Health Services Research Commons^™

Rural/Urban Disparities In Utilization Of Diabetes Self-Management Training (Dsmt) To The Fee-For-Service Medicare Population, 2017–2024, Wanying Zhu, Aleksandr Taraskin, Jeffrerey Talbert

Rural & Underserved Health Research Center Publications

Key Report Highlights

• A significant rural DSMT access gap exists. Rural beneficiaries accounted for 20.1% of Medicare beneficiaries with diabetes but only 7.8% of DSMT participants.

• Geographic availability remains limited. Only 16.8% of counties with DSMT utilization were rural.

• Access, not demand, appears to be the primary challenge. Rural counties offering DSMT achieved utilization rates more than twice those observed in urban counties (6.0% vs. 2.5%).

• Expanding rural DSMT capacity may represent a high-impact opportunity to improve diabetes self-management support among underserved Medicare beneficiaries.

Non-Metropolitan Vs. Metropolitan Variations In Alcohol, Illicit Drug, And Prescription Therapeutic Drug Misuse, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Key Findings

Alcohol Use. The prevalence of past year and past 30-day drinking was lower among non-metropolitan (non-metro) than metropolitan (metro) residents. However, non-metro drinkers engaged in more frequent binge drinking than metro drinkers. Drinking 3-5, 6-19, and 20-30 days over the past 30 days were higher among non-metro than metro residents.

Illicit Drug Use. Hallucinogens were the mostly commonly used illicit drugs among non-metro as well as metro residents. Methamphetamine use was significantly higher among non-metro than metro residents.

Prescription Pain Reliever Use. The misuse of prescription pain killers, primarily prescription opioids, was higher among non-metro than …

High-Deductible Health Plans In Rural And Urban Populations: Outpatient Utilization And Out-Of-Pocket Costs, Aaron P. Smith, Jefferey Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings This policy brief explores rural-urban differences in High-Deductible Health Plan (HDHP) enrollment, subsequent healthcare utilization, and out-of-pocket (OOP) costs. ▪ HDHP enrollment was uncommon. Rural residents were slightly less likely to enroll than urban residents across all demographic groups. ▪ Switching plans influenced utilization. Compared to those who did not change healthcare plans, switching from a Traditional plan to a HDHP was associated with a larger reduction in 2022 outpatient visits for both rural and urban residents. Moving from a HDHP to a Traditional plan was associated with a smaller reduction in 2022 outpatient visits for …

Rural And Urban Availability Of Substance Use Treatment Facilities, Aaron P. Smith, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Rural counties have higher per capita numbers of substance use disorder treatment facilities than urban counties on average, but also greater variability and large pockets of unmet need.

• The highest proportions of residents living in counties without any treatment facilities are concentrated in rural areas within the Midwestern and Southern United States.

• Rural and urban treatment facilities offer medications for opioid use disorder (MOUD) at similar rates, with inpatient facilities most likely to provide MOUD, followed by residential and outpatient settings.

Review Of Current Research Describing The Influence Of Non-Health Care Drivers Of Health In Rural And Urban Populations, Katie Youngen, Julia Cecil, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Social determinants of health (SDOH) (also called social drivers of health) are the conditions of the environment where people live, learn, work, and play that are known to affect health outcomes.¹ The primary objective of this literature review is to summarize the most recent literature related to the Healthy People 2030 domains of a) economic stability, b) education access and quality, c) neighborhood and built environment, and d) social and community context.² Our particular focus is on non-health care drivers of health. The secondary objective is to identify gaps in literature applied to rural populations.

Management Of Cardiovascular Disease Risk Factors By Rural And Urban Primary Care Practices, Lars E. Peterson, Zachary J. Morgan

Rural & Underserved Health Research Center Publications

In the United States, over 650,000 people die annually from cardiovascular disease (CVD) with high associated health care and economic costs.1 Despite a strong scientific basis for their beneficial impact on health,2 rates of preventive screening remain low.3 Levels of adherence to preventive guidelines are even lower in African American populations, socioeconomically disadvantaged populations, and underserved rural populations.4 Rural populations have higher rates of modifiable risk factors—obesity, smoking, physical inactivity—for CVD than urban populations and bear a disproportionate burden from CVD.5–7 Rates of undiagnosed and poorly treated high blood pressure are more common in rural areas.8,9 Racial/ethnic minority populations also …

Rural-Urban Differences In Dental Care Utilization After A Public Health Emergency, Quazi Minhaz Tabassum, Redwan Bin Abdul Baten, Ahmed A. Arif

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Past year dental clinic visits declined among both rural and urban populations after the COVID-19 pandemic. However, rural patients are more likely to report delayed dental service utilization than their urban counterparts.

• Participants residing in Medicaid expansion states or with health insurance coverage were 16% less likely to delay dental visits overall.

• The COVID-19 pandemic further worsened the existing challenges in dental healthcare access for urban and rural communities.

Rural Access To Certified Community Behavioral Health Clinics (Ccbhcs), Aaron P. Smith, Jeffrey Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

▪ The number of Certified Community Behavioral Health Clinics (CCBHCs) expanded from 2022 to 2023, increasing from 371 to 480. Most of the growth was driven by rural counties (57.9% increase, 126 to 199) while urban counties increased by 14.7% (245 to 281).

▪ The number of services offered at CCBHCs is similar in both rural and urban localities, but urban CCBHCs were more likely to offer services that cater to a diverse client base, such as speaking different languages, and nicotine cessation programs. Rural CCBHCs were more likely to have programs for minors, veterans, and …

Third Party Negotiated Hospital Pricing In Rural And Urban Hospitals Within 12 U.S. States, Lindsey R. Hammerslag, Aaron P. Smith, Jeffrey C. Talbert

Rural & Underserved Health Research Center Publications

No abstract provided.

Diabetes Prevalence And Monitoring In Nonmetropolitan And Metropolitan Areas Within A Commercially Insured U.S. Population, Lindsey R. Hammerslag, Jeffery Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Enrollees living in nonmetropolitan areas had 22% higher likelihood of having diabetes, even after controlling for factors like age and region.
• The prevalence of diabetes in 2019-2020 was 7.9% in nonmetropolitan areas and 6.2% in metropolitan areas.
• Annual hemoglobin A1c (HbA1c) testing occurred for 85.1% of nonmetropolitan and 85.7% of metropolitan enrollees with diabetes. After controlling for other factors, we found significantly lower testing for those in nonmetropolitan areas.
• For diabetic enrollees, having an HbA1c test in 2019 was associated with an 8% decrease in the likelihood of non-cardiovascular complications related to diabetes and a 6% …

Increased Rates Of Death From Unintentional Injury Among Non-Hispanic White, American Indian/Alaska Native, And Non-Metropolitan Communities, Lindsey R. Hammerslag, Jeffery Talbert, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Living in a nonmetropolitan area is associated with an increase in the age-adjusted death rate from unintentional injuries, from 46.2 in metropolitan areas to 59.2 in nonmetropolitan areas in 2018, with all races/ethnicity groups affected except for non-Hispanic Black.
• The ratio of unintentional injury deaths in nonmetropolitan areas, compared to metropolitan areas, was 1.28 overall, ranging from 1.05 to 1.56 depending on race and ethnicity.
• American Indians and Alaska Natives have the highest rate of living in nonmetropolitan areas (39.5%), and this group has the greatest increase in death from unintentional injury associated with living in …

Non-Metropolitan And Metropolitan Trends In Mental Health Treatment Availability In Community Health And Community Mental Health Centers, Tyrone F. Borders, Timothy Williams, Katherine Youngen, Julia Cecil

Rural & Underserved Health Research Center Publications

Key Findings

The supply of community mental health centers (CMHCs) decreased substantially from 2000 to 2019 and became nearly non-existent in non-metropolitan counties.

• The number of CMHCs in non-metropolitan counties declined from 182 to 15.
• The number of CMHCs in metropolitan counties declined from 582 to 104.

The supply of community health centers (CHCs) offering mental health services increased substantially over the same time period, or from 2000 to 2019.

• The number of CHCs in non-metropolitan counties increased from 184 to 573.
• The number of CHCs in metropolitan counties increased from 126 to 797.

The Racial And Ethnic Diversity Of The Family Physician Workforce In Non-Metropolitan And Metropolitan Counties, Lars E. Peterson, Zachary J. Morgan

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• The family physician workforce is becoming more racially diverse; however, non-metropolitan family physicians are not.
• Using data from over 24,000 family physicians who either registered to continue their American Board of Family Medicine (ABFM) certification or completed the graduate survey from 2017 to 2019, we found that early career family physicians are more diverse than later career physicians (66.9% vs. 72.8% White; 58.3% vs. 44.0% female) but, in both groups, the percentage of White non-metropolitan family physicians was even higher (82.7% to 90.5%).
• Minority non-metropolitan family physicians, particularly Black and Native American/Alaska Native physicians, are more …

Serious Mental Illness And Mental Health Treatment Utilization Among Adults Residing In Non-Metropolitan And Metropolitan Counties, Tyrone F. Borders, Timothy Williams

Rural & Underserved Health Research Center Publications

Key Findings

The past year prevalence of serious mental illness (SMI) was significantly higher among non-metropolitan than metropolitan (5.90% vs. 5.18%, P < .03) adults.

Only 67.58% of non-metropolitan and 64.29% of metropolitan adults with SMI received any mental health (MH) treatment in the past year.

Additional analyses revealed the following non-metropolitan/metropolitan treatment differences:

• A higher percentage of non-metropolitan than metropolitan adults with SMI received only medication for MH treatment (24.50% vs. 18.53%, P < .02).
• A higher percentage of metropolitan than non-metropolitan adults with SMI received inpatient, outpatient, and medication (5.42% vs. 2.63%, P < .02).
• A significantly higher percentage of non-metropolitan than metropolitan adults with …

Medicare-Paid Naloxone: Trends In Non-Metropolitan And Metropolitan Areas, Chris Delcher, Yue Cheng, Minji Sohn, Jeffery C. Talbert, Patricia R. Freeman

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Medicare pays for the largest share (> 30%) of naloxone dispensed from retail pharmacies in non-metropolitan areas.
• Medicare-paid dispensing has grown since 2013, but from 2017-2018 dispensing growth in non-metropolitan areas slowed considerably compared to metropolitan areas (42% v 121%, respectively).
• As of 2018, the rate of naloxone dispensing to Medicare enrollees in metropolitan areas was approximately double that in non-metropolitan areas (4.9 v 2.9 per 1,000 enrollees, respectively).

Spatial Analysis Of Health Care Utilization Among Medicare Beneficiaries With Coal Workers’ Pneumoconiosis And Other Related Pneumoconiosis, Ahmed A. Arif, Claudio Owusu, Rajib Paul, Christopher M. Blanchette, Ripsi P. Patel, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• The states with the highest number of Medicare beneficiaries with coal workers’ pneumoconiosis (CWP) were Kentucky, West Virginia, Virginia, and Pennsylvania.
• Significant clustering of health care utilization rates for Medicare beneficiaries with CWP was observed in the central Appalachian states of Kentucky, West Virginia, and Virginia.
• Significant clustering of health care utilization rates for Medicare beneficiaries with Other Related Pneumoconiosis was observed in Appalachia and the southeast parts of Texas and Louisiana. This clustering merits additional research to understand underlying disease etiology.

Risky Substance Use Behaviors Among Adolescents Residing In Non-Metropolitan And Metropolitan Counties In The United States, 2017-2018, Tyrone F. Borders, Michael D. Singleton, Katherine Youngen

Rural & Underserved Health Research Center Publications

Overview of Key Findings

Tobacco Use. The prevalence of any past year tobacco use was significantly higher among non-metropolitan than metropolitan adolescents (13.9% vs. 8.3%). Daily cigarette use in the past 30 days was more than 3 times more prevalent among non-metropolitan than metropolitan adolescents (1.0% vs. 0.3%) and the difference was also statistically significant.

Alcohol Use. Alcohol was the most commonly used substance among both non-metropolitan and metropolitan adolescents, although the differences in prevalence rates for past year and past 30-day alcohol use were not statistically significant. In the past year, 21.8% of non-metropolitan and 21.7% of …

Risky Substance Use Behaviors Among Adults Residing In Non-Metropolitan And Metropolitan Counties In The United States, 2017-2018, Tyrone F. Borders, Michael D. Singleton, Katherine Youngen

Rural & Underserved Health Research Center Publications

Overview of Key Findings

Tobacco Use. Non-metropolitan adults had significantly higher prevalence rates of past year tobacco use (34.7% vs. 27.9%), daily cigarette use in the past 30 days (16.5% vs. 10.3%), and smoking at least 1 pack of cigarettes per day in the past 30 days (46.9% vs. 39.1%) than metropolitan adults.

Alcohol Use. Non-metropolitan adults had a lower prevalence rate of past year alcohol use (64.0% vs. 71.0%), past 30-day alcohol use (48.7% vs. 56.6%), and past 30-day binge drinking (24.5% vs. 26.7%) than metropolitan adults.

Illicit Drug Use. Overall illicit drug use was significantly …

Rural/Urban Disparities In Utilization Of Diabetes Self-Management Training To The Fee-For-Service Medicare Population, Christian Rhudy, Aric Schadler, Jeffery C. Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• In 2016, rural fee-for-service (FFS) Medicare beneficiaries represented 21.7% of the population diagnosed with diabetes, but only 2.7% of the population utilizing Diabetes Self-Management Training.
• Utilization of DSMT services in 2016 occurred in 76 rural counties and 309 urban counties.
• Average utilization rates of DSMT services were greater in rural counties than urban counties (5.5% vs. 2.5%).

Rural/Urban Disparities In The Utilization Of Health And Behavioral Assessments/Interventions In The Fee-For-Service Medicare Population, Christian Rhudy, Eugene Shin, Jeffery C. Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• In 2016, rural county residents represented 21.8% of the fee-for-service (FFS) Medicare population, but only 1.6% of rural FFS beneficiaries live in a county with local utilization of Health and Behavioral Assessments and Interventions (HBAI) services.
• Utilization of HBAI services in 2016 occurred in 19 (9.7%) rural counties and 176 (90.3%) urban counties.
• Average utilization rates of HBAI services were higher in rural counties than urban counties (0.7% vs. 0.4%).

Rural/Urban Disparities In Utilization Of Medical Nutrition Therapy To The Fee-For-Service Medicare Population, Christian Rhudy, Eugene Shin, Jeffery C. Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• In 2016, 21.8% of the fee-for-service (FFS) Medicare population resided in a rural county, but only 3.7% of enrollees residing in a county with utilization of Medical Nutrition Therapy (MNT) services were rural county residents.
• Utilization of MNT services in 2016 occurred in 92 rural counties and 388 urban counties.
• Average utilization rates of MNT services were greater in rural counties than urban counties (3.1% vs. 1.9%).

Major Depression, Treatment Receipt, And Treatment Sources Among Non-Metropolitan And Metropolitan Adults, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• 7.8% of non-metropolitan (weighted number of persons=2,755,020) and 7.1% of metropolitan (weighted number of persons=14,868,655) adults had past year major depression.
• Treatment receipt (seeing a health professional or using prescription medication for depressive feelings) was similar among non-metropolitan (68.0%) and metropolitan (64.6%) adults.
• A closer examination of the type and source of treatment revealed the following:

• Rates of seeing a health professional were similar among non-metropolitan (60.8%) and metropolitan (58.4%) adults, but rates of using prescription medication for depressive feelings were higher among non-metropolitan (58.2%) than metropolitan (48.6%) adults.
• Rates of visiting a general practice/family doctor …

Partial Psychiatric Hospitalization Program Availability In Non-Metropolitan And Metropolitan Hospitals Nationally, Timothy Williams, Tyrone F. Borders, Lindsey Jasinski

Rural & Underserved Health Research Center Publications

Overview of Key Findings

Partial psychiatric hospitalization programs (PPHPs) are intended to reduce or avoid inpatient stays by allowing patients to reside at home while receiving intensive psychiatric services in outpatient settings.

A significantly smaller proportion of non-metropolitan than metropolitan hospitals offer PPHPs.

• 11.4% of non-metropolitan compared to 38.7% of metropolitan hospitals offer PPHPs.
• Regardless of location, hospitals that offer PPHPs have higher patient volumes and more beds than hospitals that offer PPHPs through affiliated providers or do not offer PPHPs at all.

Hospital Closures And Short-Run Change In Ambulance Call Times, Sookti Chaudhary, Alison F. Davis, Kenneth R. Troske, Suzanne Troske

Rural & Underserved Health Research Center Publications

We measure one aspect of how access to emergency care through ambulance services changes for patients when a hospital closes. We empirically estimate the time needed to transport a patient to an emergency department in an ambulance in the period immediately after the hospital closes. We find urban patients in zip codes where a hospital closes have a small change in transportation time, where rural patients average an estimated 15.7 additional minutes – a 46% increase compared to the year before the closure. This increase is primarily the result of an almost 100 percent increase in the time it takes …

Suicidal Thoughts, Plans, And Attempts By Non-Metropolitan And Metropolitan Residence, Kathi Harp, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Key Findings

• Mean prevalence rates for suicidal thoughts, plans, and attempts were significantly higher (P < .05) among residents of non-metropolitan than large metropolitan counties.
• The adjusted odds of suicidal thoughts, plans, and attempts did not improve significantly from 2010 to 2016 among residents of any county type.
• The study findings suggest that suicide prevention interventions should be further targeted toward non-metropolitan counties. However, new interventions may need to be specifically developed to meet the unique needs of residents in non-metropolitan counties.

Do Hospital Closures Affect Patient Time In An Ambulance?, Suzanne Troske, Alison Davis

Rural & Underserved Health Research Center Publications

When a hospital closes in a community, patients needing emergency care may spend more time in an ambulance to receive care in an emergency department (ED). We explore how hospital closures affect the time a patient travels from an incident location where 9-1-1 was called to the ED in an ambulance.

• Rural patients average an estimated 11 additional minutes in an ambulance the year after a hospital closure in their zip code, a 76% increase compared to before the closure.
• Urban and suburban patients have no change in transportation time in zip codes where a hospital closes.
• Patients over 64 …

Update: Rural/Urban Disparities In Pneumococcal Vaccine Service Delivery Among The Fee-For-Service Medicare Population, 2012-2015, Joseph C. Vanghelof, Aric Schadler, Patricia R. Freeman, Jeffery C. Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Between 2014 and 2015, the number of pneumococcal vaccine services delivered to fee-for-service (FFS) Medicare beneficiaries increased by 380% as a result of uptake of PCV13 vaccine.
• Continued disparities in delivery of pneumococcal vaccine services to FFS Medicare beneficiaries in rural and urban communities are noted, with a 63% higher vaccination rate observed in urban areas.
• The majority of pneumococcal vaccine services delivered to FFS Medicare beneficiaries were provided by primary care providers, although pharmacy providers delivered close to one-fourth (24.2%) of these services.
• Pharmacy providers in rural communities play an increasing role in pneumococcal vaccine …

Rural Family Physicians In Patient Centered Medical Homes Have A Broader Scope Of Practice, Lars E. Peterson, Bo Fang

Rural & Underserved Health Research Center Publications

Overview

• Rural family physicians often have a broader scope of practice, defined as the range of clinical and procedural services that they provide, than urban family physicians. The Patient Centered Medical Home (PCMH) model of care is intended to provide accessible and comprehensive care, but little is known about how practicing in a PCMH is associated with rural family physicians’ scope of practice.
• Using data from 18,846 family physicians nationally, we found that rural family physicians working in PCMH practices generally provide a wider scope of clinical and procedural services than those not working in PCMH practices.

Rural Family Physicians Have A Broader Scope Of Practice Than Urban Family Physicians, Lars E. Peterson, Bo Fang

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Little is known about whether rural family physicians provide a broader scope of practice, defined as the range of clinical and procedural services that they provide, than metropolitan family physicians.
• Using data from 18,846 family physicians, we examined variations in the provision of 21 clinical services (e.g., inpatient care, home visits, and obstetrics) and 18 procedural services (e.g., prenatal ultrasound, endoscopy, and office skin procedures) across metropolitan, large rural, small rural, and frontier areas.
• We found that the percentage of family physicians providing each type of clinical and procedural service rises with increasing rurality.

Rural/Urban Disparities In Pneumococcal Vaccine Service Delivery Among The Fee-For-Service Medicare Population, Jeffery C. Talbert, Aric Schadler, Patricia R. Freeman

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• In 2014, the overall mean vaccination rate in urban areas was 4.66 compared to a mean vaccination rate of 2.81 in rural areas, indicating a 40% lower mean vaccination rate in rural communities.
• The majority of pneumococcal vaccine services delivered to fee-for-service Medicare beneficiaries were provided by primary care providers, although pharmacy providers delivered close to one-fourth (22.2%) of these services.
• The proportion of pneumococcal vaccine services delivered by pharmacy providers was significantly greater in rural versus urban counties (29.4% vs. 21.1%).
• Consistent with previous literature, county characteristics positively associated with pneumococcal vaccine service delivery include …