A Longitudinal Analysis of Rural and Urban Veterans’ Health-Related Quality of Life

Rural veteran perception of healthcare access in South Carolina and Florida: a qualitative study

BACKGROUND

Access to mental and physical healthcare in rural areas is challenging for Veterans and their families but essential for good health. Even though recent research has revealed some of the challenges rural Veterans face accessing healthcare, a complete understanding of the gap in access is still unclear.

METHODS

This qualitative study aimed to explore participants' perceptions of healthcare access. Structured interviews were conducted with 124 Veterans and spouses of Veterans from rural qualifying counties in South Carolina and Florida.

RESULTS

The study's results revealed five main dimensions of access: geographic proximity, transportation, communication, cultural competence, and resources. Distance to service needed can negatively impact access for Veterans and their families in general, especially for those whose health is declining or who cannot drive because of their age. Lack of transportation, problems with transportation services, and lack of public transportation can lead to delays in care. Additionally, the lack of communication with the Veterans Affairs (VA) Health System and with the healthcare team, as well as inefficient communication among the healthcare team, lack of coordination of care between the VA health system and community providers, and the lack of cultural competence of healthcare providers and contracted personnel made access to services even more challenging.

CONCLUSIONS

Improving communication can help to develop a sense of trust between Veterans and the VA, and between Veterans and spouses with the healthcare team. It can also lead to increased patient satisfaction. Ensuring healthcare providers and contracted personnel are culturally competent to talk and treat Veterans can improve patient trust and adherence to treatment. Lastly, resource-related challenges included financial problems, lack of prompt access to appointments, lack of providers, limited access to local clinics and hospitals, limited local programs available, and reimbursement issues.

Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access.

OBJECTIVE

To evaluate PC wait times before and after CRH implementation.

DESIGN

Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods.

PARTICIPANTS

Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics.

MAIN MEASURES

Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations.

KEY RESULTS

PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time.

CONCLUSIONS

In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.

Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans

Alcohol misuse - defined as consuming more than 14 units of alcohol per week - is a well-established problem among veterans. This study investigated the change in quality of life among help-seeking UK veterans who completed a 28-day brief alcohol intervention delivered via a digital smartphone application (called DrinksRation) and have previously sought clinical help for a mental health disorder. This study was a secondary outcome analysis of data collected during a randomised control trial. In total, 123 UK veterans participated in the study and were randomly allocated to either the intervention or control arm. Participants completed self-report questionnaires regarding their alcohol use and quality of life (WHOQOL-BREF) at baseline, day 28 (end of intervention), day 84, and day 168. At the primary endpoint (day 84), we found significantly greater improvements in the intervention arm compared to the control arm for psychological quality of life (Cohen's d = 0.47), and environmental quality of life (d = 0.34). However, we observed no statistically significant differences between the intervention and control arm for social relationships and physical quality of life. Further, for day 168 we found no significant differences. Findings suggest that DrinksRation can increase quality of life among help-seeking veterans who have previously sought help for a mental health disorder, but the increases were modest and restricted to certain domains. Additional treatment may be needed for long-term and sustained improvements in quality of life.

Implementation of LGBTQ+ affirming care policies in the Veterans Health Administration: preliminary findings on barriers and facilitators in the southern United States

Background

In the United States Department of Veterans Affairs (VA), veterans who are lesbian, gay, bisexual, transgender, queer, and similar gender and sexual minoritized people (LGBTQ+) experience health disparities compared to cisgender, heterosexual veterans. VA's LGBTQ+ Health Program created two healthcare policies on providing LGBTQ+ affirming care (healthcare that is inclusive, validating, and understanding of the LGBTQ+ population). The current project examines providers' barriers and facilitators to providing LGBTQ+ affirming care and LGBTQ+ veterans' barriers and facilitators to receiving LGBTQ+ affirming care.

Methods

Data collection and analysis were informed by the Consolidated Framework for Implementation Research, which was adapted to include three health equity domains. Data collection involved telephone interviews conducted with 11 VA providers and 12 LGBTQ+ veterans at one rural and one urban VA medical center, and one rural VA community clinic. Qualitative data were rapidly analyzed using template analysis, a data reduction technique.

Results

Providers described limited education, limited time, lack of experience with the population, and a lack of awareness of resources as barriers. Providers discussed comfort with consulting trusted peers, interest in learning more about providing LGBTQ+ affirming care, and openness and acceptance of the LGBTQ+ community as facilitators. LGBTQ+ veterans described a lack of provider awareness of their needs, concerns related to safety and discrimination, and structural discrimination as barriers. LGBTQ+ veterans described positive relationships with providers, knowledge of their own healthcare needs, and ability to advocate for their healthcare needs as facilitators. Although VA's LGBTQ+ affirming care policies are in place, providers and veterans noted a lack of awareness regarding specific healthcare processes.

Conclusion

Allowing more time and capacity for education and engaging LGBTQ+ veterans in determining how to improve their healthcare may be the path forward to increase adherence to LGBTQ+ affirming care policies. Engaging patients, especially those from marginalized backgrounds, in strategies focused on the uptake of policy may be a path to improve policy implementation. It is possible that creating truly collaborative structures in which patients, staff, providers, leadership, and policymakers can work together towards policy implementation may be a useful strategy. In turn, improved policy implementation would result in increased physical and mental health for LGBTQ+ veterans.

Jumping Through Hoops: Community Care Clinician and Staff Experiences Providing Primary Care to Rural Veterans

BACKGROUND

The 2019 VA Maintaining Systems and Strengthening Integrated Outside Networks Act, or MISSION Act, aimed to improve rural veteran access to care by expanding coverage for services in the community. Increased access to clinicians outside the US Department of Veterans Affairs (VA) could benefit rural veterans, who often face obstacles obtaining VA care. This solution, however, relies on clinics willing to navigate VA administrative processes.

OBJECTIVE

To investigate the experiences rural, non-VA clinicians and staff have while providing care to rural veterans and inform challenges and opportunities for high-quality, equitable care access and delivery.

DESIGN

Phenomenological qualitative study.

PARTICIPANTS

Non-VA-affiliated primary care clinicians and staff in the Pacific Northwest.

APPROACH

Semi-structured interviews with a purposive sample of eligible clinicians and staff between May and August 2020; data analyzed using thematic analysis.

KEY RESULTS

We interviewed 13 clinicians and staff and identified four themes and multiple challenges related to providing care for rural veterans: (1) Confusion, variability and delays for VA administrative processes, (2) clarifying responsibility for dual-user veteran care, (3) accessing and sharing medical records outside the VA, and (4) negotiating communication pathways between systems and clinicians. Informants reported using workarounds to combat challenges, including using trial and error to gain expertise in VA system navigation, relying on veterans to act as intermediaries to coordinate their care, and depending on individual VA employees to support provider-to-provider communication and share system knowledge. Informants expressed concerns that dual-user veterans were more likely to have duplication or gaps in services.

CONCLUSIONS

Findings highlight the need to reduce the bureaucratic burden of interacting with the VA. Further work is needed to tailor structures to address challenges rural community providers experience and to identify strategies to reduce care fragmentation across VA and non-VA providers and encourage long-term commitment to care for veterans.

A Novel Gap Staffing Metric for Primary Care in the Veterans Health Administration and Implications for Rural and Urban Clinics

Primary care providers (PCPs), including physicians and advanced practice providers, are the front line of medical care. Patient access must balance PCP availability and patient needs. This work develops a new PCP staffing metric using panel size and full-time equivalent data to determine whether a clinic is adequately staffed and describes variation by clinic rurality. Data were from the Veterans Health Administration, 2017-2021. Results describe the gap staffing metric, provide summary graphics, and compare the gap staffing between rural and urban clinics. This novel gap staffing metric can inform strategic clinic staffing in health care systems.

Meeting the Needs of Rural Veterans: A Qualitative Evaluation of Whole Health Coaches' Expanded Services and Support during COVID-19

The purpose of this qualitative study was to explore perspectives of Whole Health (WH) coaches at the Veterans Health Administration (VHA) on meeting the needs of rural Veterans during the COVID-19 pandemic. The evaluation design employed a qualitative description approach, employing focus groups and in-depth interviews with a convenience sample of WH coaches across the VHA system. Fourteen coaches who work with rural Veterans participated in either one of three focus groups, individual interviews, or both. The focus group data and in-depth interviews were analyzed separately using thematic analysis, and findings were then merged to compare themes across both datasets. Four primary themes were identified: bridging social risk factors for rural Veterans, leveraging technology to stay connected with Veterans at-a-distance, redirecting Veterans to alternate modes of self-care, and maintaining flexibility in coaching role during COVID-19. One overarching theme was also identified following a post-hoc analysis driven by interdisciplinary team discussion: increased concerns for Veteran mental health during COVID-19. Coaches reported using a variety of strategies to respond to the wide-ranging needs of rural Veterans during the pandemic. Implications of findings for future research and practice are discussed.

Differences in Health-Related Quality of Life and Its Associated Factors Among Older Adults in Urban and Rural Areas

Purpose

Urban-rural health disparity is one of the most prominent challenges in China today. The goal of this study is to find differences in health-related quality of life (HRQoL) and its associated factors among older people in urban and rural areas.

Methods

A multi-stage stratified sampling method was conducted in Shanxi Province, with a total of 3250 older adults participated in this cross-sectional survey. HRQoL was assessed using the Chinese version of the EQ-5D-5L. Tobit regression models were employed to identify associated factors for HRQoL.

Results

The mean EQ-5D utility score of the total sample was 0.87± 0.23, with a statistically significant difference observed between urban (0.89 ± 0.22) and rural areas (0.86 ± 0.23). Obesity (Coe=−0.10, p=0.021) and nutrition awareness (Coe=−0.14, p=0.009) were two unique associated factors to rural older adults’ HRQoL. While, age (Urban: Coe=0.13, p=0.001; Rural: Coe=−0.019, p<0.001), socioeconomic status (Urban: Coe=0.13, p<0.001; Rural: Coe=0.14, p<0.001), number of chronic non-communicable diseases (Urban: Coe=−0.20, p<0.001; Rural: Coe=−0.15, p<0.001), sleep quality (Urban: Coe=−0.22, p<0.001; Rural: Coe=0.15, p<0.001) and daytime sleepiness (Urban: Coe=−0.13, p<0.001; Rural: Coe=−0.13, p<0.001) were found to be associated with HRQoL regardless of the residential area.

Conclusion

This study suggested that rural older adults are facing HRQoL disadvantages compared to those in urban area. Accordingly, more attention should be devoted to rural older adults’ HRQoL, particularly to the unique factors like body weight and nutrition awareness. Targeted policies and interventions should be implemented to improve HRQoL and bridge the urban-rural HRQoL gap.

Systematic scoping review of factors and measures of rurality: toward the development of a rurality index for health care research in Japan

BACKGROUND

Rural-urban health care disparities are an important topic in health services research. Hence, developing valid and reliable tools to measure rurality is needed to support high quality research. However, Japan, has no index to measure rurality for health care research. In this study, we conducted a systematic scoping review to identify the important factors and methodological approaches to consider in a rurality index to inform the development of a rurality index for Japan.

METHODS

For our review, we searched six bibliographic databases (MEDLINE, PubMed, CINAHIL, ERIC, Web of Science and the Grey Literature Report) and official websites of national governments such as Government and Legislative Libraries Online Publications Portal (GALLOP), from 1 January 1989 to 31 December 2018. We extracted relevant variables used in the development of rurality indices, the formulas used to calculate indices, and any measures for reliability and validity of these indices.

RESULTS

We identified 17 rurality indices from 7 countries. These indices were primarily developed to assess access to health care or to determine eligibility for incentives for health care providers. Frequently used factors in these indices included population size/density and travel distance/time to emergency care or referral centre. Many indices did not report reliability or validity measures.

CONCLUSIONS

While the concept of rurality and concerns about barriers to access to care for rural residents is shared by many countries, the operationalization of rurality is highly context-specific, with few universal measures or approaches to constructing a rurality index. The results will be helpful in the development of a rurality index in Japan and in other countries.

Mental health status in veterans residing in rural versus non-rural areas: results from the veterans' health study

BACKGROUND

The majority of Veterans Affair (VA) hospitals are in urban areas. We examined whether veterans residing in rural areas have lower mental health service use and poorer mental health status.

METHODS

Veterans with at least 1 warzone deployment in central and northeastern Pennsylvania were randomly selected for an interview. Mental health status, including PTSD, major depression, alcohol abuse and mental health global severity, were assessed using structured interviews. Psychiatric service use was based on self-reported utilization in the past 12 months. Results were compared between veterans residing in rural and non-rural areas. Data were also analyzed using multivariate logistic regression to minimize the influence by confounding factors.

RESULTS

A total of 1730 subjects (55% of the eligible veterans) responded to the survey and 1692 of them had complete geocode information. Those that did not have this information (n = 38), were excluded from some analyses. Veterans residing in rural areas were older, more often of the white race, married, and experienced fewer stressful events. In comparison to those residing in non-rural areas, veterans residing in rural areas had lower global mental health severity scores; they also had fewer mental health visits. In multivariate logistic regression, rural residence was associated with lower service use, but not with PTSD, major depression, alcohol abuse, and global mental health severity score after adjusting confounding factors (e.g., age, gender, marital status and education).

CONCLUSIONS

Rural residence is associated with lower mental health service use, but not with poor mental health in veterans with former warzone deployment, suggesting rural residence is possibly protective.

Mental Health Care for Service Members and Their Families Across the Globe

The U.S. Defense Department partnered with the International Initiative for Mental Health Leadership on effective leadership and operational practices for delivery of mental health (MH) as well as addiction services throughout the world for Service Members (SM) and beneficiaries. A Military Issues Work Group (MIWG) was established in 2011 to focus on challenges experienced by military SM and beneficiaries among countries. The MIWG found common concerns related to MH care delivery to rural and remote beneficiaries. Gaps in access to care were identified and prioritized to explore. This led to better collaboration and understanding of telemental health (TMH) practices and technology applications (apps) which increase access to care for rural and remote SMs and beneficiaries. An assessment of the number of SMs and dependents distant from MH care services in the USA was conducted, as well as an environmental scan for psychological health-focused mobile apps and TMH services geared toward SM, veterans, and beneficiaries. The MIWG is developing a compendium of existing military TMH programs and apps that address MH concerns and extant literature on use of technology to extend global access to care for military members and their families across the world.

Comparing Patient-Centered Medical Home Implementation in Urban and Rural VHA Clinics: Results From the Patient Aligned Care Team Initiative

Rural Veterans Health Administration (VHA) primary care clinics are smaller, have fewer staff, and serve more rural patients compared with urban VHA primary care clinics. This may lead to different challenges to implementation of the Patient-Centered Medical Home (PCMH) model, the Patient Aligned Care Team, in the VHAs' large integrated health system. In this cross-sectional observational study of 905 VHA primary clinics in the United States and Puerto Rico, we found overall PCMH implementation was greater in rural compared to urban primary care clinics. Urban-rural differences in PCMH implementation may largely be related to clinic organizational factors.

Rural Veterans' dental utilization, Behavioral Risk Factor Surveillance Survey, 2014

INTRODUCTION

Rural residents are overrepresented in the military; however, access to Veteran services is limited in rural areas. There is a need to identify rural Veteran healthcare utilization. This study addresses that need and has two purposes: a) to determine if there is an association between rural dwelling and Veteran utilization of dental services; and b) to determine if there is an association between rural dwelling and the oral health outcome of missing teeth.

METHODS

Data from the 2014 Behavioral Risk Factor Surveillance Survey were used in this study. Chi square and logistic regression analyses were conducted.

FINDINGS

Rural Veterans were less likely to have a dental visit during the previous year as compared with metropolitan Veterans in unadjusted analysis (Odds ratio = 0.71, 95% Confidence Interval, 0.64, 0.77) and in adjusted analysis [0.87 (95% Confidence Interval, 0.78, 0.96)]. In cases in which all teeth were missing, rural Veterans had an unadjusted odds ratio of 1.79 [95% Confidence Interval, 1.55, 2.08] and an adjusted odds ratio of 1.37 [95% Confidence Interval, 1.17, 1.62] as compared with metropolitan Veterans.

DISCUSSION AND POLICY IMPLICATIONS

The Veterans Health Administration develops policies for establishing centers for care for Veterans. The policy development should take into consideration that rural Veterans have not been as likely as urban Veterans to utilize dental services and have poorer oral health outcomes.

Differences Among States in Rural Veterans' Use of VHA and Non-VHA Hospitals

PURPOSE

To understand how vouchers for non-VHA care of VHA-enrolled veterans might affect rural enrollees, we determined how much enrollees use VHA and non-VHA inpatient care, and whether this use varies substantially between rural and urban residents depending on state of residence.

METHODS

For veterans listed in the 2007 VHA enrollment file as living in Arizona, Iowa, Louisiana, Tennessee, Florida, South Carolina, Pennsylvania, or New York, we merged 2004-2007 administrative discharge data for all VHA hospitalizations with all non-VHA hospitalizations listed in state health department or hospital association databases. Within states, rural and urban residents (RUCA-defined) were compared on VHA and non-VHA hospitalization rates, overall and for major diagnostic categories.

FINDINGS

Non-VHA hospital use was much greater than VHA use, though it also was more variable across states. In states with higher proportions of urban enrollees, use of non-VHA hospitals was lower for small or isolated rural town residents than urban residents; in the more rural states, it was greater. Rural enrollees also used VHA hospitals more than urban enrollees if they lived in the South, but they used VHA hospitals less in other states. Findings were consistent across principal diagnoses, except that in every state, rural veterans were hospitalized less often for mental disorders but more for respiratory diseases. Logistic regressions controlling several covariates consistently showed that very rural enrollees relied on VHA hospitals more than urban enrollees. Vouchers would likely increase non-VHA use more in states with greater rural populations.

CONCLUSIONS

Vouchers for non-VHA inpatient care might have greater impact in rural states.

Community pharmacy staff perceptions on preventing alcohol and medication interactions in older adults

OBJECTIVES

To examine rural and urban pharmacy staff perceptions on messaging, barriers, and motivators for preventing alcohol and medication interactions (AMI) in older adults (≥65 years of age).

METHODS

A survey was distributed through the local pharmacist association and statewide pharmacy registry in Kentucky. A total of 255 responses were received from pharmacists, pharmacy technicians, and pharmacy students.

RESULTS

Across rural and urban regions alike, among the AMI prevention messages provided, participants identified the most important messages to be: AMI can be potentially dangerous and life threatening; emergency rooms should be used when experiencing an AMI; and doctors and pharmacists should be consulted about AMI. The most common AMI prevention barriers indicated were stigma, costs, and low perceived risks. The most common AMI prevention motivators indicated were physical health improvement, promoting a healthy lifestyle, convenient setting, and financial incentives.

CONCLUSION

Regardless of geography, participants similarly rated the presented AMI prevention messages, barriers, and motivators. With the use of these findings, the development of an AMI prevention program is suggested to use messaging about AMI threat, behavioral management, and behavioral prevention.

Health and Health Care Access of Rural Women Veterans: Findings From the National Survey of Women Veterans

PURPOSE

Disparities in health and health care access between rural and urban Americans are well documented. There is evidence that these disparities are mirrored within the US veteran population. However, there are few studies assessing this issue among women veterans (WVs).

METHODS

Using the 2008-2009 National Survey of Women Veterans, a population-based cross-sectional national telephone survey, we examined rural WVs' health and health care access compared to urban WVs. We measured health using the Medical Outcomes Study Short-Form (SF-12); access using measures of regular source of care (RSOC), health care utilization, and unmet needs; and barriers to getting needed care.

FINDINGS

Rural WVs have significantly worse physical health functioning compared to urban WVs (mean physical component score of 43.6 for rural WVs versus 47.2 for urban WVs; P = .007). Rural WVs were more likely to have a VA RSOC (16.4% versus 10.6%; P = .009) and use VA health care (21.7% versus 12.9%; P < .001), and had fewer non-VA health care visits compared with urban WVs (mean 4.2 versus 5.9; P = .021). They had similar overall numbers of health care visits (mean 5.8 versus 7.1; P = .11 ). Access barriers were affordability for rural WVs and work release time for urban WVs. Rural WVs additionally reported that transportation was a major factor affecting health care decisions.

CONCLUSIONS

Our findings demonstrate VA's crucial role in addressing disparities in health and health care access for rural WVs. As VA continues to strive to optimally meet the needs of all WVs, innovative care models need to account for their high health care needs and persistent barriers to care.

Association between Time since Cancer Diagnosis and Health-Related Quality of Life: A Population-Level Analysis

OBJECTIVES

To examine the association between time since cancer diagnosis and health-related quality of life (HRQOL) among cancer survivors in remission.

METHODS

Analyzing data from 3,610 cancer survivors and 59,539 individuals without cancer in the Medical Expenditure Panel Survey, we examined the relationship between time since cancer diagnosis and HRQOL, taking remission status into account and controlling for patients' demographic characteristics and comorbidities. HRQOL measurements included the six-dimensional health state short form (derived from 36-item short form health survey) (SF-6D) utility scores, the physical component summary score, and the mental component summary score.

RESULTS

The relationship between time since cancer diagnosis and HRQOL varied substantially across cancer types. Compared with individuals without cancer, survivors of breast, prostate, or poor-prognosis cancer had statistically lower SF-6D scores within 2 years of diagnosis (-0.044, -0.062, and -0.088, respectively). Breast cancer survivors had SF-6D scores similar to those of individuals without cancer after 2 years, as did patients with poor-prognosis cancer after 5 years. Nevertheless, even after a period of 10 years, survivors of prostate or cervical cancer had a lower level of SF-6D scores (-0.027 and -0.042, respectively). The comparisons of physical health between cancer survivors and individuals without cancer were similar to those of SF-6D. In contrast, most cancer survivors did not experience poorer mental health; survivors of prostate or cervical cancer, however, had lower mental component summary scores after 10 years of diagnosis.

CONCLUSIONS

The level of HRQOL among cancer survivors depends on time since cancer diagnosis and cancer type. Some cancer survivors have lower HRQOL after a decade of diagnosis, even in remission.

Concurrent alcohol and medication poisoning hospital admissions among older rural and urban residents

BACKGROUND

Alcohol and medication interactions are projected to increase due to the growth of older adults that are unsafely consuming alcohol and medications. Plus, aging adults who reside in rural areas are at the highest risk of experiencing medication interactions.

OBJECTIVE

Estimate concurrent alcohol and medication (alcohol/medication) hospitalizations in adults 50+ years, comparing age groups and rural/urban regions.

METHODS

Kentucky nonfederal, acute care inpatient hospital discharge electronic records for individuals aged 50+ years from 2001 to 2012 were examined. Rate differences were estimated across age and regional strata. Differences in the underlying principal diagnosis, intent, and medications were also examined.

RESULTS

There were 2168 concurrent alcohol/medication hospitalizations among 50+ year olds identified. There was a 187% increase in alcohol/medication hospitalizations from 2001 (n = 104) to 2012 (n = 299). The per capita alcohol/medication hospitalization rate increased from 8.91 (per 100,000) in 2001 to 19.98 (per 100,000) in 2012, a 124% increase. The characteristics of the hospitalizations included 75% principal diagnosis as medication poisoning, self-harm as the primary intent (55%) in 50-64-year olds, and unintentional intent (41%) in 65+ adults. Benzodiazepines were most often involved in the poisonings (36.5%).

CONCLUSIONS

Concurrent alcohol/medication hospitalizations in Kentucky are increasing among aging adults. Greater increases in rural areas and the 65+ aged adults were seen, although there were also higher alcohol/medication hospitalizations in urban and 50-64 aged adults. These findings indicate the need for public-health prevention and clinical intervention to better educate and manage alcohol consuming older adults on safe medication and alcohol practices.

Differences in musculoskeletal health due to gender in a rural multiethnic cohort: a Project FRONTIER study

BACKGROUND

Very few studies have investigated differences in musculoskeletal health due to gender in a large rural population. The aim of this study is to investigate factors affecting musculoskeletal health in terms of hand grip strength, musculoskeletal discomfort, and gait disturbance in a rural-dwelling, multi-ethnic cohort.

METHODS

Data for 1117 participants (40 years and older, 70% female) of an ongoing rural healthcare study, Project FRONTIER, were analyzed. Subjects with a history of neurological disease, stroke and movement disorder were excluded. Dominant hand grip strength was assessed by dynamometry. Gait disturbance including stiff, spastic, narrow-based, wide-based, unstable or shuffling gait was rated. Musculoskeletal discomfort was assessed by self-reported survey. Data were analyzed by linear, logistic regression and negative binomial regressions as appropriate. Demographic and socioeconomic factors were adjusted in the multiple variable analyses.

RESULTS

In both genders, advanced age was a risk factor for weaker hand grip strength; arthritis was positively associated with musculoskeletal discomfort, and fair or poor health was significantly associated with increased risk of gait disturbance. Greater waist circumference was associated with greater musculoskeletal discomfort in males only. In females, advanced age is the risk factor for musculoskeletal discomfort as well as gait disturbance. Females with fair or poor health had weaker hand grip strength. Higher C-reactive protein and HbA1c levels were also positively associated with gait disturbance in females, but not in males.

CONCLUSION

This cross-sectional study demonstrates how gender affects hand grip strength, musculoskeletal discomfort, and gait in a rural-dwelling multi-ethnic cohort. Our results suggest that musculoskeletal health may need to be assessed differently between males and females.

Level of physical activity and quality of life: a comparative study among the elderly of rural and urban areas

Objective : To investigate if the relationship between physical activity level (PAL) and quality of life (QOL) is affected by living environment (rural or urban). Method : A quantitative, observational and cross-sectional study was performed. Of the 40 participants of both genders, 20 were residents of urban areas and 20 were residents of rural areas in the town of Pimenta Bueno (RO), Brazil. The WHOQOL BREF and IPAQ Long Version questionnaires were used to assess QOL and PAL, respectively. Mann Whitney and Fisher's Exact were used to statistically compare groups for QOL and PAL scores. The correlation between the two was tested by the Spearman test. A significance level of p<0.05 was used. Results : No differences between the rural and urban areas for QOL or PAL were found. In the rural group a positive and significant correlation was found between PAL and the physical, psychological and complete QOL domains. In terms of PAL, elderly persons from the rural area who were regularly active had higher total QOL and physical domain scores than insufficiently active elderly individuals from the rural area. When place of residence was compared, insufficiently active elderly in the urban area had higher scores on the social component of QOL than insufficiently active elderly from the rural group. Among regularly active seniors, those living in the rural area had higher physical QOL scores. Conclusion : According to the results, level of physical activity exerts a differential influence on the QOL of elderly people from rural and urban areas.

Spatiotemporal Discordance in Five Common Measures of Rurality for US Counties and Applications for Health Disparities Research in Older Adults

Introduction

Rural populations face numerous barriers to health, including poorer health care infrastructure, access to care, and other sociodemographic factors largely associated with rurality. Multiple measures of rurality used in the biomedical and public health literature can help assess rural–urban health disparities and may impact the observed associations between rurality and health. Furthermore, understanding what makes a place truly “rural” versus “urban” may vary from region to region in the US.

Purpose

The objectives of this study are to compare and contrast five common measures of rurality and determine how well-correlated these measures are at the national, regional, and divisional level, as well as to assess patterns in the correlations between the prevalence of obesity in the population aged 60+ and each of the five measures of rurality at the regional and divisional level.

Methods

Five measures of rurality were abstracted from the US Census and US Department of Agriculture (USDA) to characterize US counties. Obesity data in the population aged 60+ were abstracted from the Behavioral Risk Factor Surveillance System (BRFSS). Spearman’s rank correlations were used to quantify the associations among the five rurality measurements at the national, regional, and divisional level, as defined by the US Census Bureau. Geographic information systems were used to visually illustrate temporal, spatial, and regional variability.

Results

Overall, Spearman’s rank correlations among the five measures ranged from 0.521 (percent urban–urban influence code) to 0.917 (rural–urban continuum code–urban influence code). Notable discrepancies existed in these associations by Census region and by division. The associations between measures of rurality and obesity in the 60+ population varied by rurality measure used and by region.

Conclusion

This study is among the first to systematically assess the spatial, temporal, and regional differences and similarities among five commonly used measures of rurality in the US. There are important, quantifiable distinctions in defining what it means to be a rural county depending on both the geographic region and the measurement used. These findings highlight the importance of developing and selecting an appropriate rurality metric in health research.

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses

PURPOSE

Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis.

METHODS

The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees.

FINDINGS

For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees.

CONCLUSIONS

Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.

Rural living as context: a study of disparities in long-term cancer survivors

PURPOSE/OBJECTIVES

To explore the impact of rurality on health-related quality-of-life (HRQOL) disparities in rural long-term cancer survivors.

DESIGN

Cross-sectional survey.

SETTING

Rural-Urban Continuum Codes (RUCC) 7, 8, and 9.

SAMPLE

91 adults at least five years post-treatment.

METHODS

Mailed surveys measured HRQOL, self-esteem, and social support. Regression models were estimated to isolate (from self-esteem and social support) the effect of level of rurality on HRQOL.

MAIN RESEARCH VARIABLES

HRQOL, self-esteem, social support, and rurality.

FINDINGS

No differences in demographic characteristics existed among RUCCs. Survivors residing in RUCCs 7 or 8 tended to be similar in several dimensions of HRQOL. Survivors living in RUCC 7 reported significantly lower social function and greater financial difficulty and number of symptoms compared to survivors in RUCC 9 (the most remote). Self-esteem and social support strongly correlated with HRQOL.

CONCLUSIONS

The significant impact of rurality on HRQOL beyond self-esteem and social support suggests its role in explaining cancer survivorship disparities and directing practice. Until additional exploration can identify mechanisms behind rurality's impact, consideration of level of rurality as a potential factor in evaluating survivors' HRQOL outcomes is reasonable.

IMPLICATIONS FOR NURSING

Survivor context (e.g., level of rurality) influences HRQOL outcomes. Context or culture-relevant risk minimization and HRQOL optimization nursing practices are indicated.

Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures

This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.

INTRODUCTION

We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.

METHODS

We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.

RESULTS

Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.

CONCLUSIONS

Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.

Worsening trends and increasing disparities in health-related quality of life: evidence from two French population-based cross-sectional surveys, 1995-2003

PURPOSE

To investigate time trends in health-related quality of life (HRQoL) in France and to report existing and changing demographic, socioeconomic, and geographic disparities.

METHODS

Data were drawn from two independent national cross-sectional surveys conducted in 1995 and 2003, including 3,243 individuals aged 18–84 in 1995 and 22,743 in 2003. HRQoL was measured with the 8 subscales of the French version of the SF-36.

RESULTS

After multiple linear regression, a significant decrease was observed between 1995 and 2003 in all scales scores, from −0.11 adjusted standard deviations for Social Functioning (95% CI: −0.15 to −0.08) to −0.23 for Vitality (−0.26 to −0.19). Increasing age, female gender, divorce/widowhood, lowest educational levels, chronic conditions, and living in the Northern region were identified as independent predictors of lower HRQoL scores. Testing interactions showed significantly greater differences between 1995 and 2003 for subjects aged 75–84 and for least educated subjects (Physical Functioning, General Health). The Gini index increased for all scales.

CONCLUSIONS

We report evidence of worsening trends and possibly increasing demographic, socioeconomic, and regional disparities in HRQoL between 1995 and 2003 in France. Monitoring HRQoL in populations can provide unique and sensitive data, complementary to classical indicators based on mortality and morbidity.

The impact of living in rural and urban areas: vitamin D and medical costs in veterans

PURPOSE

Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization.

METHODS

Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural.

FINDINGS

The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization.

CONCLUSIONS

Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.

Investigating differences in health-related quality of life of Greeks and Albanian immigrants with the generic EQ-5D questionnaire

Background. Low socioeconomic status (SES) has been related by previous studies to low self-perceived HRQoL. Health is a major determinant of the society's welfare, and few studies have determined the relevant elements that contribute to health and quality of life in Greece. Aim. The aim of the study was to evaluate and test for differences in HRQoL of Greek and Albanian immigrant population according to ethnicity and their demographic and SES characteristics. Methods. The study was conducted in a sample of 660 age-matched and gender-matched Greeks and Albanian immigrants. Moderate or severe decrease in HRQoL was assessed with the generic tool EQ-5D. Differences were statistically analyzed by t-test and ANOVA. Also, logistic and linear regression analyses were conducted for the dependent variables of the EQ-5D dimensions and VAS scores, respectively. Results. The Albanian immigrants reported better self-perceived health than their Greek counterparts. Health problems increase moderately with age and lower SES and are slightly higher for women than for men. Urbanity and superior education in both Greeks and Albaniansareassociated with worse HRQoL. Conclusion. There are some structural and compositional differences in the self-perceived quality of life between the two ethnicities, as estimated by EQ-5D. The combined information presents to public health providers the relevant data to assess health policies according to health needs.

Rural-urban differences in health services utilization in the US-Mexico border region

PURPOSE

Evaluate the association between driving distance to the US-Mexico border and rural-urban differences in the use of health services in Mexico by US border residents from Texas.

METHODS

Data for this study come from the Cross-Border Utilization of Health Care Survey, a population-based telephone survey conducted in the Texas border region in spring 2008. Driving distances to the border were estimated from the nearest border crossing station using Google Maps. Outcome measures included medication purchases, physician visits, dentist visits, and inpatient care in Mexico during the 12 months prior to the survey. A series of adjusted logit models were estimated after controlling for relevant confounding factors.

FINDINGS

The average driving distance to the nearest border crossing station among rural respondents was 4 times that of urban respondents (42.0 miles vs 10.3 miles [P < .001]). Rural respondents were more likely to be dissatisfied than urban respondents with the health care provided on the US side of the border, yet they were less likely to use health services in Mexico. Driving distance to the border largely explained the observed rural-urban differences in medication purchases from Mexico. In the case of inpatient care, however, rural respondents reported a higher utilization rate than urban respondents and this rural-urban difference became more pronounced after adjusting for the effect of driving distance to the border.

CONCLUSIONS

Dissatisfaction with US health care services in rural communities in the US-Mexico border region seems to be compounded by the lack of access to health care services in Mexico due to travel distance constraints.

Quality of life in rural and urban adults 65 years and older: findings from the National Health and Nutrition Examination survey

PURPOSE

The proportion of people over 65 years of age is higher in rural areas than in urban areas, and their numbers are expected to increase in the next decade. This study used Andersen's behavioral model to examine quality of life (QOL) in a nationally representative sample of community-dwelling adults 65 years and older according to geographic location. Specifically, associations between 3 dimensions of QOL (health-related QOL [HQOL], social functioning, and emotional well-being) and needs and health behaviors were examined.

METHODS

The 2005-2006 National Health and Nutrition Examination survey was linked with the 2007 Area Resources File via the National Center for Health Statistics' remote access system. Frequencies and distribution patterns were assessed according to rural, adjacent, and urban locations.

FINDINGS

Older adults reported high levels of QOL; however, rural older adults had lower social functioning than their urban counterparts. Older blacks and Hispanics had lower scores than whites on 2 dimensions of QOL. Associations between QOL and needs and health behaviors varied. Although activities of daily living were associated with all 3 dimensions, others were associated with 1 or 2 dimensions.

CONCLUSIONS

The lower scores on social functioning in rural areas suggest that rural older adults may be socially isolated. Older rural adults may need interventions to maintain physical and mental health, strengthen social relationships and support, and increase their participation in the community to promote QOL. In addition, older blacks and Hispanics seem more vulnerable than whites and may need more assistance.

Distance is relative: unpacking a principal barrier in rural healthcare

BACKGROUND

Distance to healthcare services is a known barrier to access. However, the degree to which distance is a barrier is not well described. Distance may impact different patients in different ways and be mediated by the context of medical need.

OBJECTIVE

Identify factors related to distance that impede access to care for rural veterans.

APPROACH

Mixed-methods approach including surveys, in-depth interviews, and focus groups at 15 Veterans Health Administration (VHA) primary care clinics in 8 Midwestern states. Survey data were compiled and interviews transcribed and coded for thematic content.

PARTICIPANTS

Surveys were completed by 96 patients and 88 providers/staff. In-depth interviews were completed by 42 patients and 64 providers/staff. A total of 7 focus groups were convened consisting of providers and staff.

KEY RESULTS

Distance was identified by patients, providers, and staff as the most important barrier for rural veterans seeking healthcare. In-depth interviews revealed specific examples of barriers to care such as long travel for common diagnostic services, routine specialty care, and emergency services. Patient factors compounding the impact of these barriers were health status, functional impairment, travel cost, and work or family obligations. Providers and staff reported challenges to healthcare delivery due to distance.

CONCLUSIONS

Distance as a barrier to healthcare was not uniformly defined. Rather, its importance was relative to the health status and resources of patients, complexity of service provided, and urgency of service needed. Improved transportation, flexible fee-based services, more structured communication mechanisms, and integration with community resources will improve access to care and overall health status for rural veterans.

Scalable office-based health care

The goal of health care is to provide high-quality care at an affordable cost for its patients. However, the population it serves has changed dramatically since the popularization of hospital-based health care. With available new technology, alternative health care delivery methods can be designed and tested. This study examines scalable office-based health care for small business, where health care is delivered to the office floor. This delivery was tested in 18 individuals at a small business in Minneapolis, Minnesota. The goal was to deliver modular health care and mitigate conditions such as diabetes, hyperlipidaemia, obesity, sedentariness and metabolic disease. The modular health care system was welcomed by employees - 70% of those eligible enrolled. The findings showed that the modular health care deliverable was feasible and effective. The data demonstrated significant improvements in weight loss, fat loss and blood variables for at risk participants. This study leaves room for improvement and further innovation. Expansion to include offerings such as physicals, diabetes management, smoking cessation and prenatal treatment would improve its utility. Future studies could include testing the adaptability of delivery method, as it should adapt to reach rural and under-served populations.