Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics

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