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Residents of Rural Areas
One in 5 Americans lives in a nonmetropolitan area. Compared with their urban counterparts, rural residents are more likely to be elderly, poor,83 in fair or poor health, to have chronic conditions, and to die from heart disease.83,84 Rural residents are less likely to receive recommended preventive services and report, on average, fewer visits to health care providers.85 Rural minorities appear to be particularly disadvantaged, and differences are observed in cancer screening and management of cardiovascular disease and diabetes.86,87
Although 20% of Americans live in rural areas,vii only 9% of physicians in America practice in those settings.88 Multiple programs help to deliver needed services in rural areas, such as the National Health Service Corps Scholarship Program, Indian Health Service, and community health centers. Non-physician providers also help to deliver care. However, many facilities upon which rural residents rely, such as small rural hospitals, have closed or are in financial distress.89
Transportation needs are also pronounced among rural residents, who face longer distances to reach health care delivery sites. Of the 940 "frontier counties,"viii most have limited health care services and 78 do not have any.90,91
Many measures of relevance to residents of rural areas are tracked in the NHDR. Findings presented here highlight five quality measures and one access measure of particular importance to residents of rural areas:
|Component of health care need:
||Counseling about physical activity
||Inpatient deaths from heart attack
||Hospital admissions for pediatric asthma
||Care for illness or injury as soon as wanted
|Access to care
As in the 2004 NHDR, detailed geographic typologies have been applied to two AHRQ databases to understand variations in health care quality and access for a range of rural and urban locations (see Table 4.1).
HCUP State Inpatient Databases. Data from the HCUP State Inpatient Databases use Federal definitions of micropolitan and noncore based statistical areas (not metropolitan or micropolitan areas) published in June 2003.92 In addition, Urban Influence Codes are used to subdivide metropolitan areas into large and small metropolitan areas. Urban-rural contrasts compare residents of small metropolitan, micropolitan, and noncore based statistical areas with residents of large metropolitan statistical areas.
Medical Expenditure Panel Survey. Data from MEPS also use Federal definitions. In addition, Urban Influence Codes are used to subdivide noncore based statistical areas. Urban-rural contrasts compare residents of small metropolitan, micropolitan, and noncore based statistical areas with residents of large metropolitan statistical areas.
Table 4.1. Urban-rural categories used in HCUP State Inpatient Databases and MEPS analyses
|HCUP SID disparities analysis file, 2002: New Federal categories
||Large metropolitan: Metropolitan (metro) area of 1 million or more inhabitants
||Small metropolitan: Metropolitan (metro) area of less than 1 million inhabitants
||Micropolitan statistical area (micro): Urban area of at least 10,000 but less than 50,000 inhabitants
||Noncore based statistical area (noncore): Not metropolitan or micropolitan
|MEPS, 2002: Divides metro and noncore using Urban Influence Codes
||Noncore adjacent: Noncore adjacent to metro or micro
||Noncore not adjacent: Noncore not adjacent to metro or micro
vii Many terms are used to refer to the continuum of geographic areas. For Census 2000, the Census Bureau—s classification of "rural" consists of all territory, population, and housing units located outside of urban areas and urban clusters. The Census Bureau classified as "urban" all territory, population, and housing units located within a) core census block groups or blocks that have a population density of at least 1,000 people per square mile, and b) surrounding census blocks that have an overall density of at least 500 people per square mile.
viii "Frontier counties" have a population density of less than 7 persons per square mile; residents travel long distances for care.