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
South Carolina
Rural Health
Research Center
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
South Carolina
Rural Health Research Center
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)
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Rural Health Research Center
Study questions
 To ascertain the effects of rurality on
ACSC hospitalization rates
 To identify county-level factors
associated with ACSC hospitalization
rates
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Rural Health Research Center
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.
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Rural Health Research Center
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.
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Rural Health Research Center
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
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Rural Health Research Center


HMO penetration
Presence of a
community health
center or rural health
clinic
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
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Rural Health Research Center
Unadjusted admission rates, kids
8
7
6
5
4
3
2
1
0
6.87
3.74
4.16
Metro
large
(76)
Metro,
small
(153)
South Carolina
5.36
4.79
Rural,
adj
large
(19)
Rural
micro
(117)
Rural Health Research Center
5.73
4.94
Rural,
adj
small
metro
(95)
Rural,
adj
micro
(47)
Rural
remote
(53)
Unadjusted admission rates,
ages 18 - 64
16
14
12
10
8
6
4
2
0
10.10
7.98
8.25
Metro
large
(76)
Metro,
small
(152)
South Carolina
Rural,
adj
large
(19)
14.27
11.28
12.23
12.66
Rural
micro
(118)
Rural,
adj
small
metro
(95)
Rural, Rural
adj
remote
micro
(53)
(48)
Rural Health Research Center
Unadjusted admission rates, 65+
100
90
80
70
60
50
40
30
20
10
0
67.45
64.39
Metro
large
(75)
Metro,
small
(154)
South Carolina
71.70
Rural,
adj
large
(19)
77.35
Rural
micro
(117)
Rural Health Research Center
94.43
83.81
87.65
Rural,
adj
small
metro
(94)
Rural, Rural
adj remote
micro
(51)
(47)
Adjusted rate ratios, age 18 - 64
1.0
0.8
0.880
0.780
0.816
0.827
0.729
0.729
0.6
0.4
0.2
0.0
Metro
large
Metro,
small
South Carolina
p<.001
p<.1
p<.001
p<.001
Rural,
adj
large
(nsd)
p<.01
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Rural
micro
p<.001
(nsd)
Rural,
adj
small
metro
p<.001
p<.1
Rural,
adj
micro
p<.001
Rural
remote
Adjusted rate ratios, age 65+
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0.67
0.66
Metro
large
Metro,
small
p<.001
nsd
p<.001
p <.001
South Carolina
0.75
0.75
Rural,
adj
large
Rural
micro
p<.001
nsd
p<.001
p<.001
Rural Health Research Center
0.81
0.84
Rural,
adj
small
metro
Rural,
adj
micro
p<.001
p<.05
p>.001
Rural
remote
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.
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Rural Health Research Center
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.
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Rural Health Research Center