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Residents of Rural Areas
One in five Americans lives in a non-metropolitan area. Compared with their urban counterparts, rural residents are disproportionately elderly and poor68.
Rural residents are more likely to report fair or poor health, to have chronic conditions such as diabetes, and to die from heart disease68,69. Residents of the most rural counties experience "the highest death rates for children and young adults ... and the highest mortality for ischemic heart disease and suicide among men70."
There are fewer health care providers per capita in rural areas than in non-rural areas. Although 20% of Americans live in rural areas, only 9% of the Nation's physicians practice in rural areas71. There are programs to address the need for physicians in rural areas, such as the National Health Service Corps Scholarship Program, and programs that deliver care in rural areas, such as the Indian Health Service and community health centers. In addition, many non-physician providers work in rural areas and help to deliver needed services. However, many facilities that rural residents rely upon, such as small rural hospitals, have closed or are in financial distress72.
Transportation needs are also pronounced among rural residents, who face longer distances to reach health care delivery sites. Residents of "frontier countiesi" find it particularly difficult to obtain health care due to long distances and travel times to sources of care. Of the 940 "frontier counties," most have limited health care services and 78 do not have any at all73,74.
Rural residents are less likely to receive recommended preventive services and report, on average, fewer visits to health care providers75. Rural minorities appear to be particularly disadvantaged, and differences are observed in cancer screening and management of cardiovascular disease and diabetes76,77.
Many measures of relevance to residents of rural areas are tracked in the NHDR. In the 2003 NHDR, racial, ethnic, and socioeconomic comparisons among residents of areas outside of metropolitan statistical areas (MSAs) were presented. Recognizing that the broad category "non-MSA" masks considerable heterogeneity across the urban-rural continuum, more detailed geographic typologies have been applied to two AHRQ databases for the 2004 NHDR.
HCUP State Inpatient Databases. This year, data from the HCUP State Inpatient Databases use new Federal definitions of metropolitan, micropolitan, and non-core based statistical areas published in June 2003 (Table 4.1)78. HCUP urban-rural contrasts compare residents of micropolitan and non-core based statistical areas with residents of metropolitan statistical areas. HCUP data are used to provide information about quality of care including:
- Heart disease
- Child health
- Patient safety
Medical Expenditure Panel Survey. This year, data from MEPS also use new Federal definitions. In addition, Urban Influence Codes are used to further subdivide metropolitan and non-core based statistical areas (Table 4.1). MEPS urban-rural contrasts compare residents of small metropolitan, micropolitan, and non-core based statistical areas with residents of large metropolitan statistical areas. MEPS data are used to provide information about access to care including:
- Health insurance
- Difficulty getting care
- Health care utilization
i "Frontier" counties have a population density of less than seven persons per square mile, and residents travel a significant distance for health care.
Table 4.1. Urban-rural categories used in HCUP State Inpatient Databases and MEPS analyses
|HCUP SID disparities analysis file, 2001: New Federal categories
||Metropolitan statistical area (metro): Urban area of 50,000 or more inhabitants
||Micropolitan statistical area (micro): Urban area of at least 10,000 but less than 50,000
||Non-core based statistical area (non-core): Not metro or micro
|MEPS, 2001: Divides metro and non-core using Urban Influence Codes
||Large metropolitan: Metro of 1 million or more inhabitants
||Small metropolitan: Metro of less than 1 million inhabitants
||Non-core adjacent: Non-core adjacent to metro or micro
||Non-core not adjacent: Non-core not adjacent to metro or micro