Rural primary care in VA: Variations in scope of practice, staffing patterns, and performance

Weeks WB, Yano EM. Rural primary care in VA: Variations in scope of practice, staffing patterns, and performance. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.

Objectives: Providing the full spectrum of health care in a rural setting is a difficult undertaking: limited access to specialty care may result in more expectations of primary care providers and a higher demand for primary care. We used a survey of primary care physicians to examine the role of and the capacity to provide primary care in rural settings. Methods: We linked data on the organizational characteristics and primary care features of individual VA health care facilities from the 1999 VHA Primary Care Practices Survey with facility-level VA External Peer Review Program (EPRP) performance measures and VA National Ambulatory Care Survey patient satisfaction scores. Using the Kruskal-Wallis test, we compared the organizational characteristics, performance measures and patient satisfaction scores for VA hospitals located in rural settings by self-report (n = 19) to those located in small city and large urban settings (n = 103). Results: In fiscal year 1999, rural hospitals had fewer unique patients (11,900 vs. 26,000, p < .0001), fewer patient visits (87,800 vs. 218,800, p < .0001) and fewer primary care providers (38 vs. 60, p < .001). They were less likely to be academically affiliated (37% vs. 84%, p < .001). If affiliated, they were less likely to have primary care training programs (42% vs. 80%, p < .001). Rural hospitals were less likely to have specialty clinics that concurrently delivered primary care (e.g., for SCI, 20% vs. 56%, p < .05; for women's health, 53% vs. 76%, p < .05); they were also less likely to have integrated geriatric MD's (10% vs. 50%, p < .001), nurse practitioners (68% vs. 94%, p < .001) and psychologists (5% vs. 32%, p < .05) into primary care practice. Rural hospitals allocated more primary care personnel per patient (3.2 vs. 2.3 per 1,000 patients, p < .01) and were more likely to rely on primary care providers for their subspecialty referrals (67% vs. 29%, p < .05). Primary care providers at rural VA's were more likely to round with ward teams (69% vs. 32%, p < .01), write orders for their patients as inpatients (69% vs. 25%, p < .001), and have linkages in place that facilitate primary care provider notification of subspecialty consultation results (72% vs. 30%, p < .05). We found no differences in chronic disease quality or in preventive practice, with the exception of higher pneumococcal vaccination rates at rural facilities (0.83+/-0.10 vs. 0.74+/-0.13, p < .01). Rural VA's had better patient-reported accessibility (11.8+/-3.4 vs. 15.1+/-3.7, p < .001), courtesy (6.1+/-3.2 vs. 8.5+/-3.6, p < .01), pharmacy services (21.4+/-7.7 vs. 29.3+/-10.7, p < .01), and visit-specific (14.6+/-3.7 vs. 18.0+/-3.8, p < .001) and overall coordination (27.6+/-4.4 vs. 31.2+/-5.1, p < .01). Patients at rural VA's also rated their overall quality of care as higher (65.3+/-8.5 vs. 61.2+/-6.7, p < .01). Conclusions: Rural hospitals were smaller, less affiliated and had access to fewer specialty care services. Primary care providers in rural settings provide more specialty care services and are more likely to provide continuity across patient care settings; however, they have smaller imputed panel sizes. Patients receive comparable quality of care and appear to have greater satisfaction with rural health care settings Impact: The increased scope of primary care services seen in rural settings may require higher staffing patterns, but may result in greater patient satisfaction