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Background: Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited., Objective: The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs., Design: Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals., Subjects: All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017)., Measures: Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year., Results: In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ., Conclusions: Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity., Methods: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered., Results: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society., Conclusion: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Importance: Given the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however., Objective: To describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US., Design, Setting, and Participants: This national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020., Main Outcomes and Measures: The Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates., Results: A total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population., Conclusions and Relevance: This study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.

Objective: To describe the traumatic brain injury (TBI) care in the city of Coari, Amazonas, from 2017-2019., Methods: Ecological study based on the analysis of the data obtained by the Epidemiology Service of the Regional Hospital of Coari regarding TBI attendances in the emergency room from January 2017 to October 2019. According to the Glasgow Coma Scale, TBI was classified as mild, moderate, or severe. Other variables analyzed were sex, age, main causes of TBI, hospitalizations at the admission unit, and transfers to another health center and means of transport used., Results: One hundred ten admissions were registered: 24 mild TBI, 51 moderate, and 35 severe; higher prevalence among men (70%); and age between 20 and 29 years (29%). The main causes were motorcycle accidents (42.7%), falls (29%), and physical aggression (21%). Some 69% of the patients admitted required to be transferred to another health center, with aerial intensive care unit (ICU) as the most significant means of transport (48.7%). Thirty patients hospitalized at the admission unit progressed with hospital discharge and 4 died., Conclusions: The profile of patients affected by TBI in the city of Coari was characterized by male victims of motorcycle accidents with age between 20 and 29 years. The high transfer rates indicates the need for a better neurotrauma assistance. Further investigations and studies associated with regional specificities are essential to recommend changes on the scope of public health and therefore decrease the incidence of TBI., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We administered a questionnaire survey to assess the available clinical resources for the diagnosis and treatment of breast cancer and identify the issues faced by rural hospitals in the Tohoku region in Japan., Methods: The term rural hospital was defined by the following three criteria: the facility is a certified regional cancer center and hospital, no breast specialist is on staff, and ≥ 10 breast surgeries per year have been performed. Thirty-eight rural hospitals were eligible, and each was sent a self-administered questionnaire consisting of 26 questions by mail., Results: Responses were received from 29 of the 38 hospitals. Most of the hospitals had adequate facilities for diagnosis and treatment, but they needed specialists' support for ≥ 2 days per month. Approximately half of the hospitals indicated that applying resources for diagnosis and treatment of breast cancer, especially during planning of treatment and management of advanced breast cancer patients, was a burden. Interestingly, the hospitals felt that being able to provide treatment to their patients was more ideal rather than referring them to urban hospital like the prefectural cancer center and hospital providing specialized cancer treatment., Conclusions: The surveyed rural hospitals needed practical and knowledge-based support from specialists. Unfortunately, the number of specialists is currently insufficient in Tohoku. Increased number of certified physicians, clinical pathways for sharing patient's information and updated knowledge, and information and communication technology for treatment with specialists' intervention in rural hospitals may solve issues in Tohoku.

Problem: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent., Design: Quality improvement study., Setting: A Western Australian regional hospital., Key Measures for Improvement: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care., Strategies for Change: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education., Effects of Change: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described., Lessons Learnt: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit., (© 2019 National Rural Health Alliance Ltd.)

Purpose: Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities., Methods: Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location., Results: Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88)., Conclusions: Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Access to health care in rural areas is a major concern for local populations as well as for policy makers in developing countries. This paper examines spatial access to in-patient health care in northern rural India. In order to measure spatial access, impedance-based competition using the Three-Step floating Catchment Area (3SFCA) method, a modification of the simple gravity model, was used. 3SFCA was chosen for the study of the districts of Pratapgarh and Kanpur Dehat in the Uttar Pradesh state and Vaishali in the Bihar state, two of India's poorest states. This approach is based on discrete distance decay and also considers more parameters than other available methods, hence is believed to be a robust methodology. It was found that Vaishali district has the highest spatial access to in-patient health care followed by Pratapgarh and Kanpur Dehat. There is serious lack of health care, in Pratapgarh and Kanpur Dehat with 40% and 90% of the villages having shortage of in-patient care facilities in these respective districts. The most important factor affecting spatial access was found to be the distance to the nearest major urban agglomeration.

Objective: To explore the influencing factors on patients' health seeking behavior in rural China by employing the theory of planned action., Methods: Data from cross-sectional household-based health survey carried out in 2008 were used in the study. Correlations between outcomes and explanatory variables were studied by Logistic regression., Results: The studying population included 19 389 adult patients over the age of 15. Illness awareness, medical experience and structural restriction factors had strong effect on whether the patients chose medical service. People in different socioeconomical status suffered different influences., Conclusion: Responding to the changing trend of health service demand among rural residents, we should recognize the differentiation and allocate the healthcare resources more rationally.

Objective: To describe an aged persons mental health service in the Sunraysia district in remote Victoria., Conclusion: The aged persons mental health community team undertakes the bulk of the service's work. The data for 2 years are presented and demonstrate how effective the team is. Good relationships and linkages have been built with the local hospital, general practitioners, aged residential care services and the local aged care assessment service. During the 2 year period, very few elderly patients were admitted to the inpatient psychiatric facility and patients suffering from dementia were rarely admitted.

A variety of factors are coming together that will ignite an explosion of conversions to critical access hospital status. What hospitals are eligible to become CAHs, what are the benefits to converting and what should hospital leaders consider before taking the plunge?

Managed care has been hypothesized to increase patient travel by directing patients toward network providers. The purpose of this study is to measure the effect of Medicare HMO enrollment on hospital travel time in rural areas. Hospital travel times were determined for 85,586 inpatient discharges among rural Pennsylvania residents admitted to Pennsylvania hospitals in 1998. Medicare HMO enrollees traveled up to 10.2 minutes further for acute care than Medicare fee-for-service patients (39 versus 29 minutes). Medicare HMO enrollees were 50 percent more likely to travel outside their own counties and 70 percent more likely to travel to urban areas for acute care. The distance premium associated with HMO enrollment was largest in counties with the lowest managed care penetration.

A study, held in the Krasnodar Territory in 1994-2002, showed an increasing morbidity in residents of all age-categories. Essential differences in the prevalence of registered pathologies and in the nature of their dynamics were registered in some districts. An optimized structure of hospital beds resulted, in the above Territory, in a reduced quantity of beds, primarily in rural areas, and in their more effective utilization. More rural citizens applied for medical care to urban and territorial patient-care facilities, by 1.5 and 1.4 times respectively. Such reduction of hospital beds is possible only after advancing appropriately the regular medical check-ups and clinical care and after diminishing the need in the treatment of patients at hospitals. The data of sociological questioning of residents and of doctors held in three municipal entities by using the method of monitoring are presented. It was demonstrated that promotion of inter-district diagnostic centers, priority development of regular medical check-ups and purpose-oriented measures of reprofiling the specialized bed funds are topical issues in promoting the municipal medical care.

Problems of ensuring rural health services in New Zealand have intensified as successive governments have attempted to limit expenditure and health agencies have seen rural services as relatively 'expendable'. From the literature two sets of indicators are identified: the factors influencing successful retention of rural services and the outcomes for the community. Interview and documentation data indicate the extent to which these characteristics and outcomes were present in nine rural community health trusts in southern New Zealand during the 1990s. Variability in outcome and success of community response to threats to rural services relates to the factors identified from the literature, particularly community leadership and capability, but also the prominent role played by local professionals. Given the common political and economic context, these local factors proved important in determining which communities successfully retained hospital services.

This study assesses how local physician concentrations and distances to hospitals differ for rural communities of varying African American and Hispanic compositions. The authors used data at the town-area level (i.e., towns and their immediately surrounding minor civil divisions and census civil divisions) for 9 Southern and 6 Western states, primarily for 1990. Data were from the US. Census, American Medical Association, and American Hospital Association. Analyses compared nonmetropolitan town-areas with low, medium, and high proportions of African Americans and Hispanics on their local physician-to-population ratios and distances to nearest hospitals offering each of four levels of services. The authors found that Western town-areas having over 50% Hispanic populations had lower physician densities than other Western town-areas that were predominantly non-Hispanic White (24.2 vs. 31.2 physicians per 100,000 population). In Southern town-areas, physician densities did not covary meaningfully with the proportion of African Americans. Distances to the nearest hospitals offering basic, intermediate, and tertiary subspecialty services were generally 25% to 35% farther for Southern town-areas composed of over 60% African Americans and for Western town-areas composed of over 50% Hispanics, compared to communities with more than 80% non-Hispanic White populations within each region. These relationships were not attributable to confounding by extraneous state factors, but in some cases were explained by community sociodemographic differences other than race. Thus, the authors learned that rural communities with populations that are predominantly Hispanic, but not those predominantly African American, face longer travel distances to physicians, and both groups face longer distances to some types of hospital services than rural communities with few minorities.

This article reports on a workshop in which the major focus was a review of the barriers that prevent access to the array of community-based services available to the rural elderly. The demographics of the elderly were outlined and key components of the service system described. Attention was given to access hospital-based care, the closing of hospitals and the reasons for bypassing rural hospitals for those in large towns or cities. Special emphasis also was given to mental health services and their uneven accessibility. A review of the policy implications closed the workshop.

This article reports a study of rural hospital failure. Testing a model previously suggested by Drain and Godkin (1996), analysis incorporated four financial ratios used to graphically depict the external environment of a hospital or portfolio of hospitals relative to that of an average facility. Applied to a random sample of rural hospitals, the evidence supports the model's ability to exhibit clustering differences on five of seven selected structure-related variables, and trend activity for the group of hospitals that failed during the period under study.

The purpose of this case study was to ascertain the perceptions of health professionals who were located in six rural communities where hospital closure occurred, regarding the impact of closure on community residents. These health professionals were asked to respond to questions about effects of hospital closures on the availability of medical services such as emergency care, physician services, hospital services and nursing home care. To control for trends in medical services utilization that were unrelated to hospital closure, the study design included comparison areas where similar hospitals remained open. A standardized questionnaire was administered to three health professionals in each of the areas that experienced a hospital closure and also in the matched comparison areas. Interviews of the health professionals in closure areas provide evidence suggestive of some perceived negative effects of hospital closure on these communities. These negative effects include difficulty recruiting and retaining physicians, concern of residents about the loss of their local emergency room, and increased travel times to receive hospital services. The perceived effects of closure appeared to be mediated by the distance required for travel to the nearest hospital. Respondents perceived increased travel times to most significantly affect vulnerable populations, such as the elderly, the disabled and the economically disadvantaged. Respondents in the majority of comparison areas also reported access barriers for vulnerable populations. These barriers primarily center on problems of obtaining transportation and enduring the rigors of travel. Improvements in the availability of transportation to medical care may offer some stabilization to communities where hospitals closed; however, it also is the case that transportation improvements are needed to increase access to care in rural communities where hospitals remained open.

This article employs a quasi-experimental, pre/post comparison group design to determine whether rural hospital closures (n = 11) have had a detrimental impact on access to inpatient and outpatient care for the Medicare population. Closure areas experienced a significant decrease in medical admissions, although admission rates remained higher than in comparison areas. Physician services were not found to substitute for inpatient services following a closure. No adverse impacts on mortality were observed. Patients in closure areas were more likely to be admitted to urban teaching hospitals following the closure of their local hospital.

This overview discusses articles published in this issue of the Health Care Financing Review, entitled "Access to Health Care Services in Rural Areas: Delivery and Financing Issues." These articles focus on the following topics: rural hospitals (including closures, the impact of Federal grants, network development, and costs), managed care in rural areas, telemedicine, and the delivery of mental health services to rural Medicaid beneficiaries.

This article examines the implications resulting from the closure of 25 rural hospitals during 1990. The implications are evaluated by estimating travel distance and time to the nearest open hospitals. In addition, the types of services offered in the hospitals studied were measured to provide a view of potential change in access to services. The average travel distance and time to the nearest hospital after closure was 25.7 miles and 30.2 minutes, respectively. In most cases, the remaining hospitals offered a broader scope of services than did the hospitals that closed. A possible interpretation is that the hospital closures resulted in a tradeoff between breadth of services and rapid access for emergency conditions.

This article examines the effects of rural hospital closures and conversions on various structural dimensions of access. Based on a data set of rural hospitals in Texas during the period 1985-1990, the results indicate that closure or conversion typically had relatively little detrimental effect on hospital services and distance to alternative sources of care, but hospital bed and physician availability may have been adversely affected in certain cases. Rural hospital conversions to alternative types of health care facilities, such as ambulatory care clinics, do appear to have maintained the availability of a restricted set of medical services in some rural areas.

Hospital closure, a devastating event in the life of small communities, can have long-lasting medical, economic, and psychological consequences. This study focuses on a 1991 closure that occurred in the rural North Dakota town of Beach that left local residents 40 and 61 miles away from the nearest hospitals. Two hundred residents of the hospital's former service area were selected via systematic random sampling to share their perceptions on the causes and effects of closing their local hospital. According to respondents, this hospital closure was caused by a number of influences, with the most commonly cited being under-utilization of services by local residents, exacting government rules and regulations, doleful economic climate, dwindling population, poor and unstable local physician care, and poor management of hospital matters. Findings further indicated that Beach area residents were most concerned with poor access to emergency medical care as a result of the closing. Area dwellers perceived that the hospital closure's aftermath would include the loss of local jobs, further declines in the local economy, the suffering of elderly and children, transportation problems, and out-migration of some area residents. These concerns, coupled with the notable decrease in hospital care access, motivated many area residents to think of solutions to these problems rather than to place blame on others for the closure.

Last month, the AHA released its annual list of closed acute-care hospitals. The report showed that the number of closings dropped to 45 hospitals in 1991 from 50 hospitals in the previous year, continuing a downward trend. A MODERN HEALTHCARE special report takes a look at last year's shuttered facilities and also identifies some noteworthy correlations among the rates of hospital closures, mergers and profits.

Many rural communities are finding it necessary to create innovative ways to make healthcare more accessible to their residents. Successful rural healthcare delivery systems require the resources of an institution willing to serve the rural healthcare market, a community wanting to improve its healthcare, and dedicated practitioners. Physicians must be willing to see Medicaid and charity care patients. If physicians in the community are too busy or unwilling to accept indigent patients, the community may need more physicians. When the community recruits additional physicians, leaders must clarify that all physicians have a responsibility to serve indigent patients. As a result, a community-wide healthcare planning process is essential. Because residents might not always be aware that they should receive certain routine healthcare services or how to access those services, the community must establish strategies to reduce this knowledge gap. Urban healthcare centers can help by bringing health screening services to the rural community and by providing health education programs. Providers can close another part of the knowledge gap by helping patients fill out the insurance forms required to receive payment and by helping them find and apply for indigent patient coverage. To help solve the physician shortage problem in rural areas, communities can work with urban healthcare providers to purchase or start new practices in rural areas and then supplement the practices with additional primary care physicians or other healthcare practitioners.

Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community's economy.

This study has two objectives. First, it identifies how much the presence of community hospital beds adds to the stock of physicians practicing in nonmetropolitan counties. Second, it estimates the impact hospital closures or other reductions in beds have on the net flow of physicians into rural counties. The study relies primarily on data from the 1981 and 1986 Physician Masterfiles of the American Medical Association. We find that hospital bed reductions and closures essentially do not affect the availability of physicians--they have apparently already left by the time the downsizing occurs. Further, population change and the number of physicians already in the county determine for the most part the entry or exit of physicians.

In connection with the publication of the article "On the rural medicine" by O. L. Sigailo in "Sovetskoye Zdravokhraneniye" 1990, No. 6, we attempted in a proper controversial way to specify some statements made in the above-mentioned paper and give our view of the above problem using our own findings. Primarily, in accordance with the data of Comprehensive Soviet Encyclopedia, a possible permissible specification of the article title was provided which would properly correspond to its contents. In this respect we expressed the opinion that publications such as this should provide a wider description of measures which would characterise the state of current rural medicine and public health. By this we mean a number of demographic indicators, the health status of different population groups, the material basis and its capacity, prospects for development, approaches to health personnel of high and medium qualification. The most important thing which we reproach the author with is the absence of clear-cut statement that the major problem of rural medicine (using the terminology of Dr. Segailo) is how to use the available health resources. And, moreover, one cannot help but express one's opinion on such vital problems as preparation for total medical survey of population, disease-caused temporary disability, the transition of public health to the new economic mechanism, insurance medicine.

Providing care to people in underserved areas is a societal--not hospital--issue. That's how hospital executives reacted to our latest CEO poll. And although hospitals should have a voice in finding solutions to this problem, voice in finding solutions to this problem, the ultimate responsibility falls on the federal government.

Closure of rural community hospitals in the U.S.A. is a growing and important trend with serious implications for rural communities and the overall health care system. This study analyzes characteristics of all U.S. rural hospitals that closed between 1980 and 1986. Variables correlated with risk of closure--for-profit ownership status, non-government not-for-profit ownership status, number of other hospitals in the county, presence of a nursing or other long-term care unit, few facilities and services offered, lack of accreditation by the Joint Commission of Accreditation of Hospitals, lack of membership in a multihospital system--indicate that a rural hospital's survival depends upon its ability to compete and adapt in a volatile, competitive health care marketplace. five policy options are discussed: changes in Medicare payments, expansion of the number of hospitals designated as sole Community Hospitals, the use of swing beds, establishment of state offices of rural health, and short-term federal and state grants. Allowing hospitals the flexibility to adapt and compete, while ensuring adequate quality health care to rural residents, is suggested as the priority in rural health policy.

The existence of many small rural hospitals in the United States may appear to be an expression of institutional bias in the health care system. Thus the impending demise of a large proportion of these facilities because of their inability to compete with urban centers may seem to be appropriate. However, in the absence of alternatives to institutional care or mechanisms for systematic movement of patients to urban centers, rural hospital closure could genuinely reduce access.