synthesize barriers that hinder the Hispanic/Latinx population from receiving quality healthcare, we propose a cyclical model. The model begins with obstacles present before even visiting a healthcare provider, including structural inequalities, cultural beliefs, documentation status, scheduling, and transportation. Next, the model poses barriers during the visit with a healthcare provider, including problems with provider bias, cultural barriers, and interpretation services. Finally, the model presents barriers that occur after the medical encounter, including payment, medication adherence, indigent care, and follow-up appointments or referrals. Once the patient needs to schedule a follow-up appointment or referral, the cycle restarts with the barriers present before accessing care. All of these barriers to healthcare are areas for potential mitigation of the healthcare disparities that currently disadvantage the Hispanic/Latinx population. The proposed Hispanic Cyclical Healthcare Barrier (HCHB) model helps organize solutions to the barriers, illustrating the need for multiple interventions due to the interconnectedness of the barriers.

Falls among community-dwelling older adults in the Philippines and Viet Nam: Results from nationally representative samples

Falls are a significant public health issue globally. However, studies with nationally representative samples have yet to be done to understand falls among older adults in the Philippines and Viet Nam. Using a biopsychosocial perspective, this study investigated the prevalence of falls and their associated factors among community-dwelling older adults in these countries. Cross-sectional data were drawn from the baseline survey of the Longitudinal Study of Ageing and Health in the Philippines (2018, N = 4,606) and the Longitudinal Study of Ageing and Health in Viet Nam (2018, N = 4,378). The outcome variables were any falls in the past year. Independent variables included sociodemographic factors (age, sex, education, living in urban areas, living alone, social network size), biophysical factors (vision, chronic conditions, functional impairments, pain locations, insomnia symptoms, sleep medications, grip strength, walking speed, postural control), and psychological factors (depressive symptoms). Descriptive analysis and logistic regression analysis were used to analyze the data. The results showed that 17.7 % and 7.3 % of older Filipino and Vietnamese adults fell in the year before the study. Significant factors associated with the odds of any falls among Filipino older adults were having a higher level of education, living in urban areas, living with others, experiencing more functional impairments, reporting one or more pain locations, and having poor grip strength. In Viet Nam, having more chronic conditions, experiencing more functional impairments, and reporting two or more pain locations were found to be associated with higher odds of any falls. The population in the Philippines and Viet Nam is aging rapidly. Findings from this study are timely in identifying at-risk individuals and preparing for effective fall prevention strategies.

Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors

PURPOSE

Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors.

METHODS

Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons.

CONCLUSION

Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.

Transportation and Access to Healthcare in Morocco: An Exploratory Study of Guelmim-Oued Noun Region

Objective

The aim of this study was to examine the correlation between accessibility to healthcare facilities and transportation in the Guelmim Oued Noun region of Morocco, where transportation barriers continue to pose a major challenge to accessing healthcare, despite efforts aimed at reducing access barriers.

Methods

Data collection for this study involved the administration of a survey among 328 outpatients residing in the Guelmim Oued Noun region, Morocco. The utilization of canonical correlation served as the analytical method, employed to quantify and assess the relationship between transportation related barriers and the access of healthcare services in the specified region.

Results

Our research reveals that transportation factors account for approximately 25% of the variation in access to healthcare services. The number of transportation modes utilized by outpatients and the affordability of transportation were found to be significant contributors to the transportation dimension. These findings confirm the significant relationship between transportation and access to healthcare facilities in the region under investigation.

Conclusion

Further research is recommended to specifically address transportation barriers to healthcare access services among socially excluded populations, with a focus on promoting mobility inclusivity.

Elucidating survival and functional outcomes in patients with primary head and neck malignancies treated in academic versus community settings

BACKGROUND

Differences in treatment outcomes between community or academic centers are incompletely understood.

METHODS

Retrospective review of head and neck cancer patients between 2010 and 2020 in a rural health region. Kaplan-Meier curves and log-rank tests were used to evaluate survival outcomes, along with bivariate and multivariable Cox proportional hazards models. Linear regression was used for functional outcomes of tracheotomy and gastrostomy tube dependence.

RESULTS

Two hundred and forty-eight patients treated at an academic center were compared with 94 patients treated in community centers. In multivariable analysis, the risk of death (HR = 0.60, p = 0.019), and risk of recurrence were lower (HR = 0.29, p < 0.001) for patients treated in academic centers. Patients treated in community centers had longer gastrostomy tube dependence (p = 0.002).

CONCLUSION

Our findings suggest that treatment at an academic center was associated with a lower risk of recurrence and shorter gastrostomy tube dependence compared to treatment in the community.

Association between travel distance and face-to-face consultations with general practitioners before an incident acute myocardial infarction: a nationwide register-based spatial epidemiological study

OBJECTIVES

This study examined the association between travel distance to the general practitioner's (GP) office and no face-to-face GP consultation within 1 year before an incident acute myocardial infarction (AMI).

DESIGN

A prospective cohort study using multilevel spatial logistic regression analysis of nationwide register data.

SETTING

Nationwide study including contacts to GPs in Denmark prior to an incident AMI in 2005-2017.

PARTICIPANTS

121 232 adults (≥30 years) with incident AMI were included in the study.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was odds of not having a face-to-face GP consultation within 1 year before an incident AMI.

RESULTS

In total, 13 108 (10.8%) of the 121 232 individuals with incident AMI had no face-to-face consultation with the GP within 1 year before the AMI. Population density modified the association between travel distance and no face-to-face GP consultation. Increased odds of no face-to-face GP consultation was observed for medium (25th-75th percentile/1123-5449 m) and long (>75th percentile/5449 m) compared with short travel distance (<25th percentile/1123 m) among individuals living in small cities (OR (95% credible intervals) of 1.19 (1.10 to 1.29) and 1.19 (1.06 to 1.33), respectively) and rural areas (1.46 (1.26 to 1.68) and 1.48 (1.29 to 1.68), respectively). No association was observed for individuals living in large cities and the capital.

CONCLUSIONS

Travel distance above approximately 1 km was significantly associated with no face-to-face GP consultation before an incident AMI among individuals living in small cities and rural areas. The structure of the healthcare system should consider the importance of geographical distance between citizens and the GP in remote areas.

Psychosocial Determinants of Mental Healthcare Use Among Mexican-origin Women from Farmworker Families in Southern California

Little is known about the contribution of psychosocial factors related to mental healthcare use among Mexican-origin women from farmworker families. Therefore, this study assessed relationships between acculturative stress, depressive symptoms, mental healthcare service use, and preferences for seeking care. Linear and logistic regression models and chi-square tests were performed to analyze survey data from 78 Mexican-origin women from farmworker families. Women were recruited in collaboration with promotoras and completed measures of acculturative stress, depressive symptoms, and mental healthcare use and preferences. Overall, 29.5% of the sample reported clinically significant depressive symptomatology. Acculturative stress was positively associated with depressive symptoms (b = 0.43, 95%CI = 0.27,0.59) after controlling for years in the U.S., primary language, and demographic characteristics. In addition, acculturative stress was associated with lower odds of mental healthcare use (OR = 0.96) after controlling for years in the U.S. and depressive symptoms. However, this association was no longer statistically significant when controlling for health insurance status and access to transportation. Mexican-origin women with high levels of acculturative stress were significantly more likely to seek care from a psychiatrist/psychologist than their peers (54.3% vs. 45.7%); however, this preference was not indicative of their use of mental healthcare services. Results suggest that acculturative stress is a risk factor for depressive symptoms and might contribute to a delay in seeking mental healthcare services in Mexican-origin women from farmworker families. Thus, interventions for this group should address aspects of acculturative stress as a strategy to increase mental health services use.

Racial Disparities in Health Care Use in Gentrifying Neighborhoods

Objective

Racial disparities in health outcomes are a persistent threat in gentrifying neighborhoods. A contributor to health outcomes is health services utilization, the extent to which people receive care from a medical professional. There are documented racial disparities in health services utilization in the general population. We aim to determine whether racial disparities in health services utilization exist in gentrifying neighborhoods.

Methods

We used data from the American Community Survey to identify gentrifying neighborhoods across the United States from 2006 to 2017. We collected data on three measures of healthcare services utilization (office-based physician visits, office-based nonphysician visits, and having a usual source of care) for 247 Black and 689 White non-Hispanic respondents of the 2014 Medical Expenditure Panel Survey living in gentrifying neighborhoods. We used modified Poisson models to determine whether there is a difference in the prevalence of health services utilization by race among residents of gentrifying neighborhoods.

Results

After adjusting for age, gender, education, income, employment, insurance, marital status, region, and self-rated health, Black residents of gentrifying neighborhoods demonstrated a similar prevalence of having an office-based physician visit, a lower prevalence of having an office-based nonphysician visit (prevalence ratio: 0.74; 95% confidence interval, 0.60 to 0.91), and a lower prevalence of having a usual source of care (prevalence ratio: 0.87; 95% confidence interval, 0.77 to 0.98) than White residents.

Conclusions

The existence of racial disparities in health services utilization in US gentrifying neighborhoods demonstrates a need for policy-relevant solutions to create a more equitable distribution of health resources.

Understanding Barriers and Facilitators to High-Quality Cancer Care Among Veterans With Lung Cancer: A Qualitative Study

PURPOSE

Veteran populations have higher lung cancer incidence and worse overall survival compared with non-Veteran populations. Although recent clinical advancements have reduced lung cancer death rates, these advances are not routinely received among Veteran populations because of multilevel factors, including Veterans' complex comorbidities, limited health literacy, and other economic and social disadvantages. This study aimed to assess Veterans' perspectives regarding their lung cancer care with a specific focus on identifying modifiable barriers to evidence-based care delivery.

METHODS

We conducted 1:1 semistructured interviews with 24 Veterans diagnosed with lung cancer at the Veterans Affairs Palo Alto Health Care System. All interviews were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis.

RESULTS

Four themes emerged. These included (1) social and economic disadvantages can prevent routine delivery of evidence-based cancer care; (2) fragmented care contributes to worsening patient mental and emotional well-being; (3) lack of health system interventions to address limited health literacy inhibits patient engagement in shared decision making regarding diagnosis, genomic and molecular testing, targeted and other treatments, and end-of-life care; and (4) deep appreciation for care and VA trustworthiness facilitates adherence to cancer care recommendations.

CONCLUSION

This study revealed critical gaps in lung cancer care delivery and the role of institution-engendered trust in overcoming barriers in the VA system. Targeted solutions should address the identified barriers to routine, evidence-based lung cancer care delivery among Veterans.

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study

BACKGROUND

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear.

OBJECTIVE

This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects.

METHODS

We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age.

RESULTS

Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68).

CONCLUSIONS

These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

Native American Community Perspectives on Oral Health Access: Understanding the Impact of Rurality

PURPOSE

Oral health disparities related to access persist for American Indian/Alaska Native (AI/AN) communities compared to the general population, especially in rural areas of the United States. The objective of this study was to better understand community perspectives of oral health, how rurality impacts access to care, and attitudes towards the implementation of dental therapists in Oklahoma, particularly among the AI/AN population.

METHODS

A descriptive, observational study design was utilized. An exploratory survey was conducted online and comprised of qualitative and quantitative data. The total frequencies and percentages were evaluated for the quantitative questions. The qualitative data was analyzed using thematic analysis. Utilizing descriptive and qualitative research methods, the focus was to describe the experiences of the respondents and their characteristics related to oral health in Oklahoma.

RESULTS

A total of 201 responses were obtained, where 65% (n = 131) identified as an enrolled member or employee of a tribe represented in Oklahoma. Key qualitative themes included community access to care, community concerns, and community motivated solutions.

CONCLUSIONS

AI/AN communities are an underserved group in healthcare. Although communities in rural areas face major barriers to oral health services, evidence-based solutions can be implemented.

Latino Migrant Farmworker Youths' Perceptions of Access to Care in the Southeast: A Qualitative Approach

This study explored Latino Migrant Farmworker (LMFW) youths' perceptions regarding access to health care in the United States (U.S.). Twenty semi-structured audio-voice recorded interviews were conducted with LMFW youths (aged 15-20 years old) in Georgia and Florida. Thematic analysis was used to explore whether, and how, LMFW youths would seek health care in the U.S. as well as their personal views toward health care. Five distinct perceptions regarding accessing health care were delineated: (1) cultural-related views and attitudes toward health care, (2) transportation dependency, (3) English language as a barrier for communication, (4) lack of knowledge of available resources, and (5) embracing the obligation, and the necessity, of work. Some of LMFW youths' perceptions of seeking access to health care in the U.S. point to barriers related to social determinants of health. These barriers suggest the need for significant reform within the U.S. health care system to include farmworker youths' health needs and to promote cultural responsiveness among clinicians and rural health providers to better serve this vulnerable population.

Development of an evidence-based model for predicting patient, provider, and appointment factors that influence no-shows in a rural healthcare system

BACKGROUND

No-show appointments pose a significant challenge for healthcare providers, particularly in rural areas. In this study, we developed an evidence-based predictive model for patient no-shows at the Marshfield Clinic Health System (MCHS) rural provider network in Wisconsin, with the aim of improving overbooking approaches in outpatient settings and reducing the negative impact of no-shows in our underserved rural patient populations.

METHODS

Retrospective data (2021) were obtained from the MCHS scheduling system, which included 1,260,083 total appointments from 263,464 patients, as well as their demographic, appointment, and insurance information. We used descriptive statistics to associate variables with show or no-show status, logistic regression, and random forests utilized, and eXtreme Gradient Boosting (XGBoost) was chosen to develop the final model, determine cut-offs, and evaluate performance. We also used the model to predict future no-shows for appointments from 2022 and onwards.

RESULTS

The no-show rate was 6.0% in both the train and test datasets. The train and test datasets both yielded 5.98. Appointments scheduled further in advance (> 60 days of lead time) had a higher (7.7%) no-show rate. Appointments for patients aged 21-30 had the highest no-show rate (11.8%), and those for patients over 60 years of age had the lowest (2.9%). The model predictions yielded an Area Under Curve (AUC) of 0.84 for the train set and 0.83 for the test set. With the cut-off set to 0.4, the sensitivity was 0.71 and the positive predictive value was 0.18. Model results were used to recommend 1 overbook for every 6 at-risk appointments per provider per day.

CONCLUSIONS

Our findings demonstrate the feasibility of developing a predictive model based on administrative data from a predominantly rural healthcare system. Our new model distinguished between show and no-show appointments with high performance, and 1 overbook was advised for every 6 at-risk appointments. This data-driven approach to mitigating the impact of no-shows increases treatment availability in rural areas by overbooking appointment slots on days with an elevated risk of no-shows.

Rural-Urban Differences in Use of Dental Services and Procedures Among Medicare Beneficiaries in 2018

OBJECTIVE

Medicare beneficiaries in rural areas may face challenges in access to dental care. This study assessed rural-urban differences in the use of dental services and dental procedures by Medicare beneficiaries.

METHODS

We obtained data from the 2018 Medicare Current Beneficiary Survey cost and use files. Outcome variables examined in this study were (1) dental visits (yes/no), whether the Medicare beneficiary had ≥1 dental visit in the past year, and (2) dental procedures-preventive (yes/no), restorative (yes/no), and surgical procedures (yes/no)-whether the beneficiary had the procedure in a dental visit. The independent variable was the beneficiary's residence (rural vs urban). We used multiple logistic regression to analyze data and accounted for the survey design of the Medicare Current Beneficiary Survey. The analytic sample included 7377 respondents aged ≥65 years.

RESULTS

Approximately 57.0% (95% CI, 54.9%-59.0%) and 46.4% (95% CI, 41.6%-51.2%) of Medicare beneficiaries in urban and rural communities in the United States had a dental visit in 2018, respectively. Rural beneficiaries were significantly less likely than their urban counterparts to have preventive procedures (adjusted odds ratio = 0.51; 95% CI, 0.36-0.72) but significantly more likely to have restorative procedures (adjusted odds ratio = 1.30; 95% CI, 1.05-1.62).

CONCLUSION

We found significant disparities in use of dental services by Medicare beneficiaries in rural communities. When Medicare beneficiaries in rural areas used dental care, they were less likely than beneficiaries in urban areas to have preventive procedures but more likely to have restorative procedures, suggesting a greater burden of oral health needs among them. Policy research is needed to identify models that can incentivize prevention and improve access to dental care for Medicare beneficiaries in rural communities.

Perspective of healthcare providers on assessing the quality and accessibility of health services for chronic diseases in Jordan during Covid-19: a mixed method study

BACKGROUND

Hospital services in all parts of the world were severely affected by the crisis caused by the Coronavirus pandemic. This was particularly concerning for patients who suffer from chronic diseases.

AIM

This study aimed to: assess the level of quality and accessibility of chronic disease services from the perspectives of healthcare providers, assess the association between healthcare providers' socio-demographic factors and their perspectives on accessibility and quality level, and explore the providers' perspectives on the barriers and facilitators of quality and accessibility to chronic disease health services during the COVID -19 pandemic.

METHOD

Design: An explanatory mixed method design was employed in this study using a questionnaire and focus group discussion approach. The questionnaire consisted of three sections including, demographic, accessibility, and quality.

SAMPLE

A convenience sampling approach was used to collect the quantitative from 412 healthcare providers working at public, private, and teaching hospitals. A purposive sample of 12 healthcare providers were interviewed to collect the qualitative data.

ANALYSIS

The quantitative data were analyzed using SPSS Statistics Version 25. The qualitative data was analyzed using the thematic analysis approach.

RESULTS

This study found that the quality and accessibility of chronic disease services in northern Jordan were affected during COVID-19. Quantitative: The majority of the participants reported moderate level of accessibility and quality. Qualitative: Four main and six subthemes were identified: 1) Accessibility barriers including transportation and fear of infection; 2) Accessibility facilitators including availability of Personal Protective Equipment (PPE) and Covid-19 vaccination; 3) Quality barriers including staff shortage; 4) Quality facilitators including safety protocol.

CONCLUSION

The quality and accessibility of chronic disease services were affected due to the healthcare system restating to address the Covid-19 pandemic. Different barriers and facilitators for chronic disease healthcare services accessibility and quality were identified. The findings of this study lay the ground for healthcare decision and policymakers to develop strategies and formulate polices to ensure these patients receive the needed healthcare services, and hence improve their health outcomes.

Comparison of socio-economic determinants of COVID-19 testing and positivity in Canada: A multi-provincial analysis

BACKGROUND

The effects of the COVID-19 pandemic have been more pronounced for socially disadvantaged populations. We sought to determine how access to SARS-CoV-2 testing and the likelihood of testing positive for COVID-19 were associated with demographic factors, socioeconomic status (SES) and social determinants of health (SDH) in three Canadian provinces.

METHODS

An observational population-based cross-sectional study was conducted for the provinces of Ontario, Manitoba and New Brunswick between March 1, 2020 and April 27, 2021, using provincial health administrative data. After excluding residents of long-term care homes, those without current provincial health insurance and those who were tested for COVID-19 out of province, records from provincial healthcare administrative databases were reviewed for 16,900,661 healthcare users. Data was modelled separately for each province in accordance to a prespecified protocol and follow-up consultations among provincial statisticians and collaborators. We employed univariate and multivariate regression models to examine determinants of testing and test results.

RESULTS

After adjustment for other variables, female sex and urban residency were positively associated with testing, while female sex was negatively associated with test positivity. In New Brunswick and Ontario, individuals living in higher income areas were more likely to be tested, whereas in Manitoba higher income was negatively associated with both testing and positivity. High ethnocultural composition was associated with lower testing rates. Both high ethnocultural composition and high situational vulnerability increased the odds of testing positive for SARS-CoV-2.

DISCUSSION

We observed that multiple demographic, income and SDH factors were associated with SARS-CoV-2 testing and test positivity. Barriers to healthcare access identified in this study specifically relate to COVID-19 testing but may reflect broader inequities for certain at-risk groups.

A Survey of Cancer Risk Behaviors, Beliefs, and Social Drivers of Health in New Hampshire and Vermont

Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents (N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas (P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas.

Significance

In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account.

Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas

Federally qualified health centers (FQHCs) improve access to care for important health services (e.g., preventive care), particularly among marginalized and underserved communities. However, whether spatial availability of FQHCs influences care-seeking behavior for medically underserved residents is unclear. The objective of this study was to examine the relationships of present-day zip-code level availability of FQHCs, historic redlining, and health services utilization (i.e., at FQHCs and any health clinic/facility) in six large states. We further examined these associations by states, FQHC availability (i.e., 1, 2-4 and ≥5 FQHC sites per zip code) and geographic areas (i.e., urbanized vs. rural, redlined vs. non-redlined sections of urban areas). Using Poisson and multivariate regression models, we found that in medically underserved areas, having at least one FQHC site was associated with greater likelihood of patients seeking health services at FQHCs [rate ratio (RR) = 3.27, 95%CI: 2.27-4.70] than areas with no FQHCs available, varying across states (RRs = 1.12 to 6.33). Relationships were stronger in zip codes with ≥5 FQHC sites, small towns, metropolitan areas, and redlined sections of urban areas (HOLC D-grade vs. C-grade: RR = 1.24, 95%CI: 1.21-1.27). However, these relationships did not remain true for routine care visits at any health clinic or facility (β = -0.122; p = 0.008) or with worsening HOLC grades (β = -0.082; p = 0.750), potentially due to the contextual factors associated with FQHC locations. Findings suggest that efforts to expand FQHCs may be most impactful for medically underserved residents living in small towns, metropolitan areas and redlined sections of urban areas. Because FQHCs can provide high quality, culturally competent, cost-effective access to important primary care, behavioral health, and enabling services that uniquely benefit low-income and marginalized patient populations, particularly those who have been historically denied access to health care, improving availability of FQHCs may be an important mechanism for improving health care access and reducing subsequent inequities for these underserved groups.

Development of an Online Training Platform and Implementation Strategy for School-Based Mental Health Professionals in Rural Elementary Schools: A Mixed-Methods Study

Children in rural settings are less likely to receive mental health services than their urban and suburban counterparts and even less likely to receive evidence-based care. Rural schools could address the need for mental health interventions by using evidence-based practices within a tiered system of supports such as positive behavioral interventions and supports. However, very few school professionals, with or without mental health training, have received training on evidence-based practices. Rural schools need implementation strategies focused on training to prepare school personnel for the implementation of interventions with fidelity. Little is known about training strategies that are feasible and appropriate for the rural school context. User-centered design is an appropriate framework for the development of training strategies for professionals in rural schools because of its participatory approach and the development of products that fit the context where they are going to be used. The purpose of the study was to develop and assess components of an online training platform and implementation strategy based on the user-centered design. Quantitative and qualitative data from 25 participants from an equal number of schools in rural areas of Pennsylvania were used in the study. A mixed-methods design utilizing complementary descriptive statistics and theme analyses indicated that the training platform and implementation strategy were perceived as highly acceptable, appropriate, feasible and usable by school professionals. The resulting training platform and implementation strategy will fill a void in the training literature in rural schools.

Making a Bad Situation Worse: Examining the Challenges Facing Rural Home Care Workers

This study examines the unique challenges facing rural home care workers. Semi-structured interviews were undertaken between July 2021 and February 2022 with 23 participants that have experience in rural home care delivery. The major challenge confronting rural home care workers involved distance and transportation. This challenge emerged due to long distance between clients, unreliable vehicles, inadequate reimbursement, and inclement weather. In turn, this challenge exacerbated three other types of challenges facing rural home care workers: workforce challenges that consisted of a persistent labor shortage and shorter visits that forced workers to rush through tasks, client isolation due to the social and physical seclusion of households, and the poor working conditions of home care work more broadly. Without policy interventions that respond to these particular challenges, the care gap in rural areas can be expected to grow.

Socio-demographic disparities in health-related quality of life after hip fracture in China: evidence from the China Health and Retirement Longitudinal Study

This study analyzed the impact of hip fractures on people's health-related quality of life and its socio-demographic disparities in China.

PURPOSE

Hip fractures cause high mortality and worsened health-related quality of life (HRQoL). This study aimed to investigate whether socio-demographic-related inequities in post-hip fracture participants' HRQoL exist in China.

METHODS

Data from the China Health and Retirement Longitudinal Study (waves 2013, 2015, and 2018) were used. The measurement of HRQoL in this study focused on 5 health dimensions: depression, body pain, mobility, basic activities of daily living, and instrumental activities of daily living. A difference-in-differences (DID) analysis with multiple time periods was performed to gauge the impact of hip fracture on HRQoL. A multivariate regression approach was used to explore socio-demographic-related factors associated with inequities of HRQoL.

RESULTS

A total of 23,622 individuals were included, and 341 participants reported hip fracture events during the survey period. In participants with hip fracture, the presentation rate of body pain increased by 14% (p < 0.01) and the HRQoL of other health dimensions worsened (p ≤ 0.01) after hip fracture. The DID analysis showed that hip fracture had a negative impact on all HRQoL dimensions (p < 0.01). Socioeconomic-related factors of HRQoL inequities included school education level and location of residence. Study participants with hip fracture with greater educational attainment or living in urban areas had higher (p < 0.05) levels of HRQoL. In addition, comorbidities also correlated with a worse HRQoL (p < 0.05).

CONCLUSION

Hip fracture significantly affects people's HRQoL in China, and the impact is more profound for those with lower educational attainment or living in rural areas. Targeted interventions should be designed to narrow this inequity.

Factors associated with delaying medical care: cross-sectional study of Nebraska adults

BACKGROUND

Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state.

METHODS

Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals.

RESULTS

The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)].

CONCLUSIONS

Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

Reliving it All Over Again: Uncanny Temporalities of Injection Drug Use and Hepatitis C Diagnosis in Southwest Virginia, USA

Clinicians typically view the intersection between hepatitis C and injection drug use in terms of simultaneity - with transmission occurring via shared needles - or sequentially - with some states requiring that people stop using drugs prior to treatment. Yet, for patients, the connection between substance use and HCV infection can follow a more complex temporal pathway. In this article, we explore the non-linear temporality of "reliving" as it shapes HCV illness experience, its complex intersection with injection drug use, and the barriers patients face as they reckon with existing healthcare system responses and treatment modalities.

Medical and social determinants of health as predictors of adverse outcomes in patients with inflammatory bowel disease

There is a growing recognition that social determinants of health (SDOH) influence outcomes in patients with chronic diseases. This study aimed to investigate the influence of SDOH on outcomes in patients with inflammatory bowel disease (IBD). We conducted a retrospective cohort study of adult patients with IBD from 1996 to 2019. Patients were identified using ICD-10 codes for ulcerative colitis and Crohn's disease, and chart review was performed to validate the diagnosis and extract clinical information. SDOH factors including food security, financial resources, and transportation were self-reported by the patient. Random forest models were trained and tested in R to predict either IBD-related hospitalization or surgery. A total of 175 patients were studied, and the majority reported no financial resource, food security, or transportation concerns. For the model using clinical predictors, the sensitivity was 0.68 and specificity was 0.77 with an area under the receiver operating characteristic curve (AUROC) of 0.77. The model's performance did not significantly improve with the addition of SDOH information (AUROC of 0.78); however, model performance did vary by phenotype (AUROC of 0.86 for patients with Crohn's disease and AUROC of 0.68 for patients with ulcerative colitis). Further research is needed to understand the role of SDOH factors and IBD-related outcomes.

Urban-rural disparities in the healthy ageing trajectory in China: a population-based study

Purpose

The aim of this study is to measure the trajectory of healthy ageing among Chinese middle-aged and older population, and explore the disparity of the trajectory, as well as contributing factors, between urban and rural areas in China.

Methods

A total of 9402 respondents aged 45 years and older interviewed in four waves (2011, 2013, 2015 and 2018) were selected from the China Health and Retirement Longitudinal Study. Healthy ageing score was calculated through item response theory. A latent growth mixture model (LGMM) was applied to distinguish the trajectory of healthy aging. A multinomial logistics regression model (MLRM) was used to explore the relationship between urban-rural areas and healthy aging trajectories, and further to explore associated factors in rural and urban areas separately.

Results

The healthy ageing score was lower in rural areas than urban areas in each survey wave. Five classes (“continuing-low”, “continuing-middle”, “continuing-middle-to-high”, “significantly-declining”, “continuing-high”) were grouped through LGMM. The MLRM results showed that urban living was significantly associated with a higher likelihood of being healthy (for [continuing-low/continuing-high]: β = − 1.17, RRR = 0.31, P < 0.001, 95% CI = 0.18–0.53; and for [continuing-middle/continuing-high]: β = − 0.53, RRR = 0.59, P < 0.001, 95% CI = 0.49–0.71).

Conclusion

Healthy ageing is a prominent objective in the development of a country, and rural-urban disparities are an essential obstacle to overcome, with the rural population more likely to develop a low level of healthy ageing trajectory. Prevention and standardized management of chronic diseases should be enhanced, and social participation should be encouraged to promote healthy ageing. The policy inclination and resource investment should be enhanced to reduce disparity in healthy ageing between urban and rural areas in China.

Family support and transport cost: understanding health service among older people from the perspective of social-ecological model

Background

This study is to investigate the interaction of family support, transport cost (ex-post), and disabilities on health service seeking behavior among older people from the perspective of social ecological model.

Method

We conduct a series of regressions including the Poisson model and Multiple logit model. The Heckman two-stage procedure is also conducted to check the robustness.

Results

Given that health care resources are generally concentrated in densely populated urban areas, access to services of higher-class health care facilities is found associated with higher transport cost (ex-post). Family support could also promote the access to higher-class health care facilities. Although disability may impede such access, this effect may be mitigated by paying higher transport cost (ex-post).

Conclusions

Alleviating transport deprivation and promoting family support are critical for access to better healthcare services among older people with disabilities.

Problems and Strategies of Allocating Public Service Resources in Rural Areas in the Context of County Urbanization

Imbalances in allocating public service resources are a universal problem worldwide, especially in urban and rural areas. As a developing country with a significant imbalance between urban and rural areas, China is representative of the unbalanced allocation of public service resources. Presently, China has entered the county urbanization stage. Therefore, this study can provide a new way to realize the equalization of urban and rural public services with the county as the basic unit. Taking counties as the primary study area, this paper analyzes the new trends of population mobility in China's counties. It combines large-scale questionnaires and field surveys to investigate the new demand of rural residents for public services and the shortcomings of public service resource allocation. First, the county seat attracts a concentration of the county's rural residents and returning population, whose high expectations for the county seat's education and medical services have not yet been met. Second, the township assumes the vital function of elementary school education and medical services in rural areas, and the rural children have a great demand for elementary school education services in the township. However, there are still apparent shortcomings in support of teaching facilities and the quality of education services. Third, the problem of aging and hollowing out in rural areas is serious, and the education, medical and elderly service needs of left-behind children and the elderly are difficult to be guaranteed. Finally, this paper proposes targeted planning strategies and policy recommendations for allocating county public service resources at three levels based on the "county-town-village" hierarchy.

The impact of patient travel time on disparities in treatment for early stage lung cancer in California

BACKGROUND

Travel time to treatment facilities may impede the receipt of guideline-concordant treatment (GCT) among patients diagnosed with early-stage non-small cell lung cancer (ES-NSCLC). We investigated the relative contribution of travel time in the receipt of GCT among ES-NSCLC patients.

METHODS

We included 22,821 ES-NSCLC patients diagnosed in California from 2006-2015. GCT was defined using the 2016 National Comprehensive Cancer Network guidelines, and delayed treatment was defined as treatment initiation >6 versus ≤6 weeks after diagnosis. Mean-centered driving and public transit times were calculated from patients' residential block group centroid to the treatment facilities. We used logistic regression to estimate risk ratios and 95% confidence intervals (CIs) for the associations between patients' travel time and receipt of GCT and timely treatment, overall and by race/ethnicity and neighborhood socioeconomic status (nSES).

RESULTS

Overall, a 15-minute increase in travel time was associated with a decreased risk of undertreatment and delayed treatment. Compared to Whites, among Blacks, a 15-minute increase in driving time was associated with a 24% (95%CI = 8%-42%) increased risk of undertreatment, and among Filipinos, a 15-minute increase in public transit time was associated with a 27% (95%CI = 13%-42%) increased risk of delayed treatment. Compared to the highest nSES, among the lowest nSES, 15-minute increases in driving and public transit times were associated with 33% (95%CI = 16%-52%) and 27% (95%CI = 16%-39%) increases in the risk of undertreatment and delayed treatment, respectively.

CONCLUSION

The benefit of GCT observed with increased travel times may be a 'Travel Time Paradox,' and may vary across racial/ethnic and socioeconomic groups.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Regional variation in healthcare usage for Medicare beneficiaries: a cross-sectional study based on the health and retirement study

OBJECTIVES

To investigate whether regional variation changes with different beneficiary health insurance coverage types.

DESIGN

A cross-sectional study of the Health and Retirement Study (HRS) in 2018 was used.

SETTING

Medicare beneficiaries only covered by Medicare (group 1) are compared with those covered by Medicare and other health insurance (group 2). Outcomes included healthcare usage measures: (1) whether beneficiaries have a hospital stay and (2) the number for those with at least one stay; (3) whether beneficiaries have a doctor's visit and (4) the number for those with at least one visit. We compared healthcare usage in both groups across the five regions: (1) New England and Mid-Atlantic; (2) East North Central and West North Central; (3) South Atlantic; (4) East South Central and West South Central; (5) Mountain and Pacific. We used logistic regression for binary outcomes and negative binomial regression for count outcomes in each group.

PARTICIPANTS

We identified 8749 Medicare beneficiaries, of which 4098 in group 1 and 4651 in group 2.

RESULTS

Residents in all non-reference regions had a significantly lower probability of seeking a doctor's visit in group 1 (OR with 95% CI 0.606 (0.374 to 0.982), 0.619 (0.392 to 0.977), 0.472 (0.299 to 0.746) and 0.618 (0.386 to 0.990) in the order of above regions, respectively), which is not significant in group 2. Residents in most non-reference regions (except South Atlantic) had a significantly fewer number of seeking a hospital stay in group 2 (incident rate ratio (IRR) with 95% CI 0.797 (0.691 to 0.919), 0.740 (0.643 to 0.865), 0.726 (0.613 to 0.859) in the order of above regions, respectively), which is not significant in group 1.

CONCLUSION

Regional variation in the likelihood of having a doctor's visit was reduced in Medicare beneficiaries covered by supplemental health insurance. Regional variation in hospital stays was accentuated among Medicare beneficiaries covered by supplemental health insurance.

Understanding the relationship between eye disease and driving in very old Australian women: a longitudinal thematic evaluation

Background

Over recent decades an increasing number of adults will retain their driver’s licenses well into their later years. The aim of this study was to understand and explore the experience of driving and driving cessation in very old Australian women with self-reported eye disease.

Methods

An interpretative qualitative study. Participants were from the Australian Longitudinal Study on Women’s Health (cohort born in 1921–26), a sample broadly representative of similarly aged Australian women. Responses to open-ended questions were analysed using an inductive thematic approach, employing a process of constant comparison.

Results

Qualitative data were from 216 older women with eye disease who made 2199 comments about driving, aged between 70 and 90 years depending on the timing of their comments. Themes included: (1) Access to treatment for eye disease promotes driving independence and quality of life; (2) Driving with restrictions for eye disease enables community engagement and (3) Driving cessation due to poor vision leads to significant lifestyle changes.

Conclusions

Key findings highlighted driving cessation, or reduction, is often attributed to deterioration in vision. The consequence is dependence on others for transport, typically children and friends. Access to successful treatment for eye disease allowed older women to continue driving. We posit that occupational therapists can play an essential role in promote driving confidence and ability as women age.

Trial registration: Not applicable.

Regional Variation in National Healthcare Expenditure and Health System Performance in Central Cities and Suburbs in Japan

The increasing national healthcare expenditure (NHE) with the aging rate is a significant social problem in Japan, and efficient distribution and use of NHE is an urgent issue. It is assumed that comparisons in subregions would be important to explore the regional variation in NHE and health system performance in targeted municipalities of the metropolitan area of Tokyo (central cities) and the neighboring municipalities of Chiba Prefecture (suburbs). This study aimed to clarify the differences of the socioeconomic factors affecting NHE and the health system performances between subregions. A multiple regression analysis was performed to extract the factors affecting the total medical expenses of NHE (Total), comprising the medical expenses of inpatients (MEI), medical expenses of outpatients (MEO), and consultation rates of inpatients (CRI) and outpatients (CRO). Using the stepwise method, dependent variables were selected from three categories: health service, socioeconomic, and lifestyle. Then, health system performance analysis was performed, and the differences between regions were clarified using the Mann–Whitney U test. The test was applied to 18 indicators, classified into five dimensions referred to in the OECD indicators: health status, risk factors for health, access to care, quality of care, and health system capacity and resources. In the central cities, the number of persons per household was the primary factor affecting Total, MEI, MEO, and CRO, and the number of persons per household and the percentage of the entirely unemployed persons primarily affected CRI. In the suburbs, the ratio of the population aged 65–74 and the number of hospital beds were significantly positively related to Total, MEI, and CRI, but the number of workers employed in primary industries was negatively related to Total and MEI. The ratio of the population aged 65–74 was significantly positively related to MEO and CRO. Regarding health system performance, while risk factors for health was high in the central cities, the others, including access to care, quality of care, and health system capacity and resources, were superior in the suburbs, suggesting that the health system might be well developed to compensate for the risks. In the suburbs, while risk factors for health were lower than those in the central cities, access to care, quality of care, and health system capacity and resources were also lower, suggesting that the healthcare system might be poorer. These results indicate a need to prioritize mitigating healthcare disparities in the central cities and promoting the health of the elderly in the suburbs by expanding the suburbs’ healthcare systems and resources. This study clarified that the determinants of NHE and health system performance are drastically varied among subregional levels and suggested the importance of precise regional moderation of the healthcare system.

Transportation Patterns of Adults With Travel-Limiting Disabilities in Rural and Urban America

Introduction

Lack of transportation is a significant barrier to community participation for many disabled adults. Living in a rural area introduces additional transportation barriers, such as having to travel long distances to access services or socialize, and limited public transit options. While the importance of transportation access is clear, the mix of different transportation options used by people with disabilities to participate in their communities is less understood, particularly among those who do not or cannot drive.

Methods

We used data from the 2017 National Household Travel Survey to explore transportation behaviors among disabled adults in rural and urban areas and by four regions across the United States. We explored differences by transportation modalities (e.g., driver, passenger, public transportation, taxi/uber, walk) and trip purposes (e.g., social, independent living, healthcare, work). Our sample included 22,716 adults with travel-limiting disabilities.

Results

Several geographic differences emerged among non-drivers. Rural non-drivers were less likely to take any trip, particularly for social activities, and reported using less public transportation or walking/rolling than urban non-drivers. Further, respondents from the Northeast were more likely to report using public transportation and walking/rolling options, relative to the Midwest, South, and West. Overall, disabled rural adults reported lower odds of giving up driving, even after controlling for socio-demographic and health characteristics.

Discussion

These findings highlight the relative importance of different transportation modalities for participating in activities and the continued reliance upon personal vehicles, either as a driver or passenger, especially among rural disabled residents. Potential policy insights are discussed.

Trajectories and Outcomes of Adolescents that Ride With an Impaired Driver/Drive While Impaired

INTRODUCTION

For young drivers, independent transportation has been noted to offer them opportunities that can be beneficial as they enter early adulthood. However, those that choose to engage in riding with an impaired driver (RWI) and drive while impaired (DWI) over time can face negative consequences reducing such opportunities. This study examined the prospective association of identified longitudinal trajectory classes among adolescents that RWI and DWI with their later health, education, and employment in emerging adulthood.

METHODS

We analyzed all seven annual assessments (Waves, W1-W7) of the NEXT Generation Health Study, a nationally representative longitudinal study starting with 10^th grade (2009-2010 school year). Using all seven waves, trajectory classes were identified by latent class analysis with RWI (last 12 months) and DWI (last 30 days) dichotomized as ≥once = 1 vs. none = 0.

RESULTS

Four RWI trajectories and four DWI trajectories were identified: abstainer, escalator, decliner, and persister. For RWI and DWI trajectories respectively, 45.0% (N=647) and 76.2% (N=1,657) were abstainers, 15.6% (N=226) and 14.2% (N=337) were escalators, 25.0% (N=352) and 5.4% (N=99) were decliners, and 14.4% (N=197) and 3.8% (N=83) persisters. RWI trajectories were associated with W7 health status (χ²=13,20, p<.01) and education attainment (χ²=18.37, p<.01). Adolescent RWI abstainers reported better later health status than RWI escalators, decliners, and persisters; and decliners reported less favorable later education attainment than abstainers, escalators, and persisters. DWI trajectories showed no association with health status, education attainment, or employment.

CONCLUSIONS

Our findings suggest the importance of later health outcomes of adolescent RWI. The mixed findings point to the need for more detailed understanding of contextual and time-dependent trajectory outcomes among adolescents engaging in RWI and DWI.

Quantifying rural disparity in healthcare utilization in the United States: Analysis of a large midwestern healthcare system

PURPOSE

The objective of this study is to identify how predisposing characteristics, enabling factors, and health needs are jointly and individually associated with epidemiological patterns of outpatient healthcare utilization for patients who already interact and engage with a large healthcare system.

METHODS

We retrospectively analyzed electronic medical record data from 1,423,166 outpatient clinic visits from 474,674 patients in a large healthcare system from June 2018-March 2019. We evaluated patients who exclusively visited rural clinics versus patients who exclusively visited urban clinics using Chi-square tests and the generalized estimating equation Poisson regression methodology. The outcome was healthcare use defined by the number of outpatient visits to clinics within the healthcare system and independent variables included age, gender, race, ethnicity, smoking status, health status, and rural or urban clinic location. Supplementary analyses were conducted observing healthcare use patterns within rural and urban clinics separately and within primary care and specialty clinics separately.

FINDINGS

Patients in rural clinics vs. urban clinics had worse health status [χ2 = 935.1, df = 3, p<0.0001]. Additionally, patients in rural clinics had lower healthcare utilization than patients in urban clinics, adjusting for age, race, ethnicity, gender, smoking, and health status [2.49 vs. 3.18 visits, RR = 0.61, 95%CI = (0.55,0.68), p<0.0001]. Further, patients in rural clinics had lower utilization for both primary care and specialty care visits.

CONCLUSIONS

Within the large healthcare system, patients in rural clinics had lower outpatient healthcare utilization compared to their urban counterparts despite having potentially elevated health needs reflected by a higher number of unique health diagnoses documented in their electronic health records after adjusting for multiple factors. This work can inform future studies exploring the roots and ramifications of rural-urban healthcare utilization differences and rural healthcare disparities.

Age and Medicare Insurance are Barriers to Telemedicine Access—A Quality Improvement Project

Background

Telehealth use has had widespread expansion and adoption over the past two years. This study aims to evaluate access to telehealth essentials (TE) using a novel metric.

Methods

This single institute study surveyed outpatient surgical patients to determine their access to TE. Generalized linear mixed models were used to determine the relationship of demographic and county-level variables on access to four TE.

Results

138 patients were surveyed. Sixty-six (47.8%) were from Appalachian Kentucky. In the survey cohort, 122 (88.4%) had smart phones, 109 (80.7%) had devices with video messaging capabilities, 106 (80.9%) had cellular reception, and 112 (82.4%) had access to WiFi. Increasing age and Medicare insurance were the most consistent predictors of lack of access to TE.

Conclusion

Rural Appalachian Kentucky has access to TE. Telehealth has the potential to decrease the healthcare inequity in rural populations, but incompletely address this inequity for the aging population.

Difference in medical service use among Korean gastric cancer survivors according to regional healthcare vulnerabilities: a cohort study

PURPOSE

This study investigated the relationship between medical service use and healthcare vulnerability, pre- and post-gastric cancer diagnosis. Differences between healthcare-vulnerable and healthcare-nonvulnerable regions identified inequities that require intervention.

METHODS

This cohort study was done using the National Health Insurance claims data of patients diagnosed with gastric cancer between 2004 and 2013. The Position Value for Relative Comparison Index was used to determine whether the patients lived in a healthcare-vulnerable region. Medical service use was classified into annual outpatient treatment, hospitalization days, and emergency treatment. We used a generalized linear model to which the Poisson distribution was applied and compared regional differences in medical service use.

RESULTS

A total of 1797 gastric cancer patients who had survived 5 years post-diagnosis were included in the study, of which 14.2% lived in healthcare-vulnerable regions. The patients in vulnerable regions surviving 5-7 years post-diagnosis had a higher number of outpatient visits than those in nonvulnerable regions. Furthermore, hospitalization days were lesser for patients in vulnerable regions who survived 6 years post-diagnosis than those in nonvulnerable regions; however, this number increased in the seventh year.

CONCLUSIONS

Our results suggest that gastric cancer survivors living in healthcare-vulnerable regions have a higher probability of increased medical service use 5 years post-diagnosis compared with patients in nonvulnerable regions, which may significantly increase healthcare disparities over time. Therefore, in the future, additional research is needed to elucidate the causes of the disparities in healthcare use and the results of the differences in health outcomes.

Road and Transportation Lead to Better Health and Sustainable Destination Development in Host Community: A Case of China Pakistan Economic Corridor (CPEC)

Road and transportation plays a vital role in the sustainable development and prosperity of the area. This study investigates the impact of road and transportation on the health of the host community and its sustainable destination development. Data were collected from the host community and were analyzed through factor analysis and structure equation modeling to evaluate the in-hand data of the structural relationship. It is revealed that road and transportation has a significant role in the improvement of health. Moreover, income mediates the effects of accessibility and employment on health. This study will help the authorities and policy maker to formulate policy regarding road and transportation that will improve health of the host community and its sustainable development. The study is limited to the seven districts of Hazara division and explores the societal aspect of CPEC on the host community, future researcher may investigate other regions and may select some other variables such as effect on GDP, per capita income, etc.

Social determinants of health associated with poor outcome for rural patients following resected pancreatic cancer

BACKGROUND

The impact of rurality on outcome for patients who had resected pancreatic ductal adenocarcinoma (PDAC) is unclear. We hypothesize that poor outcomes for rural patients are associated with adverse social determinants of health (SDoH). The objective of this study is to assess the difference in overall survival (OS) of PDAC patients between rural, urban, and contributing factors.

METHODS

A cohort of 25,536 patients diagnosed with stage I-III pancreatic adenocarcinoma from 2003 to 2011 and underwent resection were evaluated from the National Cancer Database. Socioeconomic/demographic, clinicopathological, and treatment variables were compared between rural and urban residences. The 5-year OS was calculated using the Kaplan-Meier method. The Cox regression model was used to assess factors associated with OS. P value <0.05 was considered significant.

RESULTS

In univariate analysis, the rural residence was a predictor of poor OS. The 5-year OS for rural (N=4,389) and urban (N=21,147) was 18.8% (95% CI: 17.4-20.2%) and 22.3% (95% CI: 21.6-22.9%; P<0.0001), respectively. The risk of all causes of death was 10.3% higher (P<0.0001) in rural than urban patients. In multivariable analysis, rurality was not an independent predictor of OS (P=0.407). Independent predictors of worse OS included adverse social determinants of health associated with the rural population and these included a low income (P<0.0001), low education level (P<0.01), low insurance status (P<0.01), and treatment at a low-volume facility (P<0.0001).

CONCLUSIONS

Rural/urban outcome disparities for resected stage I-III pancreatic cancer outcome can be explained by adverse social determinants of health associated with rural population.

Urbanicity, Health, and Access to Services for People With Intellectual Disability and Developmental Disabilities

Previous research suggests that residence in non-metropolitan areas is associated with lower access to preventive care and poorer health. However, this research has been largely restricted to the general population, despite data demonstrating disparities in health status and access to healthcare services for people with intellectual and developmental disabilities (IDD). The current study examined several hypotheses involving the effects of rurality on access to preventive healthcare and services and health status: (1) individuals in non-metropolitan areas will have lower preventive healthcare utilization, (2) individuals in non-metropolitan areas will have poorer health outcomes, and (3) individuals in non-metropolitan areas will have poorer access to services. The current study uses data from the National Core Indicators (NCI) Adult Consumer Survey 2015-2016: Final Report which included Rural-Urban Commuting Area (RUCA) Codes for the first time. Results of logistic regression suggest that, despite connection to disability services, the health status and access to preventive healthcare services of people with IDD generally follow patterns similar to those observed in the general population. Namely, people with IDD in non-metropolitan areas have decreased access to healthcare services, preventive healthcare utilization, and health status. Despite some exceptions, it appears effects of rurality are not completely mitigated by current state and federal efforts.

Effectiveness of a Novel Implementation of the Otago Exercise Program in Rural Appalachia

BACKGROUND AND PURPOSE

Despite evidence that falls can be prevented with specific exercise interventions such as the Otago Exercise Program (OEP), translation of these programs into practice is limited in rural and medically underserved areas. The Community Health and Mobility Partnership (CHAMP) addresses this problem through a community-based implementation of the OEP in rural Appalachia where medical resources are scarce. The purpose of this study was to examine the effects of the CHAMP on physical performance and balance confidence in community-dwelling older adults.

METHODS

This study was a retrospective analysis of quasi-longitudinal data. Older adults received fall screenings at local senior centers. Those with increased fall risk received individualized OEP home exercises and were advised to return for monthly follow-up visits. Three physical performance measures-Timed Up and Go test (TUG), Four-Stage Balance Test (4SBT), and chair rise test (CRT)-and the Activities-specific Balance Confidence scale (ABC) were assessed at the initial visit (IV) and each follow-up visit. Two groups were created to distinguish participants who returned for their second follow-up (F2) visit within 3 months from those who returned between 3 and 6 months. Within-group change from IV to F2 was calculated using repeated-measures t tests. Repeated-measures 2-way analyses of variance were used to test for main and interaction effects of group and visit.

RESULTS AND DISCUSSION

One hundred thirty CHAMP participants aged 76.1 (SD = 8.1) years demonstrated statistically and clinically significant improvements in the 3 physical performance measures (mean 4SBT: IV 29.5 seconds, F2 31.5 second, P = .001), (mean TUG: IV 12.7 seconds, F2 11.9 seconds, P = .021), (mean CRT: IV 0.258 stands/second, F2 0.290 stands/second, P = .002), but not in balance confidence (mean ABC: IV 62.2, F2 64.4, P = .154). A significant interaction of group by visit for the TUG was observed, suggesting that better TUG performance was associated with quicker return for follow-up.

CONCLUSIONS

Results indicated that program participants improved from IV to F2 in measures related to fall risk.

Running an Internet Hospital in China: Perspective Based on a Case Study

Internet hospitals, as a new forum for doctors to conduct diagnosis and treatment activities based on the internet, are emerging in China and have become integral to the development of the medical field in conjunction with increasing reforms and policies in China's medical and health system. Here, we take the Internet Hospital of the First Affiliated Hospital, Zhejiang University (FAHZU Internet Hospital) as an example to discuss the operations and functional positioning of developing internet hospital medical services in relation to physical hospitals. This viewpoint considers the platform operation, management, and network security of FAHZU Internet Hospital, and summarizes the advantages and limitations in the operation to provide a reference for other areas with interest in developing internet hospitals.

State-Level Numbers and Rates of Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths in 2014

OBJECTIVE

To provide state-level traumatic brain injury (TBI)-related emergency department (ED) visit, hospitalization, and death estimates for 2014.

SETTING AND PARTICIPANTS

The Centers for Disease Control and Prevention's Core Violence and Injury Prevention Program and State Injury Indicators participating states.

DESIGN

Cross-sectional.

MAIN MEASURES

Number and incidence rates of TBI-related ED visits, hospitalizations, and deaths in more than 30 states.

RESULTS

The rates of TBI-related ED visits in 2014 ranged from 381.1 per 100 000 (South Dakota) to 998.4 per 100 000 (Massachusetts). In 2014, Pennsylvania had the highest TBI-related hospitalization rate (98.9) and Ohio had the lowest (55.1). In 2014, the TBI-related death rate ranged from 9.1 per 100 000 (New Jersey) to 23.0 per 100 000 (Oklahoma).

CONCLUSION

The variations in TBI burden among states support the need for tailoring prevention efforts to state needs. Results of this analysis can serve as a baseline for these efforts.