Article Figures & Data
Tables
Characteristic CAH Service Areas CAH = Critical Access Hospital; PCP = primary care physician; HPSA = Health Professional Shortage Area. a All of these areas had 3,500 or fewer residents per PCP. Location and PCP density Not located in an HPSA,a No. (%) 4 (16) Located in an HPSA, No. (%) 21 (84) ≤3,500 residents per PCP 1 (4) 3,501–4,500 residents per PCP 10 (40) >4,500 residents per PCP 10 (40) Licensed beds No. per CAH, mean (SD) 20.4 (4.8) Group, No. (%) 8–15 beds 7 (28) 16–25 beds 18 (72) - Table 2.
Demographic and Geographic Characteristics of All Respondents and of Bypassers vs Local Users
Group Characteristic All (N=1,264) Bypassers (n=402) Local Users (n=862) P Value SF-36 = 36-Item Short-Form Health Survey; CAH = Critical Access Hospital; PCP = primary care physician. Note: We used the χ2 test (for categorical variables) and the Student t test (for continuous variables) to test for significance of observed differences. a Possible range of scores, 1–5; higher scores indicate better health. b Possible range of scores, 1–6; higher scores indicate greater satisfaction. Age-group, % 18–34 years 10.0 10.1 9.9 35–49 years 14.9 19.0 12.9 .04 50–64 years 24.4 22.0 25.6 ≥65 years 50.7 48.9 51.5 White, % 94.2 93.8 94.4 .70 Female, % 73.4 71.0 74.4 .22 Married, % 62.7 65.6 61.3 .15 Have health insurance, % 90.7 89.1 91.4 .21 Time to closest hospital, mean (SD), min 11.5 (9.4) 11.9 (10.5) 11.4 (8.9) .40 Time to second closest hospital, mean (SD), min 41.4 (21.2) 41.9 (25.5) 41.2 (20.4) .68 Self-reported general health, mean (SD), SF-36 score a 3.1 (0.8) 3.0 (0.8) 3.1 (0.8) .20 Had inpatient care in the last 12 months, % 11.0 15.6 8.8 <.001 Satisfaction with local CAH, mean (SD), scoreb 3.9 (0.8) 3.7 (0.9) 4.0 (0.7) <.001 Education, % Less than high school 16.2 16.9 15.8 High school 37.4 39.1 36.7 .18 Some college 17.9 14.3 19.5 College or more 28.5 29.7 28.0 Income, % <$20,000 31.1 25.8 33.6 $20,000–$40,000 33.0 32.0 33.4 .02 >$40,000 35.9 42.2 33.1 PCP density, % ≤3,500 residents per PCP 20.2 20.5 20.0 .12 3,501–4,500 residents per PCP 41.1 37.1 42.9 >4,500 residents per PCP 38.8 42.3 37.1 - Table 3.
Multiple Logistic Regression Analysis of the Odds of Bypassing Local Primary Care
Characteristic Odds Ratio (95% CI) P Value CI = confidence interval; Ref = reference group; CAH = Critical Access Hospital; PCP = primary care physician. Age-group 18–34 years Ref 35–49 years 1.21 (0.67–2.18) .53 50–64 years 0.47 (0.26–0.84) .01 ≥65 years 0.62 (0.37–1.03) .06 Race Nonwhite Ref White 1.43 (0.72–2.84) .31 Sex Male Ref Female 1.32 (0.93–1.89) .12 Marital status Single, divorced, separated, or widowed Ref Married 1.40 (1.01–1.96) .047 Health insurance status Uninsured Ref Insured 0.86 (0.52–1.43) .57 Time to closest hospital 0.86 (0.57–1.29) .45 Self-reported general health 1.18 (0.95–1.45) .13 Inpatient care in the past 12 months No Ref Yes 2.69 (1.73–4.18) <.001 Satisfaction with local CAH 0.61 (0.51–0.74) <.001 Education Less than high school Ref High school 0.84 (0.54–1.30) .43 Some college 0.37 (0.21–0.65) .001 College or more 0.70 (0.43–1.12) .13 No. of licensed beds of closest CAH 0.95 (0.93–0.98) <.001 PCP density ≤3,500 residents per PCP Ref 3,501–4,500 residents per PCP 1.24 (0.79–1.92) .35 >4,500 residents per PCP 1.58 (1.02–2.46) .04 Constant 3.37 (–) .08
Additional Files
The Article in Brief
Bypass of Local Primary Care in Rural Counties: Effect of Patient and Community Characteristics
Jiexin (Jason) Liu, PhD, MBA, MS , and colleagues
Background It is important for policy makers and medical professionals to know whether patients bypass their local hospitals for other facilities, yet few studies of this issue have focused on rural areas. This study looks at the frequency with which rural patients bypass local hospitals and clinicians, and solicits suggestions for what hospitals can do to keep local patients.
What This Study Found Approximately one-third of patients living in rural areas bypass local health care professionals and facilities and get medical care elsewhere. There is a wide variation in bypass rates in the 25 rural areas sampled, ranging from 9.4% to 66%. Compared with those who use services in their local community, bypassers are younger, have higher incomes, are more likely to have had inpatient hospital care in the past year, and are less satisfied with their local hospital. When asked why people might bypass local care, respondents cite lack of services or specialty care (50%), referral out of the community by their doctor (19%), poor quality of care (15%), and poor reputation of local facilities (14%). Bypassers suggest that hospitals could keep local patients by adding more specialty services (24%), adding more doctors and services (17%), getting better doctors (17%), and providing better customer service (11%).
Implications
- The wide variation in bypass rates suggests that local communities and facilities need to develop tailored strategies that fit their own circumstances and needs.
- Policies that promote networks of clinicians could benefit rural patients.
- Lower access to primary care physicians in health professional shortage areas (HPSAs) may contribute to bypass of local health care facilities and clinicians.
