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Context: As elderly people become a larger proportion of the rural population, it is important to identify those at risk for poor health. Predictors of health-related quality of life can be useful in designing interventions., Purpose: One objective of the present study was to profile the health-related quality of life of community-dwelling, elderly people in a southwestern region of the United States. A related objective was to identify the principal factors associated with health-related quality of life, thereby identifying population subgroups in greatest need of health or social services., Methods: A telephone survey of approximately 5,000 individuals 65 years and older collected data on need for assistance with activities of daily living, physical and mental health-related quality of life, and worry about health status measures. A modified version of the Behavioral Model was used to more clearly distinguish the different groups at risk for poor health., Findings: Those groups of community-dwelling, elderly people in the poorest health were older than 75 years, had less than a high school education, were retired or unemployed, and had low household income. No differences were found by urban, rural, and frontier residence., Conclusions: To maintain the physical, social, and psychological health of older people residing in rural and urban areas, social services, medical care, and supportive services are needed, particularly among the most socially and economically disadvantaged.

Objectives: To test whether concordance or discordance of patient participation between patients and physicians is associated with higher satisfaction, and to examine the effects of patients' and physicians' participatory styles on patients' satisfaction with their physicians., Data: Data collected in the Texas Tech 5000 Survey of elderly patients in West Texas were used. Patient satisfaction with their physicians was measured by a single item from the Consumer Assessment of Health Plans (CAHPS), representing patients' ratings of their physicians. Patient participation was measured by an index derived from a three-item instrument and physicians' participatory decision-making (PDM) style was measured by a three-item instrument developed by the Medical Outcomes Study., Methods: An ordered logit multivariate regression was used to investigate the effects of patients' and physicians' participatory styles on satisfaction with physicians. The interaction between patients' participation and physicians' participatory styles was also included to examine the dependency of the two variables., Results: Controlling for confounding factors, a higher PDM score was associated with a higher rating of patient satisfaction with physicians. A higher patient participation score was related to a lower physician satisfaction rating. The combined effect of patients' and physicians' participation styles indicated that for a low patient participation score, a high PDM score was not needed to produce high satisfaction. The greater the discordance in this direction, the higher the satisfaction. However, with a high patient participation score, only an extremely high PDM score would produce relatively high satisfaction., Conclusions: The current study supports the discordance hypothesis. Participatory physicians and patient-physician communications concerning patient participation can promote higher satisfaction.

Objective: To describe how skepticism about medical care and other individual differences, including worry about health status, are associated with evaluations of health care among the noninstitutionalized elderly., Data Sources/study Setting: Data were collected through a survey of approximately 5,000 community-dwelling elders (aged 65 and older) in a southwestern region of the United States., Study Design: Global evaluations of health care were measured with two items from the Consumer Assessment of Health Plans Study (CAHPS) instrument, an overall care rating (OCR) and a personal doctor rating (PDR). Multivariate ordered logit regression models were tested to examine how medical skepticism and other factors were associated with ratings of 0-7, 8-9, and 10., Principal Findings: Consumers who were skeptical of prescription drugs relative to home remedies, who held attitudes that they understand their health better than most doctors, and who worried about their health had worse OCR and PDR. Those who held attitudes that individual behavior determines how soon one gets better when sick had better PDR and OCR., Conclusions: Health policymakers, managers, and providers may need to consider the degree to which they should attempt to satisfy skeptical consumers, many of whom may never rate their care highly. Alternatively, they may need to target skeptical consumers with educational efforts explaining the benefits of medical care.

Little is known about the quality of pharmacy services provided to the rural elderly population. This exploratory study examines rural/urban and ethnic differences in perceived access to ancillary pharmacy services among elderly people. Two telephone surveys were conducted using directory listings in West Texas to generate a longitudinal sample. Persons aged 65 years and older who were not cognitively impaired were asked to complete the survey. The number of participants in both rounds of the survey was 3,689. Seven ancillary pharmacy services were examined: delivery of medications, medication counseling, written medication information, blood pressure monitoring, blood glucose monitoring, osteoporosis screening, and immunization. The sample was stratified by county of residence (urban, rural, or frontier) and racial/ethnic background. Chi-square tests were performed to detect rural/urban and racial/ethnic differences in access to the seven ancillary services. The association between proficiency in English and access to the services was also examined. Rural residents were more likely than urban residents to report that their pharmacies provide delivery of medications, medication counseling, and immunization services, but they were less likely than their urban counterparts to report that their pharmacies provide blood pressure monitoring. Access to ancillary pharmacy services was reported as poorer by older Hispanic people compared with non-Hispanics. Deficiency in English was significantly related to inequality in reported access to ancillary pharmacy services. It is essential to consider the special needs of rural and Hispanic elderly people to ensure equitable access to ancillary pharmacy services.

Context: The bypassing of local pharmacies by consumers is an indicator of limited accessibility and, possibly, compromised quality of rural pharmacy services., Purpose: The objective of this study was to identify the characteristics of rural consumers who bypassed local pharmacies for their medication needs., Methods: The sample was derived from the Texas Tech 5000, a longitudinal survey in West Texas, and pharmacy data from the Texas State Board of Pharmacy. The sample included 1062 people aged 65 or older who lived in rural counties and had at least one community pharmacy in town. Bivariate and multivariate analyses were performed to investigate the demographic, financial, nonfinancial, prescription and over-the-counter drug use, and health characteristics that were associated with the probabilities of the subjects' using local community pharmacies, nonlocal community pharmacies, and mail-order pharmacies., Findings: In the sample, 70.8%, 13.7%, and 15.5% of elderly people primarily used local pharmacies, nonlocal pharmacies, and mail-order pharmacies, respectively. The oldest subjects, women subjects, subjects with no employer-provided or other federal insurance, subjects who had a regular doctor, and subjects living within city limits and in areas with a higher density of community pharmacies had lower probabilities of choosing nonlocal pharmacies over local pharmacies. Insurance coverage for prescriptions was one of the most important determinants in choosing mail-order pharmacies over local community pharmacies., Conclusions: Additional research is warranted to further understand the choices made by older people, as well as by younger people who use medications. In particular, further investigation of the potential differences between services provided by rural-community, urban-community, and mail-order pharmacies is needed to identify other reasons for bypassing local pharmacies.

Objective: To compare the effects of having a regular doctor and having a regular site on five preventive services, controlling for the endogeneity of having a usual source of care., Data Source: The Medical Expenditure Panel Survey 1996 conducted by the Agency for Healthcare Research and Quality and the National Center for Health Statistics., Study Design: Mammograms, pap smears, blood pressure checkups, cholesterol level checkups, and flu shots were examined. A modified behavioral model framework was presented, which controlled for the endogeneity of having a usual source of care. Based on this framework, a two-equation empirical model was established to predict the probabilities of having a regular doctor and having a regular site, and use of each type of preventive service., Principal Findings: Having a regular doctor was found to have a greater impact than having a regular site on discretional preventive services, such as blood pressure and cholesterol level checkups. No statistically significant differences were found between the effects a having a regular doctor and having a regular site on the use of flu shots, pap smears, and mammograms. Among the five preventive services, having a usual source of care had the greatest impact on cholesterol level checkups and pap smears., Conclusions: Promoting a stable physician-patient relationship can improve patients' timely receipt of clinical prevention. For certain preventive services, having a regular doctor is more effective than having a regular site.

Few population-based studies of consumers' perceptions of health care quality have included both rural residents and Hispanics. Using data collected through a random-digit telephone survey of households in the Permian Basin region of west Texas, an area with a relatively high percentage of Mexican Americans, we tested for rural/urban and ethnic differences in satisfaction with medical care. The study had several limitations, but the findings suggest that rural residents of this region rate the quality of their medical care overall more negatively than do their urban counterparts. No ethnic differences were found when controlling for demographic, social, economic, and health-status characteristics. Other factors, including part-time employment, a lack of continuous health insurance coverage, and poor health status appear to have a stronger, negative relationship with satisfaction. The collection and reporting of more specific measures of interpersonal and technical quality would further enable policy-makers, managers, and clinicians to better serve their patient populations.