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Inadequate hospital care and illness severity prompt rural patients to seek care at hospitals outside their areas

Younger patients who are severely ill and live in rural counties where hospital care is inadequate are most likely to travel outside their rural counties for hospital care. Very old, uninsured, or Medicaid patients are less willing or have less ability to travel elsewhere for hospital care, regardless of whether they live in a rural or nonrural area. As a result, these patients would suffer the most from rural hospital closures or regionalization of care, according to a recent study by Agency for Healthcare Research and Quality researcher Jayasree Basu, Ph.D., and James Cooper, M.D., formerly of AHRQ and now with the Health Care Financing Administration.

Drs. Basu and Cooper analyzed 1994 discharge records for New York residents hospitalized in New York, Pennsylvania, New Jersey, or Connecticut to identify patients admitted with ambulatory care sensitive (ACS) conditions. These are conditions—for example, asthma, diabetes, and hypertension—for which good primary care can prevent unnecessary hospitalizations.

They used the data to construct conceptual models describing the impact of key factors affecting hospitalization locally and outside local counties for ACS conditions. Some of these key factors included severity of illness, availability and quality of local hospital care, availability of primary care in local counties, distance, and insurance coverage. They applied the models to residents in three types of geographic locations along an urban-rural continuum: metropolitan, nonmetropolitan adjacent to metropolitan, and rural.

Hospital admissions outside patients' counties were generally associated with younger age, higher illness severity, and fewer county hospital resources. The study found that no matter where elderly people live, advancing age makes them less likely to travel for hospital care, even when they are severely ill.

Same-county admissions were associated with minority race and lack of insurance. Surprisingly, more patients were likely to seek outside care in rural counties with a greater number of primary care providers (PCPs). This suggests that the supply of physicians might not be the most critical factor explaining inadequate access to care. On the other hand, more PCPs could increase the retention of ACS patients in metropolitan areas and in metro-adjacent rural areas, as well as in areas with a large proportion of minority patients who are less likely to travel outside their county for care.

For more details, see "Out-of-area travel from rural and urban counties: A study of ambulatory care sensitive hospitalizations for New York State residents," by Drs. Basu and Cooper, in the Spring 2000 Journal of Rural Health 16(2), pp. 129-138.

Reprints (AHRQ Publication No. 00-R056) are available from the AHRQ Publications Clearinghouse.

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