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Rural-Urban Differences in Usual Source of Care and Ambulatory Service Use: Analyses of National Data Using Urban Influence Codes

Larson, Sharon L. PhD*; Fleishman, John A. PhD*

Original Articles

Background. Rural-urban disparities in access to and utilization of medical care have been a long-standing focus of concern.

Objective. Using the nine-category Urban Influence Codes, this study examines the relationship between place of residence and having access and utilization of ambulatory health services.

Research Design. Data come from the Medical Expenditure Panel Survey, conducted in 1996. Linear and logistic regression analyses assess the relationship between county type and having a usual source of care and ambulatory visits, controlling for demographic and health status measures.

Results. Residents of counties that were totally rural were more likely to report having a usual source of care (adjusted OR: 1.98; CI: 1.01, 3.89) than residents of large metropolitan counties. Residents of places without a city of 10,000 or more, but adjacent to a metropolitan area, were also more likely to report having a usual source of care (adjusted OR: 1.92; CI: 1.16, 3.22). In a regression analysis, residents of the most rural places reported fewer visits during the year (B = −2.42, CI: −3.68, −1.32).

Conclusions. Results suggest that using rural and urban definitions that go beyond the traditional dichotomy of metropolitan and non-metropolitan may assist policymakers and researchers in identifying types of places where there is a disparity in access and subsequent utilization of health care. Rural residents, defined as totally rural in the urban influence coding scheme, may report having a health care provider but report fewer visits to health care providers during a year.

Rural-urban disparities in access to and utilization of medical care have been a long-standing focus of concern. Several factors suggest that access barriers or underutilization will be greater in rural than urban areas. Compared with urban residents, rural residents are more likely to lack health insurance 1,2–4 and may travel long distances to obtain care. 1,5–7 Rural residents tend to be older, poorer, and in worse health than urban residents, 8,9 and these characteristics may affect health care access and utilization. Supply-side issues, such as fewer physicians and hospitals in rural settings, may also play a role in limiting access or utilization of services. 10–12

Several studies compare urban and rural residents’ access to and use of health care. Having a usual source of care (USC) is an entry point to the health care system and is one measure of access to care. 13,14 Prior research comparing metropolitan (MSA) with non-metropolitan (Non-MSA) residents found little difference in the proportion with a USC. 9,15 However, it is not clear if systematic differences would emerge using a more refined geographic typology. Findings related to rural-urban differences in utilization of ambulatory care are inconsistent. Some studies have found minimal geographic variation in the proportion of persons with at least one visit. 15,16 Among nonelderly adults in Nebraska, rural residents were more likely than MSA residents to have a personal physician and made a greater number of physician visits. 17 In contrast, studies of the elderly found that the likelihood of having any outpatient event was greater in non-metropolitan than metropolitan places, 9 and the mean number of ambulatory visits was lower among residents of non-metropolitan counties than large metropolitan core and fringe counties 16 or central city residents. 18 Rural-urban location is often measured dichotomously, by comparing residents of MSAs to those who live outside an MSA. 19–21 Using a dichotomous indicator implies that persons living in very different types of communities are aggregated and treated as a homogeneous group. 22 Using a more fine-grained geographic typology may improve understanding of rural-urban health care disparities. The nine-category Urban Influence coding scheme differentiates two types of metropolitan areas (based on population size) and seven types of non-metropolitan areas (based on adjacency to a large or small metro area and size of largest urbanized center). 12,22,23 Defining counties in terms of this typology enables analyses to distinguish the effects of adjacency versus size of settlement on access and utilization. An additional limitation of some prior studies contrasting health care delivery in rural and urban areas is that the data come from a single state or region 1,18,23–26 or are limited to the elderly. While local and regional studies do provide important data, national data can clarify whether local rural-urban disparities generalize to the national level.

This study uses data from a large, nationally representative sample, the Medical Expenditure Panel Survey (MEPS), to examine urban-rural differences in access and use of health care. We examine reports of having a usual source of care and number of ambulatory care visits among all adult respondents, not just the elderly. Controlling for a wide array of sociodemographic and health-related variables in multivariate analyses, we compare conclusions obtained from using the nine-category Urban Influence coding scheme with the dichotomous MSA/Non-MSA distinction.

*From the Agency for Healthcare Research and Quality, Rockville, Maryland.

This investigation was supported by the Agency for Healthcare Research and Quality, Rockville, MD.

The views expressed in this article are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services is intended or should be inferred.

Address correspondence and reprint requests to Dr. Sharon L. Larson, Center for Cost and Financing Studies, 2101 East Jefferson Street, Rockville, Maryland 20852. E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.