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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Retention of local patients in rural health care systems
Health Demography
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Byron J Crouse, Madison, WI Assoicate Dean for Rural and Community Health, Univ. of Wisconsin School of Medicine & Public Health
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The article by Liu and others, “Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics” addresses an aspect important to the sustainability of rural health care clinics and hospitals. The strength of this study resides in the fact that rural residents were interviewed about their use of their local health care or deciding to bypass local services. Most rural hospitals, even with the benefits afforded by being a Critical Access Hospital operate on a very narrow margin and loss of a third of the potential market as reported here can result in inadequate resources to provide expanded services. With lack of specialty services being one of the major reasons identified for bypassing local health care, a circular dynamic develops limiting growth of local services and promoting bypass of the local health care system. Their results found a wide range in the rate of bypassing local health care services. Clearly, there are significant differences between individual community circumstances. In order to address the circular nature of health care bypass, local issues need to be understood in order that an effective strategy to break the cycle can be addressed. Determining what factors are locally influencing patients to the bypass of local health care is important to develop strategies to minimize the bypass. This represents a patient-centered approach to designing health care delivery. In my experience, bypass of local health care resulted from concerns over privacy, particularly when dealing with mental health issues or contraception. In rural communities, ones automobile or truck often is sufficient to identify an individual and parking at a health care facility can identify their utilization of health care services. As health care facilities in rural settings are usually one of the lead employers in the community, seeking health care in ones community means caregivers will be neighbors and close acquaintances. This may explain some of the variations noted in rates of bypass. The elderly may be more comfortable being cared for by known providers and staff and similarly, younger more affluent may be more uncomfortable with the lesser anonymity of local care and can afford to seek care elsewhere. Quality of health care is also very important to patients. I was impressed by the number of times I would hear about ‘grandma had a bad experience at hospital/clinic X and our family won’t go there’. Poor outcomes resonate longer in the memories of families and impacts where health care is obtained. Sensitive attention to poor outcomes can mitigate the potential negative impact on the local health systems reputation. Celebration of excellence and quality health care is important to promote a good perception in the community. Patient-centered care is deemed an important component of health care today. Understanding the public's perspective of local health care services and addressing their concerns is important to minimize bypass of the local health care system through patient-centered strategies. Competing interests: None declared |
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Amanda L Golbeck, Missoula, MT, USA Professor, School of Public and Community Health Sciences, The University of Montana
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Health demography - the study of human populations as it relates to heath status or health behavior – is an evolving discipline (Pol and Thomas, 2001). The Liu et. al. study is a good example of research that falls into the category of health demography. This study focuses on the dynamic demographic process of migration involving movement, not in the classic sense to a new geographic location of residence, but to a health care facility outside of one’s normal service area. Results of the study may contribute to health care organizations’ decision making processes by increasing their understandings of consumer behaviors as they link to demographic characteristics. Health demography studies typically combine data from multiple sources. Indeed, the Liu et. al. study uses traditional demographic data from multiple standard sources, including a telephone survey (age, race, gender, marital status, education, income) and a census (population). It combines these data with health care data that are also from multiple sources, including a telephone survey (health insurance, general health, inpatient care, satisfaction with providers) and a registry (number of PCP’s). Demographers appreciate that, when data are used from multiple secondary sources, it is especially important to understand the methods used to obtain measurements, to understand their strengths and limitations, and not to just abstract and use these measurements. For example, the measurements that Liu et. al. refer to as 2004 county-level census data are actually estimates with a reference date of July 1 that are calculated using a complex component of population change method (United States Census Bureau, 2008b). These measurements are only as good as the 2000 census data that are used as a basis for the estimates, the assumptions that underlie the estimates, and the components of change data used in construction of the estimates. The amount of error contained in these estimates is usually unknown and may be relatively large, especially for small or rural areas. Administrations of geographic entities can, and do, challenge these estimates, within a process which may lead to revised estimates (United States Census Bureau, 2008a). With respect to the finding that PCP density is strongly associated with bypass, the reader is reminded that use of the population estimates in the calculation of PCP density measures assumes that these estimates are reasonably accurate within the bounds of the trichotomization of the PCP density variable as employed by the authors. References: Pol, L.G. and Thomas, R.K. (2001). The Demography of Health and Health Care, Second Edition. New York: Kluwer Academic/Plenum Publishers. United States Census Bureau (2008a). Challenge Process. Accessed on 3/19/08 at http://www.census.gov/popest/archives/challenges.html. United States Census Bureau (2008b). State and County Total Resident Population Estimates (Vintage 2007): April 1, 2000 to July 1, 2007. Accessed on 3/19/08 at http://www.census.gov/popest/topics/methodology/2007-st-co-meth.html. Competing interests: None declared |
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