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Management Brief No. 112

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Management eBriefs
Issue 112May 2016

The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Rural Healthcare Workforce

Approximately 20 percent of the US total population lives in rural areas, and Veterans living in rural areas represent one-third of the total VA patient population. Patients living in rural areas are often underserved with regard to healthcare access, with less than 12 percent of U.S. physicians practicing in rural settings. The complexity of rural healthcare provision requires careful and systematic evaluation of individual contributing factors, including our ability to assess the current demand and shortage of healthcare providers. Given the many years of training required for key healthcare personnel, predictive studies are crucial to anticipate future provider workforce needs. In recent years, more research has concentrated on exploring determinants of geographic practice choices of healthcare providers. Many approaches have been suggested and resources spent to increase the number of providers practicing in rural healthcare. Rural providers commonly treat a great diversity of conditions and perform a wide variety of procedures, and it is crucial that healthcare provider organizations support providers and identify appropriate efforts that ensure workplace retention. In addition, several programs have been implemented that target healthcare providers in training to address healthcare shortages, for example, by adding rural tracks to medical schools.

Conducted by investigators with the VA Evidence-Based Synthesis Program (ESP) located at the West Los Angeles VA Medical Center, this systematic review examined the current literature in order to:

  • Identify the current and projected need for healthcare providers in rural areas,
  • Explore geographic provider choices,
  • Synthesize evidence on interventions to increase rural provider recruitment
  • Synthesize evidence on interventions to increase provider retention, and
  • Document the efficacy of student training for current rural healthcare in the US.

ESP investigators reviewed the literature from February 2005 to February 2015 (English-language research) and identified 59 publications that met inclusion criteria. Investigators also accessed relevant reviews and online resources, in addition to consulting with topic experts.

Overall findings from this systematic review show:

  • All included studies reported current unmet healthcare provider needs that worsen with increasing rurality. The small number of studies estimating future need also predicted unmet provider needs for rural healthcare.
  • Across 24 studies, growing up in a rural community was the most consistent factor associated with a provider's practice location. Education efforts for physicians, such as rural tracks, also seem to increase the likelihood of practicing in a rural community. More research on the relative importance of factors is needed.
  • Only five evaluations were identified that focused on healthcare provider recruitment interventions.
    • An evaluation of loan repayment programs reported that 86% of surveyed rural physicians indicated that they continued medical practice at their sponsoring healthcare facility after completing their service obligation. Another evaluation reported that of those recipients whose obligated practice location was rural, 84% were practicing in rural areas and 28% of program completers were practicing in rural areas. One study highlighted that 74% of recipients were already working in or intended to work in an eligible community when they were made aware of the loan repayment program.
    • A state-wide evaluation of various rural recruiting programs reported that 80% of placed providers have remained at their initial placement site upon completion of their obligation.
    • More research on provider recruitment interventions is needed.
  • There is a lack of evidence regarding interventions to support healthcare provider retention in rural healthcare.
  • The 23 identified evaluations of rural training programs for providers in training varied in their approach and recruitment success estimates. Across approaches, medical students and residents reported a median success rate for rural healthcare recruitment of 53%.

Investigators did not identify published studies reporting on VA settings, and the definition of "rural" was operationalized differently across identified evaluations which added heterogeneity across studies. Future research should, in particular, concentrate on evaluating strategies to improve healthcare provider recruitment and retention.

Hempel S, Maggard Gibbons M, Ulloa JG, Macqueen I, Miake-Lye I, Beroes J, Shekelle P. Rural Healthcare Workforce: A Systematic Review. VA ESP Project #05-226; 2015.

View the full report — **VA Intranet only**:
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A cyberseminar titled "Rural Healthcare Workforce: A Systematic Review" will be held on July 6, 2016 from 12:00 to 1:00pm (ET). Register for this cyberseminar session here.

Please feel free to forward this information to others!

Read past HSR&D Management e-Briefs on the HSR&D website.

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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