Rural-Urban Differences in Perceived
RuralAccess to Health Services in Older Adults:
The Role of Workforce Supply
Joshua M. Thorpe, PhD, MPH
David A. Mott, PhD
Division of Social and Administrative Sciences,
University of Wisconsin – Madison School of Pharmacy
Sonderegger Research Center, UW-Madison
June 27,
27 2009
Funding: Pilot Grant, Wisconsin Longitudinal Study
(PI: R. Hauser; National Institute on Aging (AG9775 and AG-21079)
Background

Considerable healthcare needs:




80% with 1+ chronic conditions; 50% with 2+ conditions
Depression prevalence high (5(5-15%); increases with age
Managing 22-5 different Rx’s (41% managing 5+)
High need for regular prevention/screening services

Access range of services critically important

Access challenges in rural areas:

Disproportionate need for providers


Fewer local providers available to meet needs


Larger elderly population-population-- aging at a disproportionate rate
Mental health providers, specialists, pharmacy services, dentists, etc
Evidence suggesting access barriers in rural areas:



Fewer specialist and mental health visits
Less likely to receive preventive services
More likely to be hospitalized for ‘preventable’ conditions
Gaps and Research Questions

Q1: Do older adults in rural areas actually perceive
greater
t barriers
b i
iin access tto h
health
lth services
i
compared
d tto
those in more urban areas?

Q2: If differences in perceived access exist, are these
Q2:
rural--urban differences in
differences being mediated by rural
workforce
kf
supply?
l ?

Q3: More broadly
Q3:
broadly, what % of the total variation in
perceived access is explained by countycounty-level
characteristics (rurality, workforce, etc)?

Q3b: Of the total county
county--level contribution, what is the relative
contribution of workforce supply versus other sources?
Conceptual Model:
A d
Andersen
Behavioral
B h i
l Model,
M d l 1995
I di id l L l
Individual-Level
*Predisposing
*Enabling
Rurality
*Need
Individual-Level
Perceived Health
Evaluated Health
Community-Enabling
Healthcare System
*Workforce Supply
*Other features
External Environment
Consumer
Satisfaction (access)
Methods – Data

Three data sources

Wisconsin Longitudinal Study (WLS). Random
sample of over 10,000 graduates from Wisconsin
high schools in 1957.

Subset to those completing 2004 wave (n=5,465),


Area Resource File


who
oa
also
so cu
currently
e t y live
e in Wisconsin
sco s ((final
final
a n=4,898).
n=4,898
,898)).
,898)
non--p
non
pharmacy
y workforce
Wisconsin Department of Regulation and Licensing

County--level pharmacy data
County
Methods –
K
Key
Independent
I d
d t Variables
V i bl

Co nt -level
CountyCounty
le el R
Rurality
ralit

Rural Urban Continuum Codes (2003 ARF)




Metropolitan (3 categories)
Non--Metro (6 categories: 3 urban, 3 rural)
Non
Current study: Metropolitan (reference), Urban, Rural
C
CountyCounty
-level
l
lW
Workforce
kf
S
Supply
l

Provider--toProvider
to-Population Ratios (per 100,000)






Primary care physicians (GP
(GP, Family
Family, General IM)
Specialist physicians (Medical + Surgical)
Hospitals
Psychiatrists
Pharmacies
Nurse Practitioners + Physician Assistants
Methods –
D
Dependent
d t Variables
V i bl

Perceptions
p
of Access


Group Health Association of America Consumer Satisfaction (Davies
& Ware, 1991).
“Thinking about your own health care, how would you rate…”
rate…”








Responses: poor, fair, good, v. good, excellent
Parsimony: Exploratory Factor Analysis

Results:



…your access to mental health care if you needed it?
…your access to specialty care if you needed it?
…the services available for getting prescriptions filled?
…your
your access to hospital care if you needed it?
…your access to emergency care if you needed it?
…the time waiting to get in for a routine medical care appointment?
1-factor solution
factor loadings: 0.55 (routine) – 0.87 (hospital care)
Cronbach α: 0.86
Sum score = “Perceived Access” (higher=better)
Methods –
IndividualI di id l-Level
Individual
L
l Control
C t l variables
i bl
Predisposing
Age
Sex ((male=1))
Marital status
Education
Enabling
Perceived financial
adequacy
Health insurance
Income
Need
ADLs/IADLs
Health Utilityy Index
SF12 Physical Component
SF12 Mental Component
# chronic conditions
Methods –
A l ti A
Analytic
Approach
h
R li
Rurality
a
W kf
Workforce
S
Supply
l
b
Perceptions
of Access
c (direct effect)

Multivariate Path Analysis to test:





Mediated effects = product of coefficients (a*b)



Total effects (i.e., unadjusted) of rurality on perceived access
Mediated
ed ated e
effect
ect o
of rurality
u a ty via
aa
all workforce
o o ce variables
a ab es
Specific mediated effects of rurality via each workforce type
Residual direct effect (adjusted) of rurality on perceived access
95% CI’s calculated using biasbias-corrected bootstrap
Models adjusted for personperson-level (Andersen model) differences
Analyses were conducted using Mplus v5.0
Results (descriptive) –
Selected Respondent Characteristics
Range in Sample
Mean
SD
Min
Max
Rurality (RUCC codes)
% Metropolitan
65.5
0
1
% Urban
28.8
0
1
% Rural
58
5.8
0
1
Age (years)
64
63
67
% Male
46
0
1
12
21
0
1
9
Education (years)
13.8
2.4
% Married
79.7
# comorbid conditions
1.9
1.8
0
14
Perceived Access (sum score)
22.6
4.0
7
30
Results (descriptive) –
% Perceiv
ving Barrie
er
(fair/p
poor vs. go
ood/vg/ex
xcellent)
% Reporting Barriers by Rurality and Type of Service
25%
Metro
Urban
Rural
20%
15%
10%
5%
0%
Mental Health
Specialists
p
Rx Services
Hospitals
p
Type of Health Service
Note: All contrasts between metro/rural statistically significant (p<.05)
Routine Care
Results (Question 1) –
D
Does
perceived
i d access vary by
b rurality?
li ?

Total ((unadjusted)
j
) Effects of County-Level
y
Ruralityy on
Perceived Access in older adults

Answer to Q1, Yes.
Rural vs. Metro
-1.2**
-0.5**
Perceived
Access
Urban vs. Metro


Perceived access was, on average, 1.2 points lower in rural vs.
metropolitan counties.
Perceived access was, on average, 0.5 points lower in urban vs.
metropolitan counties.
Results (Question 2) – Rural
Are these disparities mediated by rural
rural-urban
urban
differences in workforce supply? Rural vs. Metro
P hi t i t
Psychiatrists
Specialists
Pharmacies
T t l = -1.2**
Total
1 2**
Rural vs. Metro
Direct = -0.69* ; Total Ind.= -0.51**
Perceived
Access
Hospitals
PA+NPs
Note: All models adjusted for
Person-level differences
PC MDs
Short Answer to Q2:
YES, in a bad direction
for rural areas
Results (Question 2) – Urban
Are these disparities mediated by rural
rural-urban
urban
differences in workforce supply? Urban vs. Metro
P hi t i t
Psychiatrists
Specialists
Pharmacies
T t l = -0.41**
Total
0 41**
Urban vs. Metro
Direct = -0.32* ; Total Ind.= -0.09
Perceived
Access
Hospitals
PA+NPs
Note: All models adjusted for
Person-level differences
PC MDs
Short Answer to Q2:
No, not for urban vs.
metro areas
Results (Question 3) –
What is the p
proportion
p
of variation in p
perceived
access that occurs at the county-level (vs. person)?

Multilevel modeling (xtmixed, Stata v10.1)
% Total Variance,
C
County
vs. P
Person
…of the County-level Variance,
W kf
Workforce
vs. O
Other
h
County-Level
5% ; p<.01
Person-Level
95%
Workforce
56% ; p<.01
p .01
Other
Summary
Q1:: Older adults in nonQ1
non-metro counties ((rural & urban)) had
lower perceived access to medical care.
Q2a (rural vs. metro):

Taken together, WF supply variables significantly mediated the disparity


Rural  lower supply  lower perceived access
Differences in WF supply, however, does not completely explain disparity
Q2 (rural vs. metro): Significant specific pathways:

Hospital supply mitigated disparity; Specialty supply exacerbated
Q2b (urban vs. metro): WF not significant mediator of disparity
Q3:: 5% off ttotal
Q3
t l variation
i ti iin perceived
i d access att countycounty
t -level
l
l

Of this 5%, over half (56%) related to WF disparities across counties
Limitations

WF supply and Rurality measured at countycounty-level


May not reflect heterogeneity at lowerlower-levels
Pop--provider ratio measures
Pop

May not fully capture system barriers


Validity of “Perceptions
Perceptions of access”?
access ?

Measurement work needed (e.g., cognitive interviews)



E.g., Penchansky’s other 4 A’s (accommodation, acceptability, etc)
1-factor solution for 6 different service types?
How do respondents conceive “access”?
access ?
Generalizability. Cohort of Wisconsin high school
graduates from 1957
1957.

Cohorts from different years? Older adults outside of Wisconsin?
Different racial/ethnic compositions?
Conclusions

Older adults in rural counties -- a group with great
potential need for healthcare -- perceive greater
challenges in accessing a range of health services.

Increasing overall workforce supply (and specialists in
particular) may reduce the access disparity between
rural and metropolitan counties.


Not necessarily for urban/metro disparity
In our sample, the “upper“upper-bound” of policies hoping to
increase perceived access by altering county
county--level
characteristics
h
t i ti was around
d 5%
5%.
Questions?