Greater Rurality Increases Barriers to Primary Health Care: Evidence of a Gradient in Access or Quality

1. Greater Rurality Increases Barriers to Primary Health Care: Evidence of a Gradient in Access or Quality Janice C. Probst, PhD James N. Laditka, PhD Sarah B. Laditka, PhD Arnold School of Public Health University of South Carolina

2. Problematic access to primary care • Demand • Rural residents more likely to be uninsured, underinsured • Rural residents face greater travel burdens than their urban peers • Supply: • Ratios decline as communities become more rural and remote

3. Rural residents may have worse outcomes • Physician / population ratios are lower in rural than in urban areas • Higher death rates for children, young adults, working age adults • Later stage at cancer diagnosis • Higher hospitalization rates for ambulatory care sensitive conditions (ACSC)

4. Study questions • To ascertain the effects of rurality on ACSC hospitalization rates • To identify county-level factors associated with ACSC hospitalization rates

5. Methods • Cross Sectional Analysis • Data source: 2002 State Inpatient Database, Area Resource File,Census • Population: 580 counties across CO, FL, KY, MI, NY, NC, SC, & WA.

6. Definitions • ACS diagnoses use AHRQ definitions • Rurality was defined using Urban Influence Codes. • Exclusions: • Counties with very small age‑specific populations, • Small rural counties (13) immediately adjacent to metropolitan areas.

7. Analysis • Separate analyses for children, working age adults, and older adults (65+) • Poisson regression • Supply side control factors (county level): • Physician supply • Hospital bed supply • Number ED’s • ED visit rates • HMO penetration • Presence of a community health center or rural health clinic

8. Analysis, continued • Demand side controls (county level): • Estimated uninsured population (children, working age adults only) • Race/ethnicity (proportion black, Hispanic, Asian, or American Indian, measured separately) • Population change between 1990 and 2000 • Percent residents with high school + education • Population density • Unemployment rate • Death rates for several relevant chronic conditions

9. Unadjusted admission rates, kids

10. Unadjusted admission rates, ages 18 - 64

11. Unadjusted admission rates, 65+

12. Adjusted rate ratios, age 18 - 64

13. Adjusted rate ratios, age 65+

14. Conclusions • Among adults: • Increasing degrees of rurality were generally associated with higher ACSC rates, • The most rural areas were at greatest risk. • Geographic differences in ACSC rates were not attributable to physician supply, county rates of health insurance coverage, education levels, or similar factors, as these were held constant in the analysis.

15. Conclusions • We speculate that travel impedance, poorer quality of ambulatory care in rural communities, or lack of outpatient supportive services that could substitute for inpatient care contribute to higher ACSC rates in the most rural areas. • Policies are needed to enhance health care access in rural areas.