2018 Research Publications

Browse the full list of research publications from the Rural Health Research Centers.

Products – Freely accessible products include policy briefs, fact sheets, full reports, chartbooks, and interactive data websites.

Journal Articles – Articles in peer-reviewed journals may require a subscription or affiliation with a subscribing library. For these publications, Gateway lists the article citation, a brief summary, a link to additional information and access to the full-text of the article, if available.

Assessing the Unintended Consequences of Health Policy on Rural Populations and Places
Report
RUPRI Health Panel: Rural Policy Analysis and Applications
Date: 12/2018
This paper explores the unintended consequences of health policy through an analysis of policy actions that have affected, or had the potential to affect, rural people, places, and/or providers in ways counteractive to policy intent.
The Rural Hospital and Health System Affiliation Landscape – A Brief Review
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 11/2018
The shift from traditional fee-for-service to value-based payment requires major capital investment. In this paper, we examine rural hospital and health system motivations for affiliation and present a non-exhaustive list of common affiliation structures with representative examples.
Update: Rural/Urban Disparities in Pneumococcal Vaccine Service Delivery Among the Fee-for-Service Medicare Population, 2012-2015
Policy Brief
Rural and Underserved Health Research Center
Date: 11/2018
Delivery of pneumococcal vaccines to fee-for-service Medicare beneficiaries increased 380% from 2014-2015 as a result of uptake of pneumococcal conjugate vaccine (PCV13). However, a significant rural-urban disparity remains. Pharmacy providers delivered a significantly greater proportion of vaccines in rural versus urban counties.
Changes to the Merit-Based Incentive Payment System Pertinent to Small and Rural Practices, 2018
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 11/2018
This policy brief highlights key regulatory changes to the Merit-based Incentive Payment System that occurred in 2018. It discusses the implications of these changes with an emphasis on how these changes may affect small and rural practices.
Trends in Hospital System Affiliation, 2007-2016
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 11/2018
This policy brief updates a RUPRI Center brief published in 2014 and documents the continued growth in system affiliation by both metropolitan and non-metropolitan hospitals.
Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations From Rural Physicians
Journal Article
WWAMI Rural Health Research Center
Date: 10/2018
Rural physicians with a Drug Enforcement Administration waiver to prescribe buprenorphine who were treating a higher than average number of opioid use disorder patients were interviewed about strategies and best practices for overcoming commonly cited barriers to incorporating and providing medication assisted treatment into their practices.
Differences in Medicare Utilization and Expenditures in the Last Six Months of Life Among Patients With and Without Alzheimer's Disease and Related Disorders
Journal Article
University of South Carolina Rural Health Research Center
Date: 10/2018
The purpose of this study was to examine differences in utilization of inpatient services and Medicare expenditures (overall and by category) in the last six months of life for patients with, versus those without, a diagnosis of Alzheimer's disease and related disorders.
Patterns of Telehealth Use Among Rural Medicaid Beneficiaries
Journal Article
Rural Telehealth Research Center
Date: 10/2018
This study uses data from the 2011 Medicaid Analytic eXtract (MAX) to examine the prevalence of telehealth use among rural and urban Medicaid beneficiaries, characteristics of telehealth users, types of telehealth services provided, and diagnoses associated with telehealth use.
Implementation Strategies for Telestroke: A Qualitative Study of Telestroke Networks in North Carolina
Journal Article
Rural Telehealth Research Center
Date: 09/2018
Through semi-structured interviews with 24 telestroke representatives, this study examines the adoption decision process and strategies employed during telestroke network development, implementation, and sustainability. We found differences across networks in terms of network structure, quality monitoring, and performance feedback.
Rural-Urban Differences in Risk Factors for Motor Vehicle Fatalities
Journal Article
University of Minnesota Rural Health Research Center
Date: 09/2018
This study uses 2017 County Health Rankings data to run stratified regression models to estimate county-level correlates of motor vehicle fatalities (MVFs) by rural and urban location. We found that rural counties have higher rates of MVFs than urban counties (22 vs. 14 per 100,000, p<0.001).
Projected Contributions of Nurse Practitioners and Physicians Assistants to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas
Journal Article
WWAMI Rural Health Research Center
Date: 08/2018
This study projected the potential increase in medication assisted treatment availability for opioid use disorder (OUD) provided by nurse practitioners (NPs) and physician assistants (PAs) for rural patients under the Comprehensive Addiction and Recovery Act, which allows NPs and PAs to obtain a waiver to prescribe buprenorphine for OUD.
Spread of Medicare Accountable Care Organizations in Rural America
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 08/2018
This policy brief describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2016 to 2017. This brief, which includes data through December 2017, follows a similar analysis released in October 2016 that described ACO trends from 2013 to 2015.
Rural Hospital Mergers From 2005 Through 2016
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 08/2018
This brief describes the number and geographic distribution of rural hospital mergers from 2005-2016.
Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 08/2018
This brief assesses changes from 2014 to 2018 in average Health Insurance Marketplace plan participation and pre-subsidy premiums in rural and urban places. Insurance carriers reduced participation across both, while the gap between average premiums in expansion and non-expansion states is widening at a similar rate in rural and urban counties.
Medicaid Income Eligibility Transitions Among Rural Adults
Policy Brief
Maine Rural Health Research Center
Date: 08/2018
The Affordable Care Act allows Medicaid expansion to adults under 65 with income below 138% of poverty. Research suggests income shifts affecting Medicaid eligibility are common, but the rural impact is unclear. This national study examines rural and urban adults' annual income shifts above or below the Medicaid expansion eligibility threshold.
The Importance of Rural Hospitals: Transfers and 30-day Readmissions Among Rural Residents and Patients Presenting at Rural Hospitals
Journal Article
University of South Carolina Rural Health Research Center
Date: 07/2018
This study looked at reasons why transfers and readmissions occurred among Medicare patients who first came to rural hospitals.
Insuring Rural America: Health Insurance Challenges and Opportunities
Policy Brief
RUPRI Health Panel: Rural Policy Analysis and Applications
Date: 07/2018
This brief discusses a series of policy considerations in three main categories: policies related to rural insurance risk, policies related to provider networks, and policies related to rural payment rates and structures.
Different Populations Served by the Medicare Home Health Benefit: Comparison of Post-Acute Versus Community-Entry Home Health in Rural Areas
Policy Brief
WWAMI Rural Health Research Center
Date: 07/2018
This study describes differences between rural, fee-for-service Medicare beneficiaries who are admitted to home health from the community (community-entry) and those who are admitted to home health following an inpatient stay (post-acute) in terms of their clinical and non-clinical characteristics as well as the communities in which they live.
Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 07/2018
Rural pharmacies play an important role in health service delivery to rural populations. This RUPRI Center brief updates previous findings on the continued decline in the number of independently owned rural pharmacies since the implementation of Medicare Part D. This brief provides follow-up data on rural pharmacy closures through March 2018.
Organizational Attributes Associated With Medicare ACO Quality Performance
Journal Article
RUPRI Center for Rural Health Policy Analysis
Date: 07/2018
Peer-reviewed paper evaluating associations between geographic, structural, and service-provision attributes of Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and the ACOs' quality performance.
A National Examination of Caregiver Use of and Preferences for Support Services: Does Rurality Matter?
Journal Article
University of Minnesota Rural Health Research Center
Date: 07/2018
The objective of this study was to assess rural-urban differences in caregiver use of and preferences for support services.
Rural Health Clinic Participation in the Merit-Based Incentive System and Other Quality Reporting Initiatives: Challenges and Opportunities
Policy Brief
Maine Rural Health Research Center
Date: 07/2018
This brief discusses the Merit-Based Incentive Payment System (MIPS) within the context of past and current Rural Health Clinic (RHC) quality reporting initiatives and assesses options for encouraging RHCs to voluntarily participate in MIPS.
Service Provision and Quality Outcomes in Home Health for Rural Medicare Beneficiaries at High Risk for Unplanned Care
Journal Article
WWAMI Rural Health Research Center
Date: 06/2018
This study examined service provision and quality outcomes among rural Medicare beneficiaries who used home health from 2011-2013 and were at high risk for unplanned care. More skilled nursing visits and visits by more types of providers were associated with higher hospital readmission and emergency department use and lower community discharge.
Rural-Urban Difference in Workplace Supports and Impacts for Employed Caregivers
Journal Article
University of Minnesota Rural Health Research Center
Date: 06/2018
This study finds that employed rural caregivers had significantly fewer workplace benefits available to them compared with urban caregivers. In particular, employed rural caregivers were less likely to have access to telecommuting, employee assistance programs, and paid leave.
Geographic Variation in the Supply of Selected Behavioral Health Providers
Journal Article
WWAMI Rural Health Research Center
Date: 06/2018
This study examined the supply of select behavioral health providers by metropolitan, micropolitan, and non-core county and Census Division. Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S., with disparities between Census Divisions and rural vs. urban areas.
Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5‐Year Update
Journal Article
WWAMI Rural Health Research Center
Date: 06/2018
This study compares the geographic distribution of physicians, physician assistants, and nurse practitioners waivered to prescribe buprenorphine in 2012 and 2017.
Prescribing Practices of Rural Physicians Waivered to Prescribe Buprenorphine
Journal Article
WWAMI Rural Health Research Center
Date: 06/2018
This study finds more than 60% of rural counties don't have a physician waivered to prescribe buprenorphine, which is used to treat opioid use disorder.
What Makes Physician Assistant (PA) Training Programs Successful at Training Rural PAs?
Policy Brief
WWAMI Rural Health Research Center
Date: 06/2018
While a majority of physician assistant (PA) programs identify production of rural PAs as an important program goal, many only have limited rural recruitment and training activities. This study identified PA program characteristics and training activities that are strongly associated with the production of a high proportion of rural graduates.
Geographic Variation in Uncompensated Care Between Rural and Urban Hospitals
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 06/2018
The purpose of this brief is to compare uncompensated care in rural and urban hospitals and to describe how it varies across regions of the country.
Organizational Attributes With Medicare ACO Quality Performance
Journal Article
RUPRI Center for Rural Health Policy Analysis
Date: 05/2018
Cross-sectional and longitudinal analyses of Medicare Shared Savings Program Accountable Care Organizations' (ACOs') quality performance found rural ACOs' score was comparable to those in other categories. ACOs with hospital-system sponsorship, larger beneﬁciary panels, and higher post-hospitalization follow-up rates had better performance.
Telestroke Adoption Among Community Hospitals in North Carolina: A Cross-Sectional Study
Journal Article
Rural Telehealth Research Center
Date: 05/2018
This study identifies community and hospital characteristics associated with the adoption of telestroke among acute care hospitals in North Carolina.
Telepharmacy Rules and Statutes: A 50-State Survey (Journal Article)
Journal Article
RUPRI Center for Rural Health Policy Analysis
Date: 05/2018
Peer-reviewed paper identifying state-enacted regulations and legislation authorizing use of community telepharmacy initiatives and describing implications for patients in underserved rural communities. Also provides a table listing states that permit telepharmacy, and pilot programs and waivers that enable telepharmacy initiatives.
Serum Anion Gap Predicts Lactate Poorly, but May Be Used to Identify Sepsis Patients at Risk for Death: A Cohort Study
Journal Article
Rural Telehealth Research Center
Date: 04/2018
Our study of 4,159 emergency department patients determined anion gap and serum bicarbonate poorly predict changes in lactate and mortality. In resource-limited settings where lactate is unavailable, anion gap ≥ 20 mEq/L may be used to further risk-stratify patients for ongoing sepsis care, but lactate remains a preferred biomarker.
Rural and Urban Provider Market Share of Inpatient Post-Acute Care Services Provided to Rural Medicare Beneficiaries
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 04/2018
The purpose of this brief is to characterize rural providers' market share of inpatient post-acute care services provided to rural Medicare beneficiaries.
Market Characteristics Associated With Rural Hospitals' Provision of Post-Acute Care
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 04/2018
This brief uses data from Medicare cost reports, the Provider of Services File, and the U.S. Department of Agriculture to provide a window into current hospital-based post-acute care offerings by summarizing both hospital- and market-level factors that are associated with rural hospitals that provided post-acute care between 2012 and 2015.
Geographic Variation in the 2016 Profitability of Urban and Rural Hospitals
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 03/2018
This study describes the geographic variation in 2016 profitability of critical access hospitals (CAHs), other rural hospitals (Medicare Dependent Hospitals, Sole Community Hospitals, and rural Prospective Payment System (PPS) hospitals denoted as "ORH"), and urban PPS hospitals by census region, census division, and state.
Medicare Accountable Care Organization Growth in Rural America, 2014-2016
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 03/2018
This RUPRI Center data report describes Medicare accountable care organization (ACO) growth in non-metropolitan U.S. counties from 2014 to 2016. ACOs are the most widespread of the Centers for Medicare & Medicaid Services (CMS) value-based payment programs and demonstrations.
Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States
Journal Article
University of Minnesota Rural Health Research Center
Date: 03/2018
This study examines whether the loss of obstetric services in hospitals in rural U.S. counties led to changes in childbirth outcomes or locations.
Residential Settings and Healthcare Use of the Rural "Oldest-Old" Medicare Population
Policy Brief
Maine Rural Health Research Center
Date: 03/2018
This study used Medicare Current Beneficiary Survey data to profile rural/urban Medicare beneficiaries ages 85 & older. Rural adults in this age group are more likely to be disabled and live alone in the community or in nursing homes and less likely to live in assisted living facilities. Findings highlight rural needs for community-based services.
Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents
Journal Article
University of Minnesota Rural Health Research Center
Date: 02/2018
Using data from interviews with rural hospital discharge planners, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions.
Rural Family Physicians in Patient Centered Medical Homes Have a Broader Scope of Practice
Policy Brief
Rural and Underserved Health Research Center
Date: 02/2018
The Patient Centered Medical Home (PCMH) is supposed to provide accessible and comprehensive care. Using data from family physicians seeking to continue their American Board of Family Medicine certification in 2014 and 2015, we found that rural family physicians in PCMH practices generally provide more services than those in non-PCMH practices.
Rural Family Physicians Have a Broader Scope of Practice Than Urban Family Physicians
Policy Brief
Rural and Underserved Health Research Center
Date: 02/2018
While the scope of practice of family physicians has been shrinking, they still practice broadly, often due to fewer health care resources in rural areas. Using data from family physicians seeking continued board certification in 2014 and 2015, we found that a high percentage of rural family physicians provide nearly every clinical service queried.
Rural/Urban Disparities in Pneumococcal Vaccine Service Delivery Among the Fee-for-Service Medicare Population
Policy Brief
Rural and Underserved Health Research Center
Date: 02/2018
Using 2014 Medicare data, we found a significant disparity in pneumococcal vaccine service delivery to fee-for-service Medicare beneficiaries. Although primary care providers delivered the majority of pneumococcal vaccines to this population, pharmacy providers delivered a significantly greater proportion of vaccines in rural versus urban counties.
Distance and Networks: A Regional Analysis of Health Insurance Marketplaces
Policy Brief
RUPRI Center for Rural Health Policy Analysis
Date: 02/2018
Using 2015-16 data on 15 Midwestern states, we examine the possibility that geographic distance to care plays a role in insurance issuer participation, premiums, and enrollment success through its effect on network adequacy and assess the moderating role that state-level policies on network adequacy standards and Rating Area design may have.
Range Matters: Rural Averages Can Conceal Important Information
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 01/2018
This short brief uses three examples to demonstrate how focusing on averages without also considering the data range can conceal important information: 1) average rural hospital profitability, 2) distance from closed rural hospitals to the next closest hospital, and 3) HIV prevalence by county.
Illicit Drug and Opioid Use Disorders Among Non-Metropolitan Residents
Policy Brief
Rural and Underserved Health Research Center
Date: 01/2018
We provide estimates of the prevalence of illicit drug and opioid use disorders among non-metropolitan adults ages 18-64. Prevalence rates did not decline from 2011-2013 to 2014-2015 despite the implementation of major substance use treatment policies. Of particular concern, heroin use disorder prevalence increased in recent years.
Perceived Treatment Need and Utilization for Illicit Drug and Opioid Use Disorders in Non-Metropolitan Areas
Policy Brief
Rural and Underserved Health Research Center
Date: 01/2018
The vast majority of non-metropolitan adults 18-64 who satisfy criteria for an illicit drug use or opioid use disorder do not perceive a need for treatment or receive formal substance use treatment. Despite policies to increase treatment access during the 2008-2015 study period, we found few changes in perceived treatment need and utilization.
Access to Care: Populations in Counties With No FQHC, RHC, or Acute Care Hospital
Policy Brief
North Carolina Rural Health Research and Policy Analysis Center
Date: 01/2018
To help provide a quick understanding of how many people may have more limited access to primary care and where they live, this brief focuses on three main primary care providers in rural areas (Federally Qualified Health Centers, Rural Health Centers, and acute care hospitals).