Research in Action
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One-fourth of America's population lives in rural areas. Compared with urban Americans, rural
residents have higher poverty rates, a larger percentage of elderly, tend to be in poorer health,
have fewer doctors, hospitals, and other health resources, and face more difficulty getting to
Hospital closures and other market changes have adversely affected rural areas, leaving State and
Federal policymakers, and others concerned about access to health care in rural America.
Considerable changes in the health care delivery system over the past decade have intensified the
need for new approaches to health care in rural areas. Managed care organizations, for example,
may not be developed easily in rural areas, partly because of low population density.
AHCPR is meeting these challenges through several major rural health initiatives. AHCPR's role is
health services research—finding out what works best in health care for rural communities.
Rural Health Research Agenda
AHCPR has brought together rural health experts to develop a research agenda on key health care
issues facing rural Americans. These issues are:
- Access to care. Many small rural hospitals have closed, while other health care
are in financial straits. Unavailability of resources and transportation problems are barriers
to access for rural populations.
- Supply of primary care physicians and other health care providers. The supply of
primary care practitioners and other health care providers in rural areas is decreasing.
Some are leaving rural areas to join managed care organizations elsewhere.
- Health promotion and disease prevention. Goals for improving the Nation's health
the next decade, outlined in Healthy People 2000, can be achieved only if rural
populations are included in efforts to remove barriers to access and use of clinical
- Health care technology. Technologies including telemedicine offer promise of
access to health care, but their most efficient and effective applications need further
- Organization of services for vulnerable rural populations. Low population density in
rural areas makes it inherently difficult to deliver services that target persons with special
health needs. Groups at particular risk include: the elderly; the poor; people with HIV or
AIDS; the homeless; mothers, children, and adolescents; racial or ethnic minorities; and
persons with disabilities.
- Consumer choice and the rural hospital. Factors that drive changes in rural hospitals
have a critical effect on consumer choice and access.
Based on its rural health services research agenda, AHCPR has conducted and funded projects
whose findings include:
- Almost one in three adults living in rural America is in poor to fair health. Nearly
half have at least one major chronic illness. Yet, rural residents average fewer physician
contacts per year than those in urban communities.
- Traumatic injuries are more common in rural areas, and residents face worse
outcomes and higher risks of death than urban patients, partly because of transportation
problems and lack of advanced life support training for emergency medical personnel.
Identifying these factors may help shape solutions.
- Rural hospitals show a greater shift toward outpatient services, and greater declines
in admissions and lengths of stay than urban hospitals. Economic pressures have driven
rural hospitals to shift rapidly to outpatient care.
- Alcoholism and drug abuse are growing problems in rural areas. With a scarcity of
mental health professionals in rural areas, fewer than one in five rural hospitals has
treatment services for these conditions.
- Rural and urban residents are equally likely to lack health insurance. Underinsurance
is as much of a problem for rural residents as being uninsured.
- Analytic geographic mapping techniques are valuable for rural health policy and
health services research. A guide to using these decisionmaking tools now is available as
an innovative resource in examining rural health care delivery.
- Different solutions are required to keep primary care providers in rural areas
needed to attract them there initially.
Rural Health Centers
AHCPR has funded five rural health research centers, in Colorado, Minnesota, New York State,
North Carolina, and Washington State, to do health services research on issues of cost, quality,
and access, including health care delivery to vulnerable populations. Findings will be available in
AHCPR has awarded almost $10 million in grants to demonstrate innovative ways to deliver
health services through managed care in rural areas of Arizona, Iowa, Maine, Nebraska,
Oklahoma, and West Virginia.
These demonstration projects are developing provider/consumer/academic coalitions to bring
managed care options to rural areas.
AHCPR holds national workshops for State and local health policymakers, addressing rural issues
- The shortage of health professionals.
- The role of communities in designing health care delivery systems.
Another workshop, co-sponsored by AHCPR, has examined
innovative ways to deliver and finance essential rural health services (1990).
AHCPR also holds workshops for health policymakers in individual States on issues specific to
their needs. For example, AHCPR recently conducted a workshop on rural health issues for
Wyoming policymakers, and another workshop on Georgia's rural health problems is planned.
Some current AHCPR research projects are addressing:
- Differences in home health care services delivered to the rural and urban elderly.
- Effects of obstetric care provider shortages on prenatal care and adverse pregnancy
- Effects of rural hospital closures on hospital care for rural Medicare populations.
- Organizational barriers to delivering recommended vaccinations to children in rural
AHCPR's clinical practice guidelines are helping to improve health care for rural
- The number of home-acquired pressure ulcers has decreased as a result of nurses at a home
health agency in West Virginia using the pressure ulcer prevention guideline, and distributing
the patient guide as an educational tool.
- Based on sickle cell guideline recommendations, North Carolina policymakers have mandated
State-wide screening for newborns.
- Some hospitals serving rural populations in Iowa and Wisconsin are using the acute pain
management guideline to monitor and control patients' pain more aggressively.
AHCPR Publication No. 96-P040
Current as of March 1996