Academic health centers (AHCs) are simultaneously challenged by an increasingly competitive clinical market place and magnified inefficiencies of education and research, resulting in a loss of interest in the social mission implicit and traditional in American medicine.1 Yet, external pressures on AHCs to address the social mission are increasing. AHCs receive significant funding from federal, state, and community sources to support their educational, research, and clinical missions, and these stakeholders are increasingly holding AHCs accountable for their responsiveness to social needs of the people they serve, including those in rural communities.2
At the beginning of the 21st century, over 20% of the United States population continues to reside in rural communities, with 59 million people living in areas defined as rural (fewer than 2,500 people per town unit) or frontier (fewer than six people per square mile).3 The purpose of this paper is therefore to review briefly the health challenges facing rural America and to discuss the current and potential role of AHCs in helping to improve the health of rural populations.
The Challenges Facing Fural America
Although limited, data indicate that individuals living in rural areas are more likely to engage in risky health behaviors4,5 and suffer work-related injuries, and face increased likelihood of physical limitations due to chronic health conditions4–6 than people living in urban or suburban areas. Disparities in health status among minority populations, as well as infant mortality and chronic obstructive pulmonary disease death rates, are also greater in rural than in urban populations.5,7 Addressing these unique and varied problems requires a combination of community-based and personal health care interventions.
Quality of care.
While rural hospitals have fewer safety events than urban hospitals,8 rural patients are less likely to receive effective care9 or receive recommended preventive medicine interventions.10 Thus, for example, myocardial infarction patients treated in rural hospitals are less likely to receive aspirin, heparin, or reperfusion therapy.9 In addition, a study of elderly diabetic patients found that those living in larger rural communities with access to generalist and specialty care were more likely to receive recommended services than patients in rural areas with access only to generalists.11 This suggests that linking AHC specialists with community-based generalists has the potential to enhance the quality of care for rural Americans.
Health care facilities.
Rural hospitals are smaller and less complex and rely more on generalists than urban hospitals.8 Rural hospitals also have fewer financial, information, and personnel resources than urban hospitals, which can affect the scope of care provided by rural health care providers.11 In addition, rural hospitals deal more frequently with care issues such as triage and transfer of patients, which are faced less frequently in urban hospitals.8,12 Their smaller patient populations pose difficulties in risk-adjustment, and many rural hospitals lack the expertise and resources to undertake quality improvement measures.13 AHCs that partner with rural institutions in quality initiatives must account for these differences.
Rural communities are becoming increasingly older, as younger adults leave these areas to find work and older retirees move into them.6 In addition, rural populations are becoming increasingly culturally diverse. In 1950, four out of every ten rural people lived on a farm. Today, less than 10% of the rural population resides on farms and only 14% of rural Americans are involved in farming-related employment.14 These shifts are placing increased demands on community services in rural areas,14 and will require a health workforce competent in providing care to the elderly and a culturally diverse population.
Income and employment.
The majority of the persistent poverty counties in the United States are located in the rural areas of the country, with more than 20% of their residents living at or below U.S. poverty standards.15 Employment opportunities are also limited, with many employers choosing not to provide health insurance.6 These factors, coupled with the lower educational status of the rural population, lead to greater numbers of uninsured individuals in rural communities and decreased access to health care services, and are likely related to poorer health outcomes.6
The Current and Potential Role of Academic Health Centers
Two recent reports, Rural Healthy People 2010, a companion document to Healthy People 2010, and an Institute of Medicine (IOM) Report, Quality Through Collaboration, identify four priorities for improving rural health that fall within the purview of AHCs.6,16 These four priorities are: (1) increasing access to health care, (2) addressing specific and unique health concerns, (3) improving quality of care, with a strong focus on community-level interventions, and (4) improving community health.6,16
Increasing access to care through workforce enhancement
The IOM recently highlighted the need for rural citizens to have timely and appropriate access to primary and specialty care.16 Unfortunately, rural counties continue to suffer from a shortage of health care providers and this shortage is likely to increase in the near future. Federal and state programs have been successful at placing primary care physicians in rural counties.17,18 Yet, a significant maldistribution of physicians remains. While 20% of the U.S. population lives in rural counties, only 9% of physicians practice in these counties.19
Four factors cloud the prospects for improvement in the immediate future. First, current measures of physician availability likely overestimate physician supply20 and a deficit of physicians is looming.21 Second, more women are entering medicine and they are less likely to practice in rural areas.21 Third, the number of students choosing family medicine residencies, the only specialty that distributes itself according to population, is declining. This is likely to result in fewer physicians choosing rural practice. Finally, subspecialty training is increasingly specialized, resulting in fewer truly general surgeons, orthopedists, and others able to care for a broad range of clinical problems in their specialty.19,22
There is now solid evidence, gleaned from family medicine studies, to help AHCs whose missions include producing rural primary care physicians.23–25 Students admitted to medical school who are from rural backgrounds and who express the intent to enter family practice are much more likely to enter and remain in rural practice than are other applicants.23,26 AHCs can facilitate the admissions process for such students through innovative outreach programs25 and through partnerships with rural universities.24 In addition, curricula that include mentoring with a family physician and exposure to rural community-based clinical sites increase the likelihood of students entering rural practice.24,26
Regarding graduate medical education, family medicine residency training programs that include a significant rural training component are associated with an increased likelihood of rural practice selection and retention.27,28 In addition, rural fellowships in family medicine, typically lasting one year, also have a strong track record of placing well-prepared graduates in rural communities,27,29 and Bureau of Health Professions Title VII funding for primary care education has been consistently associated with recipient institutions’ trainees entering rural practice.30
Rural communities also have a need for general pediatricians and internists, as well as emergency room physicians, obstetrician–gynecologists, psychiatrists, general surgeons, and general orthopedists.19,31,32 Although general surgeons are essential to the financial health of rural hospitals, they are underrepresented in smaller rural communities, and their numbers in rural communities are likely to decline.22 Program development and evaluation to recruit and train students in these specialties who will practice in rural communities is needed. These programs should begin with admissions preferences for students from rural communities who have a desire to train in a given specialty and return to a rural community, and should include curricula that expose these students to physicians in rural practice and the needs to be addressed by their specialty. For example, a general surgical curriculum for rural surgeons could include operative orthopedics, operative obstetrics–gynecology, and trauma surgery.
Finally, telemedicine can extend subspecialty care into rural areas and AHCs are frequent providers of this service. Telemedicine consultation, now available in many rural communities, is useful in a variety of conditions and situations, including adult and child psychiatry, trauma care, pediatric and adult ICU care, dermatology, medical subspecialties, and developmental disabilities.33–37 Telemedicine has been shown to improve health outcomes, it has high provider and patient satisfaction scores, it increases perceived health care quality, and it is a cost-effective option in rural areas where there is high utilization of the service, particularly in areas more remote from specialty care.38–40
Addressing specific and unique rural health concerns
A second area identified in Rural Healthy People 2010 relates to addressing the specific needs of rural communities. For example, rural communities struggle to provide adequate emergency medical services.6 AHCs can help prepare family physicians, general internists, midlevel providers, and emergency room physicians to meet the unique challenges of rural emergency room care.32,41 AHCs also can provide real-time telemedicine consultation to physicians caring for trauma patients35 and can play a role in developing triage and transfer protocols, in collaboration with local emergency medical services (EMS) agencies and rural emergency rooms. Partnerships between emergency medicine residency programs and local and state EMS agencies can lead to educational opportunities for residents and to medical supervision for rural EMS services.42
Mental health care is another specific need of rural communities that often is not met.6 Telepsychiatry is an effective and acceptable method to provide mental health services to rural populations.36 In addition, collaborative relationships between AHCs and community mental health providers can enhance the care provided by community providers and facilitate consultation and referral.43
Improving quality of care
An important approach to improving quality of care in rural areas is through the collaboration and partnership of AHCs with local and regional partners in their referral region.16 One outreach program, based at the Massey Cancer Center at Virginia Commonwealth University, deepened relationships with five rural hospitals where oncologists held consultation clinics. In addition to providing direct patient care, the oncologists worked with interested family physicians and internists to enhance their cancer knowledge and management practices. This was supplemented with telephone consultation by oncologists and cancer center nurses.44 Cancer center oncology nurses also worked with local nursing staff and there were opportunities for additional training of local staff at the Massey Cancer Center. Initiation of this program improved a number of quality measures, including the rates of breast-sparing surgery and adjuvant chemotherapy. In addition, the patients received more care in their home community, where they were closer to their social supports.44
In a randomized trial, an educational intervention was developed that was based at an academic cancer referral center but was directed toward rural physicians. This intervention resulted in decreased travel for patients and increased follow-up care from local physicians.45 As another example, pharmacy schools associated with AHCs can work with rural hospitals to provide 24-hour access to pharmacists for consultation, and additional educational opportunities for trainees.8 AHCs can also provide training in quality improvement and leadership to practicing physicians and other health care leaders in rural areas.16
The opportunities for collaboration also provide fertile ground for health services research designed to expand our understanding of health and health care in our rural communities. One successful program used a provider-based research network to launch an incident reporting system. Data collection and management was handled at the AHC, with involvement of participating physicians in review and planning of quality improvement measures.46 AHCs can also build on existing relationships with community-based providers and Area Health Education Centers (AHECs) to identify and develop quality improvement demonstration projects in rural communities.47 Grant writing expertise in AHCs can complement health needs identification and resource allocation in communities in a research partnership.
A second important approach to improving quality of care in rural areas is through the use of information technology and evidence-based medicine (EBM). Whether it is the availability of electronic health records (EHRs) or broadband access to telemedicine resources, rural communities are often at the wrong end of the “digital divide.” Rural communities are less likely to have broadband access, and rural providers are less likely to have access to EHRs.16 However, access to the latest medical evidence is necessary to improve the quality of care.16 AHC libraries possess technical and informatics expertise, as well as the ability to teach physicians to use these systems to access the best information to meet their patients’ needs. Several AHCs have developed successful outreach programs to rural hospitals and providers. These programs typically offer online access to databases, a “circuit-rider” reference librarian who provides training to rural health care providers, and phone or e-mail consultation with reference librarians.48 Other technology-based programs may include distance-learning technologies to train health care workers49 and access to information at the point-of-care both for patient-care purposes and to provide physicians with a convenient source for continuing medical education.48,50
Improving community health
In order for AHCs to fully meet their societal obligation to improve health in rural communities, they must be willing to collaborate with rural communities in providing community-level interventions. Rural communities may rightly be skeptical of AHCs’ intentions. All too often, AHCs have “objectified” communities and individuals for the purposes of research and enhancing clinical revenues, fostering an attitude of mistrust.51 However, there are a number of successful academic and community partnerships that have mutually benefited both rural communities and AHCs. These programs build on the strengths and interests of both parties to achieve common and mutually beneficial goals.52,53 As a theoretical and practical construct underlying some of the most effective partnerships, community-based participatory research involves all participants in an equitable manner, typically involving education and social action to effect change.51
One example is the Deep South Network for Cancer Control. This network is a multistate partnership targeted at eliminating disparities in cancer mortality among African-Americans in Mississippi and Alabama. Built upon the foundation of a preexisting Alabama statewide network,53 the network’s partners include the University of Alabama-Birmingham Comprehensive Cancer Center; the University of Southern Mississippi; Tuskegee University; government agencies such as the Alabama Department of Public Health; and community agencies such as the National Black Church Family Council. The network provides training for community health advocates, community interventions, training for junior investigators in community-based participatory research, and mechanisms for carrying out funded research. This network has been successful in recruiting minorities to clinical trials and in reducing disparities in mammography screening rates.54
AHCs’ Mission to Serve the Public
Helping communities in rural America to address their health needs provides new opportunities for AHCs to fulfill their missions of clinical care, education, and research. Taking full advantage of these opportunities requires AHCs to partner with public and private stakeholders to identify the needs of local rural communities and to develop and implement solutions. Medical schools and affiliated hospitals need to work with, and at times follow the lead of, other allied schools, such as schools of nursing, pharmacy, and public health. Additionally, to more fully address health disparities in rural areas, AHCs must advocate at the regional and national level for universal health coverage for all Americans.
At a time when many AHCs operate in an environment of dwindling resources, seeking new problems and challenges to address may appear counterproductive. However, social support for AHCs relies in part on public perception of how well AHCs meet societal needs.55 If AHCs are to meet their societal obligations, they need to identify and work to meet the needs of their regional communities, which often will include rural and frontier areas. Through partnership, creativity, and fealty to their societal obligations, AHCs will be able to reach beyond their visible horizon and improve the health of the 59 million Americans who live far from their doors.
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