A Review of the Literature:
Rural vs. Urban Ambulatory Healthcare
There are approximately three million Veterans enrolled in the VA healthcare system who live in rural areas (as defined by VA). The Rural Veterans Care Act of 2006 was signed into law to improve care for Veterans living in rural settings. Ensuring that the healthcare 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 in 2006.
Investigators at the VA Evidence-based Synthesis Program in Minneapolis, MN conducted a review of the literature from 1990 through June 2010 to examine the evidence regarding potential disparities between rural and urban areas in the provision and delivery of ambulatory care, and how differences in care may contribute to disparities in health outcomes. Because Veterans who use VA healthcare have been found to use more non-VA healthcare overall, investigators expanded the focus of this review to include comparisons of rural vs. urban healthcare in non-VA healthcare systems. Articles were categorized under the following ambulatory care services: preventive care, ambulatory care sensitive conditions (conditions in which inadequate outpatient treatment leads to increases in hospitalization), cancer care, diabetes, end-stage renal disease, cardiovascular disease, HIV/AIDS, neurologic conditions, and mental health.
Investigators reviewed 102 studies to answer these four key questions:
Do adults with healthcare needs living in rural areas have different intermediate (e.g., hemoglobin A1c, blood pressure) or final health outcomes (i.e., mortality, morbidity, quality of life) than those living in urban areas?
- Some evidence was identified regarding healthcare disparities for the following conditions: suicide rates, hospitalization for ambulatory care sensitive conditions, stage of cancer presentation, and end-stage renal disease (ESRD).
- The available evidence suggests that there is no disparity in diabetes care, the prevalence of ESRD, or control of hypertension.
Is the structure (e.g., types of available providers) or the process (e.g., likelihood of referral) of healthcare different for adults with healthcare needs who live in urban vs. rural environments?
- Urban residents tended to receive more medications, but the evidence was limited. There were no consistent differences in the receipt of or adherence to medication.
- Office visits, medical procedures, and diagnostic tests were less frequent in rural settings, with consistently lower screening rates for breast and cervical cancer.
- In rural areas, cancers were more likely to be un-staged at diagnosis.
- Rural residents were less likely to see medical specialists, including mental health specialists.
- Rural residents were as likely as urban residents to have a usual source of care (e.g., particular clinic); however, rural residents were more likely to have better continuity of care with a specific provider.
- Highly rural areas have an insufficient supply of healthcare providers.
- Data on quality of care were only available for a few conditions, with some evidence suggesting lower quality of care in rural areas for patients with HIV or cancer; findings were less consistent for depression treatment.
If there are differences in the structure or the process of healthcare in rural vs. urban environments, do those differences contribute to variation in overall or intermediate health outcomes for adults with healthcare needs?
- Although many studies documented differences in healthcare structure or processes, very few studies associated these differences with variation in health outcomes.
- Among the limited findings were: higher rates of invasive cervical and breast cancers (associated with lower screening rates in rural areas); improved adherence to guideline care for diabetes treatment (associated with improved access to rural healthcare clinics); higher rates of suicide in rural areas (associated with differential use in antidepressants, especially older antidepressants); and better continuity of care (associated with fewer providers in rural areas).
If there are differences in intermediate or final health outcomes for adult patients with healthcare needs, what other systems factors moderate those differences (e.g., availability of specialists, type of treatment needed, travel distance)?
- Other factors identified include: insurance, travel distance, patient attitudes, and racial disparities. For example, for many conditions covered in this review, racial disparities were greater in urban than in rural areas; however, racial disparities were greater in rural areas for mortality rates among Hispanics for ESRD.
Notes and Limitations:
Few studies had enrolled Veterans, and several important clinical conditions have not been addressed. There also were several conditions for which there was a paucity of evidence regarding their prevention, diagnosis, or treatment in rural healthcare settings (e.g., COPD, chronic pain, hepatitis C, substance use disorders, traumatic brain injury). Moreover, few studies associated healthcare differences with health outcomes. Therefore, most of the conclusions in this review are, at best, suggestive.
An important methodologic issue is the lack of consistency across studies regarding the conventions used to define levels of rurality across communities, zip codes, or counties. This inconsistency affects interpretation of the individual studies, as well as comparability of findings across studies.
The authors also note that, because the evidence base relied on peer-reviewed articles, their review did not include national reports examining potential differences in rural vs. urban healthcare. Because these reports serve to inform policymakers, findings from the 2010 National Healthcare Disparities Report and the 2010 VHA Facility Quality and Safety Report are compared with the results of this systematic review and are provided at the end of this review.
VA's Office of Quality and Performance plans to use this evidence review to inform VA's measurement systems and reports. They also will work with the Office of Rural Health to create more robust indicators of rural health disparities, and they believe this partnership will be strengthened by this report. In addition, VA investigators can use this report to help focus their efforts and assure that their research is applicable to Veterans in rural and highly-rural areas.
Suggestions for Future Research:
Investigators recommend several areas for future research, such as:
- Examine rural vs. urban healthcare processes and outcomes for conditions relevant to Veterans (e.g., TBI, PTSD, chronic pain, hepatitis C).
- Where a rural disparity exists, determine what factors underlie the disparity.
- Determine whether differences in healthcare processes result in disparities in health outcomes.
- Examine potential interactions between rural residence and race and/or geographic region in healthcare disparities.
This report is a product of the HSR&D 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.
Spoont M, Greer N, Su J, Fitzgerald P, Rutks I, and Wilt T. Rural vs. Urban Ambulatory Healthcare: A Systematic Review. VA-ESP Project #09-009;2011.
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