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Purpose: To determine the effect on health and functional status outcomes of enrollment of noninstitutionalized elderly Medicaid recipients in prepaid plans compared with traditional fee-for-service Medicaid.Design: A randomized controlled trial. Beneficiaries were randomly assigned to prepaid care in one of seven capitated health plans compared with fee-for-service care. Only the Medicaid portion of their care was capitated. Patients were followed for 1 year.Setting: The Medicaid Demonstration Project in Hennepin County, Minnesota, which includes Minneapolis.Patients: 800 Medicaid beneficiaries who were 65 years or older at the beginning of the evaluation. Beneficiaries were interviewed at baseline (time 1) and 1 year later (time 2). Ninety-six percent of beneficiaries were available for follow-up interviews at time 2.Main Outcome Measures: General health status, physical functioning, mental health status, activities of daily living, instrumental activities of daily living, corrected visual acuity, and blood pressure and glycosylated hemoglobin measurements for hypertensive and diabetic persons, respectively.Results: There were no differences between prepaid and fee-for-service groups in the number of deaths (20 compared with 24, P > 0.2), the proportion in fair or poor health (56.5% compared with 59.7%, P > 0.2), physical functioning, activities of daily living, visual acuity, or blood pressure or diabetic control. Patients in the prepaid group reported a trend toward better general health rating scores (10.2 compared with 9.8, P = 0.06) and well-being scores (10.0 compared with 9.7, P = 0.07) than patients in the fee-for-service group. The difference in the likelihood of a patient in the prepaid group having a physician visit relative to the fee-for-service group was -16.5% (adjusted odds ratio, 0.46; 95% CI, 0.29 to 0.74) and for an inpatient visit was -11.2% (adjusted odds ratio, 0.55; CI, 0.32 to 0.94).Conclusions: There was no evidence of harmful effects of enrolling elderly Medicaid patients in prepaid plans, at least in the short run. Whether these findings also apply to settings in which health maintenance organizations are formed exclusively for Medicaid patients should be studied further. [ABSTRACT FROM AUTHOR]

CONTEXT: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. PURPOSE: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. METHODS: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. FINDINGS: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. CONCLUSIONS: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions. [ABSTRACT FROM AUTHOR]

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural: healthcare organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies fo medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America. [ABSTRACT FROM AUTHOR]

Purpose: The Agency for Healthcare Re-search and Quality and the federal Office of Rural Health Policy collaborated to convene an expert group to address issues of quality improvement in the rural health care environment. Outcomes: The group identified issues, barriers, and opportunities related to bringing rural health care into the mainstream of the national quality 'revolution.' A framework for rural quality and specific action steps was proposed. Recommendations were made in the areas of workforce, organizational performance, measurement, dissemination of innovation, and external factors impacting quality. Specific recommendations included fostering development of rural consortia, relevant quality measures for the rural environment, technical assistance capacity, appropriate financial incentives, leadership capacity, and databases. [ABSTRACT FROM AUTHOR]

Access to pharmacy services is an important rural health policy issue but limited research has been conducted on it. This article describes rural retail pharmacies in Minnesota, North Dakota, and South Dakota, including their organizational characteristics, staffing, services provided, and planned future changes; examines the availability of pharmacy services and pharmacy closures in rural areas of these three states; and briefly discusses policy issues that affect the delivery of pharmacy services in rural areas. Study data came from a phone survey of 537 rural pharmacies, an analysis of pharmacy licensure data, and phone interviews with clinic, public health, and social services staff in rural communities with potential pharmacy access problems. Using a standard of 20 miles to the nearest pharmacy, most rural residents of these three states currently have adequate geographic access to pharmacy services. However, rural pharmacists and clinic, public health, and social services staff rate financial access to pharmacy services for the elderly and the uninsured as a major problem. Key policy issues that will affect future access to pharmacy services in rural areas include pharmacy staffing and relief coverage; alternative methods of providing pharmacy services; thefinancial viability of rural pharmacies; and the potential impact of a Medicare prescription benefit on rural consumers and rural pharmacies. [ABSTRACT FROM AUTHOR]

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.

Purpose: Social isolation is an urgent threat to public health. Meanwhile, health outcomes across multiple measures are worse in rural areas, where distance to neighbors is often greater and opportunities for social interaction may be scarcer. Still, very little research examines rural-urban differences in social isolation. This study addresses that gap by examining differences in social isolation by rurality among US older adults., Methods: Using Wave 2 of the National Social Life, Health, and Aging Project data (n = 2,439), we measured differences between urban and rural (micropolitan or noncore) residents across multiple dimensions of social isolation. We also conducted multivariable analysis to assess the associations between rurality, sociodemographic characteristics, and loneliness, overall and by rurality. Finally, we conducted multivariable analysis to assess the association between social isolation and self-rated health, adjusting for rurality., Findings: Compared to urban residents, rural residents had more social relationships and micropolitan rural residents were more likely to be able to rely on family members (95.8% vs 91.3%, P < .05). Micropolitan rural residents reported lower rates of loneliness than urban residents after adjusting for sociodemographic and health characteristics (b = -0.32, P < .05), whereas noncore rural, non-Hispanic black residents had a greater likelihood of reporting loneliness (b = 4.33, P < .001)., Conclusions: Overall, noncore and micropolitan rural residents reported less social isolation and more social relationships than urban residents. However, there were differences by race and ethnicity among rural residents in perceived loneliness. Policies and programs to address social isolation should be tailored by geography and should account for within-rural differences in risk factors., (© 2019 National Rural Health Association.)

Purpose: Quality scores are strongly influenced by sociodemographic characteristics and health behaviors, many of which lie outside of the clinician's control. As a result, there is vigorous debate about whether, and how, to risk-adjust quality measures. Yet, rurality has been largely missing from this debate, even though population and environmental characteristics are demonstrably different by rurality. We addressed this gap by examining the influence of county-level population sociodemographic, environmental, and health characteristics on 3 Medicare quality measures., Methods: We used a cross-sectional analysis of 2016 County Health Rankings data to estimate differences in 3 Medicare quality scores (preventable hospitalizations, HbA1c monitoring, and mammography screening) by rurality. We then adjusted for county-level sociodemographic and environmental characteristics in multivariable regression models in order to see whether the association between rurality and quality was impacted., Findings: Both micropolitan and noncore counties exhibited lower quality scores than metropolitan counties for all 3 measures. After adjustment, noncore counties still had poorer quality on all 3 measures, while micropolitan counties improved on 2 measures. Several county-level sociodemographic and environmental characteristics were associated with quality, although the direction of association depended on the quality measure., Conclusions: Differences in Medicare quality scores by rurality cannot be entirely explained by differences in population or environmental characteristics. Still, to the extent that clinicians are evaluated-and paid-based on measures that are influenced by both population sociodemographic characteristics and geographic location without adequate risk adjustment, the challenges of delivering care in rural areas will only be exacerbated., (© 2017 National Rural Health Association.)

Background: There has been considerable debate in recent years about whether, and how, to risk-adjust quality measures for sociodemographic characteristics. However, geographic location, especially rurality, has been largely absent from the discussion., Objective: To examine differences by rurality in quality outcomes, and the impact of adjustment for individual and community-level sociodemographic characteristics on quality outcomes., Data Sources: The 2012 Medicare Current Beneficiary Survey, Access to Care module, combined with the 2012 County Health Rankings. All data used were publicly available, secondary data. We merged the 2012 Medicare Current Beneficiary Survey data with the 2012 County Health Rankings data using county of residence., Research Design: We compared 6 unadjusted quality of care measures for Medicare beneficiaries (satisfaction with care, blood pressure checked, cholesterol checked, flu shot receipt, change in health status, and all-cause annual readmission) by rurality (rural noncore, micropolitan, and metropolitan). We then ran nested multivariable logistic regression models to assess the impact of adjusting for community and individual-level sociodemographic characteristics to determine whether these mediate the rurality difference in quality of care., Results: The relationship between rurality and change in health status was mediated by the inclusion of community-level characteristics; however, adjusting for community and individual-level characteristics caused differences by rurality to emerge in 2 of the measures: blood pressure checked and cholesterol checked. For all quality scores, model fit improved after adding community and individual characteristics., Conclusions: Quality is multifaceted and is impacted by individual and community-level socio-demographic characteristics, as well as by geographic location. Current debates about risk-adjustment procedures should take rurality into account.

Purpose: Although much has been written about Medicare Part D enrollment, much less is known about beneficiaries' personal experiences with choosing a Part D plan, especially among rural residents. This study sought to address this gap by examining geographic differences in Part D enrollees' perceptions of the plan decision-making process, including their confidence in their choice, their knowledge about the program, and their satisfaction with available information., Methods: We used data from the 2012 Medicare Current Beneficiary Survey and included adults ages 65 and older who were enrolled in Part D at the time of the survey (n = 3,706). We used ordered logistic regression to model 4 outcomes based on beneficiaries' perceptions of the Part D decision-making and enrollment process, first accounting only for differences by rurality, then adjusting for sociodemographic, health, and coverage characteristics., Findings: Overall, half of all beneficiaries were not very confident in their Part D knowledge. Rural beneficiaries had lower odds of being confident in the plan they chose and in being satisfied with the amount of information available to them during the decision-making process. After adjusting for all covariates, micropolitan residents continued to have lower odds of being confident in the plan that they chose., Conclusions: Policy-makers should pay particular attention to making information about Part D easily accessible for all beneficiaries and to addressing unique barriers that rural residents have in accessing information while making decisions, such as reduced Internet availability. Furthermore, confidence in the decision-making process may be improved by simplifying the Part D program., (© 2016 National Rural Health Association.)

Rural residents are more likely to be enrolled in traditional fee-for-service Part D Medicare prescription drug plans, and they face particular challenges in accessing pharmaceutical care. This study examines rural/urban differences in satisfaction with Medicare Part D coverage. Using data from the 2012 Medicare Current Beneficiary Survey (N = 3,107 beneficiaries aged 65 and older), we find that rural residents have significantly lower satisfaction with Part D coverage but that regional variation in satisfaction is largely explained by differences in health services use and type of Part D plan (stand-alone versus Medicare Advantage). We conclude by suggesting a multifaceted approach to improving satisfaction with Part D for rural residents.

Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical-access hospitals, which entitles them to Medicare cost-based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). Several changes to eligibility for critical-access status have recently been proposed. Most of the changes focus on mandating that hospitals be located a certain minimum distance from the nearest hospital. Our study found that critical-access hospitals located within fifteen miles of another hospital generally are larger, provide better quality, and are financially stronger compared to critical-access hospitals located farther from another hospital. Returning to the PPS would have considerable negative impacts on critical-access hospitals that are located near another hospital. We conclude that establishing a minimum-distance requirement would generate modest cost savings for Medicare but would likely be disruptive to the communities that depend on these hospitals for their health care., (Project HOPE—The People-to-People Health Foundation, Inc.)

Purpose: Previously published findings based on field tests indicated that emergency department patient transfer communication measures are feasible and worthwhile to implement in rural hospitals. This study aims to expand those findings by focusing on the wide-scale implementation of these measures in the 79 Critical Access Hospitals (CAHs) in Minnesota from 2011 to 2013., Methods: Information was obtained from interviews with key informants involved in implementing the emergency department patient transfer communication measures in Minnesota as part of required statewide quality reporting. The first set of interviews targeted state-level organizations regarding their experiences working with providers. A second set of interviews targeted quality and administrative staff from CAHs regarding their experiences implementing measures., Findings: Implementing the measures in Minnesota CAHs proved to be successful in a number of respects, but informants also faced new challenges. Our recommendations, addressed to those seeking to successfully implement these measures in other states, take these challenges into account., Conclusions: Field-testing new quality measure implementations with volunteers may not be indicative of a full-scale implementation that requires facilities to participate. The implementation team's composition, communication efforts, prior relationships with facilities and providers, and experience with data collection and abstraction tools are critical factors in successfully implementing required reporting of quality measures on a wide scale., (© 2014 National Rural Health Association.)

Research on hospitalist programs has primarily focused on large, urban facilities. To fill a gap in the literature on hospitalist use in rural hospitals, the authors conducted a national survey of 402 rural hospitals with 100 or fewer beds that had reported having hospitalists. The survey examined reasons for using hospitalists, characteristics of hospitalist practices, and the impacts of hospitalist use in rural settings. Rural hospitals most commonly establish a hospitalist program to address medical staff requests, call coverage, and quality issues. Respondents report positive impacts of hospitalist programs on quality of care and primary care physician recruitment and retention, but mixed financial impacts. Assessments of the impact of hospitalists in rural hospitals need to take into account the variety of practitioner specialties functioning as hospitalists, the amount of time they spend as hospitalists, and the multiple roles they play in the rural hospital and community., (© The Author(s) 2014.)

Purpose: To examine the role of Regional Extension Centers (RECs) in helping rural physician practices adopt electronic health records (EHRs) and achieve meaningful use., Methods: Using data from the Office of the National Coordinator for Health Information Technology, we conducted a county-level regression analysis using ordinary least squares to better understand rural-urban differences in REC participation, EHR implementation, and meaningful use, controlling for counties' economic conditions. We prepared case studies of 2 RECs that are serving a large number of rural practices, based on interviews with key individuals at the RECs, their partner organizations, and rural primary care practices that received assistance from the RECs., Findings: RECs are largely achieving their objective of targeting providers in communities that face barriers to EHRs. REC participants are disproportionately rural and more likely to come from high poverty and low employment communities. The case study RECs had long-standing relationships with rural providers, as well as extensive staff expertise in quality improvement and EHR implementation, and employed a variety of strategies to successfully assist rural providers. Rural providers report that REC assistance was invaluable in helping them implement EHRs and achieve meaningful use status., Conclusion: Modifying the criteria for Medicare and Medicaid EHR incentives could help additional rural providers pay for EHRs. REC federal funding is scheduled to end in 2014, but practices that have not yet adopted EHRs may need significant, ongoing assistance to receive meaningful use., (© 2013 National Rural Health Association.)

Background: Approximately 15% of the 4 million annual US births occur in rural hospitals., Objective: To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location., Research Design and Subjects: This was a retrospective analysis of hospital discharge records for all births in the 2002-2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N = 7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals)., Measures: Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated., Results: In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio = 0.79 (0.78-0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio = 1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births)., Conclusions: From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.

Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs)., Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6-member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection., Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures., Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting., (© 2012 National Rural Health Association.)

Context: Quality measures focused on outpatient settings are of increasing interest to policy makers, but little research has been conducted on hospital outpatient quality measures, especially in rural settings., Purpose: To evaluate the relevance of Centers for Medicare and Medicaid Services' (CMS) outpatient quality measures for rural hospitals, including critical access hospitals., Methods: Researchers analyzed Medicare hospital outpatient claims and hospital compare outpatient quality measure data for rural hospitals to assess the volume of conditions addressed by the measures in rural hospitals. A literature review and information from national quality organizations were used to assess the external and internal usefulness of the measures for rural hospitals. A panel of rural hospital quality experts reviewed the measures and provided additional input about their usefulness and data collection issues in rural hospitals., Results: The rural relevant CMS outpatient measures include most of the emergency department (ED) measures. The outpatient surgical measures are relevant for the majority of rural hospitals providing outpatient surgery. Several measures were not selected as relevant for rural hospitals, including the outpatient imaging and condition-specific measures., Conclusions: To increase sample sizes for smaller rural hospitals, CMS could combine data for similar inpatient and outpatient measures, use composite measures by condition, or use a longer time period to calculate measures. A menu of outpatient measures would allow smaller rural hospitals to choose relevant measures depending on the outpatient services they provide. Global measures and care coordination measures would be useful for quality improvement and have sufficient sample size to allow reliable measurement in smaller rural hospitals., (© 2012 National Rural Health Association.)

Purpose: Communication problems are a major contributing factor to adverse events in hospitals.(1) The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality measurement of interfacility patient transfer communication., Methods: Input from existing measures, measurement and health care delivery experts, as well as hospital frontline staff was used to design and modify ED quality measures. Three field tests were conducted to determine the feasibility of data collection and the effectiveness of different training methods and types of partnerships. Measures were evaluated based on their prevalence, ease of data collection, and usefulness for internal and external improvement., Findings: It is feasible to collect ED quality measure data. Different data sources, data collection, and data entry methods, training and partners can be used to examine hospital ED quality. There is significant room for improvement in the communication of patient information between health care facilities., Conclusion: Current health care reform efforts highlight the importance of clear communication between organizations held accountable for patient safety and outcomes. The patient transfer communication measures have been tested in a wide range of rural settings and have been vetted nationally. They have been endorsed by the National Quality Forum, are included in the National Quality Measurement Clearinghouse supported by the Agency for Health Care Research and Quality (AHRQ), and are under consideration by the Centers for Medicare and Medicaid Services for future payment determinations beginning in calendar year 2013., (© 2011 National Rural Health Association.)

Purpose: This study examines the current status of meaningful use of health information technology (IT) in Critical Access Hospitals (CAHs), other rural, and urban US hospitals, and it discusses the potential role of Medicare payment incentives and disincentives in encouraging CAHs and other rural hospitals to achieve meaningful use., Methods: Data from the American Hospital Association (AHA) Annual Survey IT Supplement were analyzed, using t tests and probit regressions to assess whether implementation rates in CAHs and other rural hospitals are significantly different from rates in urban hospitals., Findings: Of the many measures we examined, only 4 have been met by a majority of rural hospitals: electronic recording of patient demographics and electronic access to lab reports, radiology reports, and radiology images. Meaningful use is even less prevalent among CAHs. We also find that rural hospitals lag behind urban institutions in nearly every measure of meaningful use. These differences are particularly large and significant for CAHs., Conclusion: The meaningful use incentive system creates many challenges for CAHs. First, investments are evaluated and subsidies determined after adoption. Thus, CAHs must accept financial risk when adopting health IT; this may be particularly important for large expenditures. Second, the subsidies may be low for relatively small expenditures. Third, since the subsidies are based on observable costs, CAHs will receive no support for their intangible costs (eg, workflow disruption). A variety of policies may be used to address these problems of financial risk, uncertain returns in a rural setting, and limited resources., (© 2011 National Rural Health Association.)

Context: Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower-income Americans (133 to 400 percent of FPL) without access to employer-based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state-level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage., Methods: Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state-level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization., Findings: This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians' productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase., Conclusions: The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care., (© 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.)

Health information technology (IT), such as computerized physician order entry and electronic health records, has potential to improve the quality of health care. But the returns from widespread adoption of such technologies remain uncertain. We measured changes in the quality of care following adoption of electronic health records among a national sample of U.S. hospitals from 2004 to 2007. The use of computerized physician order entry and electronic health records resulted in significant improvements in two quality measures, with larger effects in academic than nonacademic hospitals. We conclude that achieving substantive benefits from national implementation of health IT may be a lengthy process. Policies to improve health IT's efficacy in nonacademic hospitals might be more beneficial than adoption subsidies.

Objective: To examine the relationship between public health system network density and organizational centrality in public health systems and public health governance, community size, and health status in three public health domains., Data Sources/study Setting: During the fall and the winter of 2007-2008, primary data were collected on the organization and composition of eight rural public health systems., Study Design: Multivariate analysis and network graphical tools are used in a case comparative design to examine public health system network density and organizational centrality in the domains of adolescent health, senior health, and preparedness. Differences associated with public health governance (centralized, decentralized), urbanization (micropolitan, noncore), health status, public health domain, and collaboration area are described., Data Collection/extraction Methods: Site visit interviews with key informants from local organizations and a web-based survey administered to local stakeholders., Principal Findings: Governance, urbanization, public health domain, and health status are associated with public health system network structures. The centrality of local health departments (LHDs) varies across public health domains and urbanization. Collaboration is greater in assessment, assurance, and advocacy than in seeking funding., Conclusions: If public health system organization is causally related to improved health status, studying individual system components such as LHDs will prove insufficient for studying the impact of public health systems.

Implementation of patient safety initiatives can be costly in time and energy. Because of small volumes and limited resources, rural hospitals often are not included in nationally driven patient safety initiatives. This article describes the Tennessee Rural Hospital Patient Safety Demonstration project, whose goal was to strengthen capacity for patient safety initiatives in 8 small Tennessee rural hospitals using a multi-organizational collaborative model. The demonstration identified and facilitated implementation of 3 patient safety interventions: the Agency for Healthcare Research and Quality (AHRQ) patient safety culture survey, use of personal digital assistants (PDAs), and sharing of emergency room protocols. The experience suggested that a collaborative model between rural hospitals, a payer, a hospital association, a quality improvement organization, and academic institutions can effectively support patient safety activities in rural hospitals. Successful implementation of the 3 patient safety interventions depended on leadership provided by nursing and patient safety/quality managers and open, trusting communications within the hospitals.

We construct statistical models to assess whether hospital size will impact the ability to identify "true" hospital ranks in pay-for-performance (P4P) programs. We use Bayesian hierarchical models to estimate the uncertainty associated with the ranking of hospitals by their raw composite score values for three medical conditions: acute myocardial infarction (AMI), heart failure (HF), and community acquired pneumonia (PN). The results indicate a dramatic inverse relationship between the size of the hospital and its expected range of ranking positions for its true or stabilized mean rank. The smallest hospitals among the augmented dataset would likely experience five to seven times more uncertainty concerning their true ranks.

Background: Many persons dying of cancer enroll in home-based hospice prior to death. It is established in the literature that persons in rural settings are less likely to use hospice than persons living in urban areas. We examine whether this is due, in part, to a lack of hospice providers serving rural areas., Methods: The 100% Medicare enrollment and hospice files for 2000-2002 were the basis for this study. We used a Bayesian smoothing technique to estimate the ZIP-code-level service area for each Medicare-certified hospice in the United States. These service areas were combined to identify ZIP codes not served by any hospice., Results: Overall, approximately 332,000 elders (7.5% of ZIP codes) reside in areas not served by home-based hospice. Each year over 15,000 deaths occur in these unserved areas. There was a strong association between lack of service and urban/rural gradient. One hundred percent of the ZIP codes in the most urban areas (>1,000,000 people) are served by hospice and only 2.8% of the ZIP codes in urban areas of less than 1,000,000 are unserved. In rural areas adjacent to urban areas, over 9% of ZIP codes are unserved and in rural areas not adjacent to an urban area almost 24% of ZIP codes are not served by hospice., Conclusions: While the majority of the elderly population of the US resides in areas currently served by Medicare-certified hospice, there is a geographically large area that lacks home-based hospice services. Current payment policies may need to be adjusted to facilitate hospice availability to these rural populations.

Context: Critical access hospitals (CAHs) face many challenges in implementing quality improvement (QI) initiatives, which include limited resources, low volume of patients, small staffs, and inadequate information technology. A primary goal of the Medicare Rural Hospital Flexibility Program is to improve the quality of care provided by CAHs., Purpose: This article describes key quality improvement initiatives for a national sample of CAHs that are actively involved in implementing quality-related initiatives in collaboration with support hospitals and statewide organizations., Methods: Researchers conducted a national telephone survey of 72 CAHs and 2 in-depth case studies of CAHs., Findings: The survey and case studies demonstrate that many CAHs are successfully implementing QI activities, including patient safety initiatives, improvements in overall QI processes and peer review processes, and implementation of QI projects focused on treatment of 1 or more specific diseases. The CAHs are involved with multiple external organizations in these activities. The administrators of the 2 case study CAHs have made QI a priority for their hospitals; ensured that resources are available for QI activities; and worked with their support hospitals, statewide organizations, and other CAHs to develop and implement rural-relevant QI initiatives., Conclusions: Cost-based Medicare reimbursement has been a key factor in the ability of CAHs to fund additional staff, staff training, and equipment to improve patient care. The commitment of hospital leaders and key staff is a crucial factor in moving QI initiatives forward in CAHs.

Context: Increased interest in the measurement of hospital quality has been stimulated by accrediting bodies, purchaser coalitions, government agencies, and other entities., Purpose: This paper examines quality measurement for hospitals in rural settings. We seek to identify rural hospital quality measures that reflect quality in all hospitals and that are sensitive to the rural hospital context., Methods: We develop a conceptual model for measuring rural hospital quality, with a focus on the special issues posed by the rural hospital context for quality measurement. With the assistance of a panel of rural hospital and hospital quality measurement experts, we review hospital quality measures from national and rural organizations for their fit to rural hospitals., Findings: Based on this analysis, we recommend an initial core set of quality measures relevant for rural hospitals with less than 50 beds. This core set of 20 measures includes 11 core measures from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) related to community acquired pneumonia, heart failure, and acute myocardial infarction; 1 measure related to infection control; 3 measures related to medication dispensing and teaching; 2 procedure-related measures; 1 financial measure; and 2 other measures related to the use of advance directives and emergency department monitoring of trauma vital signs., Conclusion: Based on the special measurement needs posed by the rural hospital context, we suggest avenues for future quality measure development for core rural hospital functions (eg, triage, stabilization, and transfer, and emergency care) not considered in existing quality measurement sets.

This article examines the development and operation of rural health networks in the United States based on data collected from telephone surveys of rural health networks containing at least one rural hospital in the United States in 1996 and four years later in 2000. The implications of network development for health care managers participating in, or considering participation in, a rural health network are discussed.

This study evaluates why rural primary care physicians sell their practices. A random sample of rural primary care practices in California, Utah, Ohio, Texas, and Virginia were surveyed to investigate changes in ownership of the practices during the period 1995-1998. These five states were selected because they represent areas with different experiences with physician-hospital integration and varied rates of managed care penetration. A series of logistic regressions were conducted to examine the factors that led independent physicians to sell their practices to either nonlocal buyers, local hospitals, or local physicians. Findings suggest that sales to nonlocal buyers represent the majority of practice ownership changes. The motivations for ceding control to nonlocal buyers center on managed care concerns, recruitment concerns, and administrative burdens. Sellers were also concerned about their level of net income prior to being acquired. However, the preacquisition financial concerns of sellers were not significantly stronger than the financial concerns of practices that remained independent. The environmental conditions that motivate rural physicians to sell their practices are not expected to improve. Therefore, additional sales of rural primary care practices to nonlocal buyers are expected. Further research is necessary to determine whether this shift in control will lead to changes in the quality or accessibility of care.

Policymakers are concerned that some rural hospitals have suffered significant losses under the Balanced Budget Act (BBA) of 1997 and that access to inpatient and emergency care may be at risk. This article projects that the median total profit margin for rural hospitals will fall from 4 percent in 1997 to between 2.5 and 3.7 percent after the BBA, Balanced Budget Refinement Act (BBRA) of 1999, and Benefits Improvement and Protection Act (BIPA) of 2000 are fully implemented in 2004. The Critical Access Hospital (CAH) Program is expected to prevent reductions in inpatient and outpatient prospective payments from causing an increase in rural hospital closures.

A disproportionate share of the Medicare beneficiaries who lost coverage as a result of recent health maintenance organization (HMO) withdrawals have been from rural areas. Rural beneficiaries are less likely than urban beneficiaries are to have another Medicare+Choice (M+C) option. We surveyed a nationwide random sample of 1,093 rural beneficiaries to assess the impact of HMO withdrawals. A high proportion of beneficiaries ended up without any coverage beyond traditional Medicare; on average, beneficiaries experienced significant increases in premiums; and the proportion of beneficiaries with prescription drug coverage decreased significantly. These results raise questions about whether the federal government should encourage plans to enter rural markets where they will be the only M+C plan and where their withdrawal could have negative consequences for enrollees who lose coverage.