Approximately 3 million veterans, slightly more than one-third of all veterans enrolled in
the Department of Veterans Affairs (VA) health care system, live in rural areas. This pattern
is likely to continue, as a comparable proportion of Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) veterans are from rural areas. The Rural Veterans Care Act of 2006
was signed into law to improve care for rural veterans. Ensuring that the health care needs of
rural veterans are met has become a top priority for VA, resulting in a considerable expansion
of community based outpatient clinics (CBOCs), inclusion of rural health/access as a research
priority, and creation of the VA Office of Rural Health (ORH) in 2006.
Although there have been reports comparing health quality of life (both physical and mental)
for rural and urban veterans, it remains unclear whether the observed lower health quality
of life in rural veterans is due to disparities in health care, differences in disease prevalence,
or other population differences. This systematic review examines the evidence regarding
potential disparities between rural and urban areas in health care provision and delivery, and
how differences in health care may contribute to disparities in health outcomes. Differences in
rural-urban prevalence rates of diseases and other health conditions are beyond the scope of this
review. Because veterans who use VA health care have been found to use more non-VA health
care overall, we expanded the focus of this review to include comparisons of rural vs. urban
health care in non-VA health systems.
The systematic literature review addressed the following key questions:
Do adults with health care needs who live in rural areas have different
intermediate (e.g., hemoglobin A1c [HbA1c], Blood pressure, etc.) or final health outcomes (i.e.,
mortality, morbidity, quality of life [QOL]) than those living in urban areas?
Is the structure (e.g., types of available providers) or the process (e.g.,
likelihood of referral) of health care different for adults with health care needs who live in urban
vs. rural environments?
If there are differences in the structure or the process of health care in rural vs.
urban environments, do those differences contribute to variation in overall or intermediate health
outcomes for adults with health care needs?
If there are differences in intermediate or final health outcomes for adult
patients with health care needs, what other systems factors moderate those differences (e.g.,
availability of specialists, type of treatment needed, travel distance)?