Janice C. Probst, PhD James N. Laditka, PhD Sarah B. Laditka, PhD Arnold School of Public Health

Rural Health Research Center

South Carolina

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

Janice C. Probst, PhD

James N. Laditka, PhD

Sarah B. Laditka, PhD

Arnold School of Public Health

University of South Carolina

Rural Health Research Center

South Carolina

Problematic access to primary care

Demand Rural residents more likely to be

uninsured, underinsured Rural residents face greater travel

burdens than their urban peers Supply:

Ratios decline as communities become more rural and remote

Rural Health Research Center

South Carolina

Rural residents may have worse outcomes Physician / population ratios are lower in

rural than in urban areas Higher death rates for children, young

adults, working age adults Later stage at cancer diagnosis Higher hospitalization rates for ambulatory

care sensitive conditions (ACSC)

Rural Health Research Center

South Carolina

Study questions

To ascertain the effects of rurality on ACSC hospitalization rates

To identify county-level factors associated with ACSC hospitalization rates

Rural Health Research Center

South Carolina

Methods

Cross Sectional Analysis Data source: 2002 State Inpatient Database, Area

Resource File,Census

Population: 580 counties across CO, FL, KY, MI, NY, NC, SC, & WA.

Rural Health Research Center

South Carolina

Definitions

ACS diagnoses use AHRQ definitions Rurality was defined using Urban

Influence Codes. Exclusions:

Counties with very small age‑specific populations,

Small rural counties (13) immediately adjacent to metropolitan areas.

Rural Health Research Center

South Carolina

Analysis

Separate analyses for children, working age adults, and older adults (65+)

Poisson regression Supply side control factors (county level):

Physician supply Hospital bed supply Number ED’s ED visit rates

HMO penetration Presence of a

community health center or rural health clinic

Rural Health Research Center

South Carolina

Analysis, continued

Demand side controls (county level): Estimated uninsured population (children, working

age adults only) Race/ethnicity (proportion black, Hispanic, Asian, or

American Indian, measured separately) Population change between 1990 and 2000 Percent residents with high school + education Population density Unemployment rate Death rates for several relevant chronic conditions

Rural Health Research Center

South Carolina

Unadjusted admission rates, kids

3.74 4.164.79

5.36 4.94

6.875.73

012345678

Metrolarge(76)

Metro,small(153)

Rural,adj

large(19)

Ruralmicro(117)

Rural,adj

smallmetro(95)

Rural,adj

micro(47)

Ruralremote

(53)

Rural Health Research Center

South Carolina

Unadjusted admission rates, ages 18 - 64

7.98 8.2510.10

11.28 12.23 12.6614.27

02468

10121416

Metrolarge(76)

Metro,small(152)

Rural,adj

large(19)

Ruralmicro(118)

Rural,adj

smallmetro(95)

Rural,adj

micro(48)

Ruralremote

(53)

Rural Health Research Center

South Carolina

Unadjusted admission rates, 65+

67.45 64.3971.70 77.35

83.81 87.6594.43

0102030405060708090

100

Metrolarge(75)

Metro,small(154)

Rural,adj

large(19)

Ruralmicro(117)

Rural,adj

smallmetro(94)

Rural,adj

micro(47)

Ruralremote

(51)

Rural Health Research Center

South Carolina

Adjusted rate ratios, age 18 - 64

0.7800.729

0.8800.816 0.827

0.729

0.0

0.2

0.4

0.6

0.8

1.0

Metrolarge

Metro,small

Rural,adj

large

Ruralmicro

Rural,adj

smallmetro

Rural,adj

micro

Ruralremote

p<.001p<.1

p<.001p<.001

(nsd)p<.01

p<.001(nsd) p<.001

p<.1

p<.001

Rural Health Research Center

South Carolina

Adjusted rate ratios, age 65+

0.67 0.660.75 0.75

0.81 0.84

0.00.10.20.30.40.50.60.70.80.91.0

Metrolarge

Metro,small

Rural,adj

large

Ruralmicro

Rural,adj

smallmetro

Rural,adj

micro

Ruralremote

p<.001nsd

p<.001p <.001

p<.001nsd

p<.001p<.001

p<.001p<.05

p>.001

Rural Health Research Center

South Carolina

Conclusions

Among adults:

Increasing degrees of rurality were generally associated with higher ACSC rates,

The most rural areas were at greatest risk.

Geographic differences in ACSC rates were not attributable to physician supply, county rates of health insurance coverage, education levels, or similar factors, as these were held constant in the analysis.

Rural Health Research Center

South Carolina

Conclusions

We speculate that travel impedance, poorer quality of ambulatory care in rural communities, or lack of outpatient supportive services that could substitute for inpatient care contribute to higher ACSC rates in the most rural areas.

Policies are needed to enhance health care access in rural areas.