Improving Health Among Rural Residents in the US

Social Isolation and Safety Issues among Rural Older Adults Living Alone: Perspectives of Meals on Wheels Programs

Ensuring the safety and social well-being of rural populations, especially rural older adults living alone with complex medical conditions, is challenging, given large, sparsely populated communities and limited resources. Using qualitative data from surveys with 42 rural Meals on Wheels programs from across the U.S., we highlight particular challenges to meeting the social and safety needs of rural older adults living alone. Respondents described challenges, opportunities, and successes in meeting the needs of their clients. We describe these under four domains: main challenges, what can be done to address social isolation and loneliness, safety issues, improving safety, and current successes. We also identify cross-cutting themes related to programs' rural environment (long distances, inclement weather), infrastructure (housing quality, access to broadband Internet and technological connectivity, road conditions), funding and resource availability, and service provision (availability of health care and partner organizations.) We describe each of these in more detail and also share policy recommendations for improving health and safety of older adults living alone in rural areas, including funding nutrition programs as a health benefit and addressing aging, poor-quality housing stock.

Rural-urban differences in health care unaffordability

PURPOSE

To compare health care unaffordability in rural versus urban contexts while also examining the impact of sociodemographic/socioeconomic variables on this relationship.

METHODS

We examined survey responses from the 2019-2021 National Health Interview Survey (n = 90,761). We conducted chi-squared tests comparing urban and rural subsamples and multivariable logistic regression analyses examining the associations between rurality and 3 measures of health care unaffordability while also including interactions between rurality and individual characteristics of respondents.

FINDINGS

In bivariate analyses, compared to their urban counterparts, rural residents were more likely to report problems paying medical bills (15.0% vs 11.5%, P <.001) and being unable to pay medical bills (9.3% vs 7.1%, P < .001). In fully adjusted multivariable regression analyses, rural residents were significantly less likely than their urban counterparts to report being worried about paying medical bills (AOR: .915, CI: .871-.961, P < .001). We found significant interactions between rural residency and insurance type, age, income to poverty ratio, and race/ethnicity for the outcome of problems paying medical bills; and significant interactions between rural residency and income to poverty ratio and race and ethnicity for the outcome of being unable to pay medical bills.

CONCLUSION

Rural residents report higher rates of 2 measures of health care unaffordability as compared to their urban counterparts. In multivariable logistic models, rural residency is not associated with higher rates of health care unaffordability; however, significant interactions exist between rural residency and individual variables demonstrating the heterogenous experiences of health care unaffordability based on these intersectional identities.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Access to Health Care for Transgender and Gender-Diverse Adults in Urban and Rural Areas in the United States

The objective of this study is to examine access to care based on gender identity in urban and rural areas, focusing on transgender and gender diverse (TGD) populations. Data on TGD (n = 1,678) and cisgender adults (n = 403,414) from the 2019 to 2020 Behavioral Risk Factor Surveillance System were used. Outcome measures were four barriers to care. We conducted bivariate and multivariable logistic regressions to assess associations between access, rurality, and gender identity. Bivariate results show that TGD adults were significantly more likely to experience three barriers to care. In multivariable models, TGD adults were more likely to delay care due to cost in the full sample (adjusted odds ratio [AOR]: 2.00, p < .001), rural subsample (AOR: 2.14, p < .01), and urban subsample (AOR: 1.97, p < .01). This study revealed greater barriers to care for TGD adults, with the most frequent barriers found among rural TGD adults. Increased provider awareness and structural policy changes are needed to achieve health equity for rural TGD populations.

Hospital-Level Care at Home for Acutely Ill Adults in Rural Settings: Proof of Concept

Residents in rural areas face barriers to accessing acute care. Rural home hospital (RHH) or delivery of acute care at home could represent an important clinical care model. This study assessed the feasibility and acceptability of RHH as a substitute to traditional hospital care. Patients were cared for by a remote RHH attending physician and an RHH registered nurse deployed to the home. The study team conducted daily check-ins with RHH clinicians to assess workflows for completion. Surveys assessed patient experience and qualitative interviews assessed perceived acceptability, safety, and quality of care. We completed qualitative analysis of the interviews and coded qualitative data into domains and subdomains through an iterative process. RHH was successfully deployed to three acutely ill patients in rural Utah. RHH admission, daily care, and discharge processes were accomplished for each patient. From qualitative analysis, we identified four domains: (1) Perceived comfort level during RHH admission, (2) Perceived safety during RHH admission, (3) Perceived quality of care during RHH admission, and (4) Perception of RHH workflows. We found acute care was delivered to rural homes with satisfactory patient and clinician experience. Team dynamics, technology build, robust clinical and operational workflows, and care coordination were important to a successful admission. Learnings from this study can inform program design and training for RHH teams and startup for larger RHH evaluation. Home hospital care is expanding rapidly in the United States and RHH could represent an important clinical care model.

Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival

BACKGROUND

Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer.

METHODS

We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression.

RESULTS

We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26).

CONCLUSIONS

Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.

Unmet Needs for Help With Mobility Limitations Among Older Adults Aging in Place: The Role of Rurality

OBJECTIVES

This study identifies differences in unmet mobility needs among older adults living in rural versus urban areas.

METHODS

We used data from Round 9 of the National Health and Aging Trends Study (NHATS), limiting our analyses to respondents who had not moved since baseline (average housing tenure of 27 years; n = 3343). We conducted bivariate and multivariate analyses to detect rural/urban differences in unmet mobility needs, adjusting for socio-demographics, health status, and housing characteristics.

RESULTS

Rural residence was associated with higher odds of any unmet mobility needs for older adults aging in place (adjusted odds ratio: 1.64, 95% confidence interval: 1.10-2.44, p < .05). The relationship between rurality and unmet needs for help with mobility limitations remained significant in fully adjusted models.

DISCUSSION

Rural older adults aging in place have greater unmet needs for help with mobility limitations. This study highlights several important gaps in supporting rural older adults aging in place.

Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals

Importance

Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.

Objective

To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.

Design, Setting, and Participants

This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.

Exposures

Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.

Main Outcome and Measures

The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.

Results

Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.

Conclusions and Relevance

In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

Impact of the COVID-19 pandemic on cancer patients in western Pennsylvania: rural-urban disparities

PURPOSE

Disparities in cancer care persist between patients living in rural versus urban areas. The COVID-19 pandemic may have impacted concerns related to care and personal health differently in rural cancer patients. Using survey data collected from cancer patients in western Pennsylvania, we examined pandemic-related distress, concerns related to cancer care, impact on personal health, and the extent to which these differed by urban-rural residence.

METHODS

Patients filled out an initial survey in August-December 2020; a second survey was completed in March 2021. The following patient concerns related to the pandemic were evaluated: threat of COVID-19 to their health, pandemic-related distress, perceptions of cancer care, and vaccine hesitancy. Multivariable logistic regression models were used to examine relationships between these outcomes and urban-rural residence as well as patient-related factors, including anxiety symptoms and social support.

RESULTS

The study sample included 1,980 patients, 17% resided in rural areas. COVID-19 represented a major or catastrophic threat to personal health for 39.7% of rural and 49.0% of urban patients (p = 0.0017). Patients with high general anxiety were 10-times more likely to experience pandemic-related distress (p < 0.001). In the follow-up survey (n = 983), vaccine hesitancy was twice as prevalent among rural patients compared to urban (p = 0.012).

CONCLUSIONS

The extent to which perceptions of the threat of COVD-19 to personal health and vaccine hesitancy exacerbates rural-urban disparities in cancer care and prognosis warrants further study. Cancer patients may be vulnerable to heightened anxiety and distress triggered by the pandemic.

Factors Associated With Health Care Professionals' Choice to Practice in Rural Minnesota

Importance

Rural health inequities are due in part to a shortage of health care professionals in these areas.

Objective

To determine the factors associated with health care professionals' decisions about where to practice.

Design, Setting, and Participants

This prospective, cross-sectional survey study of health care professionals in Minnesota was administered by the Minnesota Department of Health from October 18, 2021, to July 25, 2022. Advanced practice registered nurses (APRNs), physicians, physician assistants (PAs), and registered nurses (RNs) renewing their professional licenses were eligible.

Exposures

Individuals' ratings on survey items related to their choice of practice location.

Main Outcomes and Measures

Rural or urban practice location as defined by the US Department of Agriculture's Rural-Urban Commuting Area typology.

Results

A total of 32 086 respondents were included in the analysis (mean [SD] age, 44.4 [12.2] years; 22 728 identified as female [70.8%]). Response rates were 60.2% for APRNs (n = 2174), 97.7% for PAs (n = 2210), 95.1% for physicians (n = 11 019), and 61.6% for RNs (n = 16 663). The mean (SD) age of APRNs was 45.0 (10.3) years (1833 [84.3%] female); PAs, 39.0 (9.4) years (1648 [74.6%] female); physicians, 48.0 (11.9) years (4455 [40.4%] female); and RNs, 42.6 (12.3) years (14 792 [88.8%] female). Most respondents worked in urban (29 456 [91.8%]) vs rural (2630 [8.2%]) areas. Bivariate analysis suggested that family considerations are the most important determinant of practice location. Multivariate analysis revealed that having grown up in a rural area was the strongest factor associated with rural practice (odds ratio [OR] for APRNs, 3.44 [95% CI, 2.68-4.42]; OR for PAs, 3.75 [95% CI, 2.81-5.00]; OR for physicians, 2.44 [95% CI, 2.18-2.73]; OR for RNs, 3.77 [95% CI, 3.44-4.15]). When controlling for rural background, other associated factors included the availability of loan forgiveness (OR for APRNs, 1.42 [95% CI, 1.19-1.69]; OR for PAs, 1.60 [95% CI, 1.31-1.94]; OR for physicians, 1.54 [95% CI, 1.38-1.71]; OR for RNs, 1.20 [95% CI, 1.12-1.28]) and an educational program that prepared for rural practice (OR for APRNs, 1.44 [95% CI, 1.18-1.76]; OR for PAs. 1.70 [95% CI, 1.34-2.15]; OR for physicians, 1.31 [95% CI, 1.17-1.47]; OR for RNs, 1.23 [95% CI, 1.15-1.31]). Autonomy in one's work (OR for APRNs, 1.42 [95% CI, 1.08-1.86]; OR for PAs, 1.18 [95% CI, 0.89-1.58]; OR for physicians, 1.53 [95% CI, 1.31-1.78]; OR for RNs, 1.16 [95% CI, 1.07-1.25]) and a broad scope of practice (OR for APRNs, 1.46 [95% CI, 1.15-1.86]; OR for PAs, 0.96 [95% CI, 0.74-1.24]; OR for physicians, 1.62 [95% CI, 1.40-1.87]; OR for RNs, 0.96 [95% CI, 0.89-1.03]) were important factors associated with rural practice. Lifestyle and area considerations were not associated with rural practice; family considerations were associated with rural practice for RNs only (OR for APRNs, 0.97 [95% CI, 0.90-1.06]; OR for PAs, 0.95 [95% CI, 0.87-1.04]; OR for physicians, 0.92 [95% CI, 0.88-0.96]; OR for RNs, 1.05 [95% CI, 1.02-1.07]).

Conclusions and Relevance

Understanding the interconnected factors involved in rural practice requires modeling relevant factors. The findings of this survey study suggest that loan forgiveness, rural training, autonomy, and a broad scope of practice are factors associated with rural practice for most health care professionals. Other factors associated with rural practice vary by profession, suggesting that there may not be a one-size-fits-all approach to recruitment of rural health care professionals.

Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum

OBJECTIVE

To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents.

METHODS

We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison.

RESULTS

Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth.

CONCLUSION

Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Cancer survival in the United States 2007-2016: Results from the National Program of Cancer Registries

BACKGROUND

Cancer survival has improved for the most common cancers. However, less improvement and lower survival has been observed in some groups perhaps due to differential access to cancer care including prevention, screening, diagnosis, and treatment.

METHODS

To further understand contemporary relative cancer survival (one- and five- year), we used survival data from CDC's National Program of Cancer Registries (NPCR) for cancers diagnosed during 2007-2016. We examined overall relative cancer survival by sex, race and ethnicity, age, and county-level metropolitan and non-metropolitan status. Relative cancer survival by metropolitan and non-metropolitan status was further examined by sex, race and ethnicity, age, and cancer type.

RESULTS

Among persons with cancer diagnosed during 2007-2016 the overall one-year and five-year relative survival was 80.6% and 67.4%, respectively. One-year relative survival for persons living in metropolitan counties was 81.1% and 77.8% among persons living in non-metropolitan counties. We found that persons who lived in non-metropolitan counties had lower survival than those who lived in metropolitan counties, and this difference persisted across sex, race and ethnicity, age, and most cancer types.

CONCLUSION

Further examination of the differences in cancer survival by cancer type or other characteristics might be helpful for identifying potential interventions, such as programs that target screening and early detection or strategies to improve access to high quality cancer treatment and follow-up care, that could improve long-term outcomes.

IMPACT

This analysis provided a high-level overview of contemporary cancer survival in the United States.

Influences of relative deprivation on health inequality of rural residents in China: A moderated mediation model

Analyzing the relationship between individual relative deprivation and rural residents' health inequality is a deepening of the research on the social impact of individual relative deprivation. On the theoretical basis of the absolute and relative income hypothesis, using the data of China Family Panel Studies in 2018, taking other residents in the village as the reference group, this paper selects the relative income deprivation and absolute income to comprehensively quantify the generalized impact of farmers' income gap, introduces the psychological capital guidance mechanism, and constructs a moderated-mediation model for the impact of relative deprivation on the health inequality of rural residents in China from the three dimensions of self-assessment of health, mental health and physical health. The estimation results of the multi-layer model show that the relative income deprivation of rural residents has a significant impact on health inequality, among which the impact of mental health is the strongest. Compared with physical health, the mediated transmission of psychological capital has a more significant impact between the relative deprivation of rural residents and mental health. Compared with low-income groups, high-income residents can better alleviate the negative effect of income relative deprivation on psychological capital poverty and health inequality, and the regulatory effect on physical health is most significant. Therefore, China can improve the health of the rural poor through fiscal policies such as improving the tax system and strengthening the supervision of various government funds.

Characteristics of Hospitals Eligible for Rural Emergency Hospital Designation

This cross-sectional study compares the characteristics, finances, services, and challenges at hospitals that are eligible vs not eligible to become rural emergency hospitals.

Association Between Broadband Capacity and Social Vulnerability Factors in the United States: A County-Level Spatial Analysis

This study evaluated relationships between county-level social vulnerability and broadband access using spatial clustering and regression approaches. County-level broadband availability (Federal Communications Commission [FCC] and Microsoft; 2019-2020), social vulnerability (COVID-19 Community Vulnerability Index [CCVI]; 2020), and primary care access (Area Health Resource File; 2019-2020) data sets were used. Two measures of broadband availability were considered: (1) Microsoft system-reported proportion of county population with broadband and (2) difference in FCC-reported and Microsoft-reported proportions of county population with broadband. Cluster maps were constructed using local Moran's I, and spatial Durbin models were estimated using primary care shortage designation and CCVI themes (socioeconomic status, minority status, housing/transportation/disability, epidemiological risk, health care system, high-risk environment, and population density). Among 3102 counties, county-level broadband coverage varied widely between Microsoft (0.39) and FCC (0.84), with greater coverage in the East and West, and larger discrepancies between FCC and Microsoft data in the South and Appalachia. In spatial regressions, a one-point increase in socioeconomic status vulnerability (0-least; 10-most vulnerable), was associated with a 2.0 percentage point (pp) reduction in broadband access (P < 0.001). Similar inverse relationships were observed with housing, epidemiological, and health care system variables. There were greater divergences between FCC and Microsoft measures with each one-point increase in socioeconomic status (1.4 pp), epidemiological risk (0.6 pp), and health care system (0.7 pp) vulnerability. More vulnerable counties had lower broadband and larger divergences between FCC and Microsoft data. Broadband is necessary for utilizing telehealth services; careful considerations in measuring broadband access can facilitate policies that improve equitable access to care.

Perinatal outcomes for rural obstetric patients and neonates in rural-located and metropolitan-located hospitals

OBJECTIVE

To compare rural obstetric patient and neonate characteristics and outcomes by birth location.

METHODS

Retrospective observational cohort study of rural residents' hospital births from California, Pennsylvania, and South Carolina. Hospitals in rural counties were rural-located, those in metropolitan counties with ≥10% of obstetric patients from rural communities were rural-serving, metropolitan-located, others were non-rural-serving, metropolitan-located. Any adverse obstetric patient or neonatal outcomes were assessed with logistic regression accounting for patient characteristics, state, year, and hospital.

RESULTS

Of 466,896 rural patient births, 64.3% occurred in rural-located, 22.5% in rural-serving, metropolitan-located, and 13.1% in non-rural-serving, metropolitan-located hospitals. The odds of any adverse outcome increased in rural-serving (aOR 1.27, 95% CI 1.10-1.46) and non-rural-serving (aOR 1.35, 95% CI 1.18-1.55) metropolitan-located hospitals.

CONCLUSION

One-third of rural obstetric patients received care in metropolitan-located hospitals. These patients have higher comorbidity rates and higher odds of adverse outcomes likely reflecting referral for higher baseline illness severity.

The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis

Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China.

Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI.

Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03–1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81–1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1–256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant.

Conclusion: The results highlight the need to improve rural hospitals’ infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.

Health care utilization in Alaska Native people receiving chronic disease specialty care by videoconsultation compared to propensity-matched controls

INTRODUCTION

Previous studies have had mixed findings about the effects of telemedicine on health care utilization. We designed this study to assess differences in health care utilization between ever users of telemedicine for chronic disease specialty care compared to propensity-matched controls.

METHODS

This observational study of usual care in the Alaska Tribal Health System evaluated telemedicine use (videoconsultation) and healthcare utilization using data from the electronic medical record between 1 January 2015 and 30 June 2019. Eligibility criteria included: age 18 and older, chronic condition diagnosis, and residing in one of four study regions. Cases had ever used telemedicine while controls had not. We used propensity score matching to achieve covariate balance between cases and controls, and then estimated the effect of telemedicine on outcomes using multivariable models. Outcomes included rates of hospitalizations, outpatient visits, and emergency department visits.

RESULTS

Cases (ever users of telemedicine) had higher hospitalization rates (rate ratio 1.31, p < 0.01) and higher outpatient visit rates (rate ratio 1.23, p < 0.01). Cases had lower rates of emergency department visits, though non-statistically significant (rate ratio 0.87, p = 0.07). Cases were more likely than controls to have no emergency department visits per follow-up time (49% vs 36%, p < 0.01).

DISCUSSION

We found higher rates of inpatient and outpatient health care utilization in people who had ever used telemedicine compared to propensity-matched controls, with potentially lower rates of emergency department visits. These findings contribute to the literature on telemedicine and should be considered in the context of other factors influencing telemedicine use and outcomes.

Approaches to Serving Rural Older Adults in State Plans on Aging: A Policy Content Evaluation

Every state is required to submit a State Plan on Aging describing how it will use resources from the Older Americans Act (OAA), including a section specific to serving rural older adults. This paper describes a policy content evaluation of all 50 State Plans on Aging, focusing on Section 307(a)(10), which describes how states will serve rural older adults. We identified the most common and innovative approaches to using OAA funds to serve rural older adults across states. The most common information included about using OAA funds to serve rural older adults was describing the funding formula used to allocate resources. However, states varied in their definition of rural and in the details of their funding formulas. A minority of states also described additional approaches to serving rural older adults, including prioritizing Black, Indigenous, or rural residents of color; outreach; and targeted service delivery.

Air, Land, and Sea: Gene-Environment Interaction in Chronic Disease

Each of us reflects a unique convergence of DNA and the environment. Over the past 2 decades, huge biobanks linked to electronic medical records have positioned the clinical and scientific communities to understand the complex genetic architecture underlying many common diseases. Although these efforts are producing increasingly accurate gene-based risk prediction algorithms for use in routine clinical care, the algorithms often fail to include environmental factors. This review explores the concept of heritability (genetic vs nongenetic determinants of disease), with emphasis on the role of environmental factors as risk determinants for common complex diseases influenced by air and water quality. Efforts to define patient exposure to specific toxicants in practice-based data sets will deepen our understanding of diseases with low heritability, and improved land management practices will reduce the burden of disease.

"They're not leaving their home; this is where they were born, this is where they will die.": Key Informant Perspectives From the U.S. Counties With the Greatest Concentration of the Oldest Old

The "oldest old," age 85 and older, constitute one of the fastest growing segments of the U.S. population. Yet, surprisingly little is known about the characteristics of U.S. counties with the highest percentage of the oldest old, nearly all of which are rural. We used qualitative analysis of key informant interviews (n = 50) with county commissioners and other county-level representatives from rural counties with the highest prevalence of the oldest old, targeting the 54 rural counties with ≥5% of the population age 85+. We found that the rural counties with the highest proportion of residents age 85+ face unique challenges to supporting successful aging among the oldest old, including resource constraints, limited services, isolated locations, and widespread service areas. Still, interviewees identified particular reasons why the oldest old remain in their counties, with many highlighting positive aspects of rural environments and community.