preventive care in rural primary care practice

1113

Preventive Care in Rural Primary Care Practice Russell Harris, M.D., M.P.H., and Linda Leininger, M.D., M.P.H.

Delivering preventive care in a primary care practice is often more difficult for rural than for urban practices. First, rural compared with urban patients tend to be older, poorer, and less well insured, all characteristics associated with lower levels of preventive care. Second, there are many more patients per physician in rural than urban settings. Third, the distance from sources of preventive care is much greater for rural than for urban people. Fourth, rural practices tend to be smaller, with fewer resources to perform high-quality preventive care. Long-term programs to increase recruitment and retention of primary care physicians and improve insurance coverage for rural people may eventually improve preventive care utilization. A more immediate approach is to change the organization of medical practice, including developing satellite clinics, redefining the roles of nurses and nurse practitioners, and using organized systems within practices to reach and follow-up underserved groups. Initial impressions from the North Carolina Pre- scribe for Health project indicate that an organized approach to preventive care within physicians' offices may improve utilization of carefully designed packages of preventive care. More information is needed to under- stand the differences among rural, urban, and suburban areas in delivering preventive care to primary care patients. Cancer 1993; 72:1113-8.

Key words: Prevention, primary care practice, rural.

There is strong evidence that the American population receives less preventive care than is optimal.' There is also growing, though inconclusive, evidence that rural Americans receive less preventive care than urban/sub-

Presented at the National Conference on Cancer Prevention and Early Detection, Chicago, Illinois, September 10-12, 1992.

Received from the UNC-Lineberger Comprehensive Cancer Center and the Division of General Medicine and Clinical Epidemiol- ogy, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill.

Supported by National Cancer Institute grant 5ROlCA54343. Address for reprints: Russell Harris, M.D., M.P.H., Cancer Pre-

vention Program, CB# 7300, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7300.

Accepted for publication March 26, 1993.

urban Americans. In this paper, we review the evidence for a rural deficit in preventive care, suggest several explanations for this deficit, and corfhder long- and short-term solutions to the problem. While one might argue that the problem requires develop& systems for preventive care outside of usual medical practice, we assume that the simplest strategy would be to increase preventive care in the places where rural people already receive their usual health care. For this reason, we will focus on solutions that involve primary care medical practice.

We will include as evidence observations we have made during visits to rural primary care practices in North Carolina over the past year as part of our Na- tional Cancer Institute-funded Prescribe for Health project (see below).

A Comment about the Term "Rural"

The U.S. Bureau of the Census defines people as resid- ing in a rural area if they live in a town of 2,500 people or fewer, or in the open country. In addition, the Cen- sus Bureau also defines counties as being either metropolitan (those with a population center of at least 50,000 people) or nonmetropolitan (all those that are not metropolitan). Although these two typologies do not classify all people the same way, they generally provide the same description of the number of rural Americans. Because of ease of analysis, we will use pri- marily the metropolitan/nonmetropolitan classification in this paper.

Both classifications are oversimplifications. First, places classified as rural (or nonmetropolitan) vary enor- mously, both in population density and in economic and social structures.* There also are regional variations in rural areas; for example, almost all of the so-called frontier counties (those with fewer than six persons per square mile) are in the western half of the ~ o u n t r y . ~ Second, neither classification takes into account the rise of suburbia, one of the most important demographic changes in this country during the past 50 years.4

1114 CANCER Supplement August 2, 2993, Volume 72, No. 3

Clearly, the problem of providing medical care (including preventive care) in suburban areas differs from the same problem in core urban areas or isolated rural areas. For this reason, we will refer to nonmetropolitan areas as rural, and to metropolitan as urban/suburban, remembering that the classification is far from exact.

Is There a Preventive Care Deficit for Rural Americans?

About 25% of the current U.S. population lives in rural areas. Although this percentage has been declining slowly since the country’s founding, in absolute numbers there are more rural Americans today than ever before.2 Thus the question of whether there is a deficit in preventive care for rural America is important.

Few data exist on differences in preventive care received in rural areas as compared with urban/suburban areas. The evidence available, however, supports the existence of at least a small preventive care deficit for rural populations. For example, when asked in the 1985 National Health Interview Survey, 41.8% of rural women indicated that they had had a Pap smear in the last year, whereas 46.8% of urban/suburban women had had Similarly, 45.4% of rural women stated that they had had a breast examination in the past year, compared with 51.8% of urban/suburban women3

The 1987 Behavioral Risk Factor Surveillance system surveyed women in 33 states who were aged 50 years and older, and who had seen a physician for a routine examination in the last year. A comparison of percentages of women who had had a screening mammogram within that year, by state, shows that only one rural state (defined here as a state in which at least 50% of the population lives in nonmetropolitan areas) was ranked in the highest tertile, whereas three rural states were in the middle, and five rural states were in the lowest. The percentages of women aged 50 years and older screened with mammography within the past year in the rural states ranked in the lowest tertile ranged from 19% to 2770.~

The preventive care deficit may exist in other areas in addition to cancer screening. The 1988-91 Missouri Behavioral Risk Factor Surveillance System compared the percentage of persons in rural areas who had never had their cholesterol measured with that in core cities (St. Louis and Kansas City) and in other metropolitan areas. Although the trend from 1988 to 1991 was that fewer persons in all geographic areas had never had their cholesterol measured, a discrepancy between rural and core city urban areas remained. In 1991, 32% of rural persons and 20% of urban persons had never had their cholesterol measured.6

Further compounding the problem of less preventive care delivered to persons in rural areas is evidence that rural people may be more likely to engage in high- risk behavior. The 1985 National Health Interview Sur- vey found that only 25.5% of rural adults use seat belts all or most of the time, compared with 38.9% of urban/ suburban adults. Likewise, fewer rural residents (35.2%) exercise regularly, compared with urban/suburban residents (41.5%). Slightly more rural residents (17.9%) had driven a car when intoxicated than had urban/suburban residents (1 6.6%). Finally, although the percentage of rural adults who smoke cigarettes was about the same as urban/suburban adults (29.4% compared with 30.3%), slightly more rural adults were heavy smokers (28.7% versus 26.0% smoked 25 or more cigarettes per day).3

The documented differences between rural and urban/suburban areas in preventive care and risky behav- iors are not great. It is not clear whether they may be accounted for by differences in age, socioeconomic sta- tus, and other demographic factors (see below), or whether some other aspect of rurality is playing a role. It also may be that these differences would be greater if we had better measures of rural, urban, and suburban. But the data we have consistently indicate that, what- ever the explanation, a real preventive care deficit exists in rural areas.

Are Rural Americans Different from Urban/ Suburban Americans in Ways That Would Affect Preventive Care?

Rural Americans differ in important ways from urban/ suburban American~.~,~ Most of these differences probably would decrease the likelihood of rural people re- ceiving preventive care. First, rural people tend to be somewhat older than urban/suburban people (Table 1). While 13% of rural people are aged 65 years or over, 10.7% of urban/suburban people are this age. Second, rural people tend to be poorer than urban/suburban people. Median family income in 1987 was about $33,000 for urban/suburban families, but only about $24,000 for rural families (Table 1). About 17% of rural families but only 12.5% of urban/suburban had an income below the federal poverty level. Third, rural people tend to be less well educated, with about 9% college graduates as opposed to almost 13% in urban/suburban areas. Fourth, rural people tend to be less well insured than urban/suburban people. In 1984, about 12% of urban/suburban and 14.5% of rural people had no health insurance (Table l).2,3

Rural Preventive Care/Harris and Leininger 1115

Table 1. Characteristics of Rural and Urban/Suburban Populations*

Urban/ Rural suburban

Characteristic (nonmetrouolitan) (metrouolitan)

Total population (1987) 56,324,000 187,072,000 Population density per

Percentage of population

Percentage of high school

Percentage with college

Median family income

Percentage with family

square mile (1987) 19 328

65+ years (1980) 13.0 10.7

graduates (1980) 83.1 85.0

education ( 4 t years) (1980) 9.2 12.8

(1987) $24,397 $33,131

income below poverty

Percentage with no health

* OTA report.

level (1987) 16.9 12.5

insurance 14.5 12.3

The characteristics of older age, lower income, lower educational level, and lower insurance coverage have been associated with lower levels of preventive are.^,^

Is Primary Care Medical Practice in Rural America Different from Urban/Suburban Practice in Ways That Would Affect Preventive Care?

Rural people generally have less physician contact than urban/suburban people. The number of primary care physicians per 100,000 population is much higher in urban/suburban areas than in rural areas (86.8 versus 55.3 in 1988).3 This difference is due to a smaller number of general internists, general pediatricians, and ob- stetrician/gynecologists in rural compared with urban/ suburban areas, as physician per population ratios for general/family physicians are about the same for rural and urban/suburban areas.3 More than two-thirds of the federally designated health manpower shortage areas are in rural areas. About 29% of rural and 9.2% of urban/suburban people live in health manpower shortage arease3 Rural people made an average of 4.8 physician visits during 1988, while urban/suburban people made an average of 5.5 physician visits, even after ad- justing for age differences between areas.3

Although data are sparse on the organization of medical practice, it appears that rural primary care physicians generally practice in smaller groups than urban/

suburban physicians. Among licensed family physicians, general practitioners, and internists in North Carolina, 46% of rural and 35% of urban/suburban physicians are in solo practice, even after excluding aca- demic, postgraduate, and governmental physicians (Sheps Center for Health Services Research, University of North Carolina, Chapel Hill. Unpublished data, 1992.). Observations from the North Carolina Prescribe for Health project (see below) also indicate that, at least in North Carolina, rural groups are smaller than urban/ suburban groups, with fewer employees and smaller office facilities. On-call groups for rural physicians also appear to be smaller than those for urban/suburban physicians .

The American Medical Association's socioeconomic monitoring system has found that rural primary care physicians work about the same number of office hours each week as urban/suburban physicians,' yet see many more office patients in that time. Rural family physicians, for example, see 126.1 office visits per week compared to 11 1.8 visits for similar urban/suburban physicians in areas of less than 1,000,000 and 100.6 visits per week for urban/suburban family physicians in areas of more than l,OOO,OOO.' Clearly, rural physicians are spending less time per patient visit than urban/suburban physicians. As rural primary care physicians may refer less and care for a wider spectrum of disease severity than urban/suburban primary care physicians, it is likely that rural primary care physicians care for patients with a greater burden of disease. This may also decrease the time available for preventive care.

Thus, rural medical practice differs from urban/ suburban practice in several ways that could affect preventive care: (1) there are more rural areas with no primary care physicians; (2) those rural areas with physicians have fewer of them per population; (3) rural primary care physicians are organized in smaller groups, with fewer office personnel and smaller offices; and (4) rural physicians tend to spend less time with each patient. In a real sense, rural physicians, more than urban/suburban, are practicing "crisis medicine" (a term used by a rural general internist in a Prescribe for Health interview), rushing from one immediate need to another, unable to fully consider the prevention agenda for each patient.

Finally, recruiting and retaining primary care physicians in rural areas is becoming more difficult. Recent census figures indicate that college-educated people in- creasingly are concentrated in urban/suburban areas." Physicians, being members of this educated group, are no exception to the trend.


Are There Other Barriers to Preventive Care in Rural America That Are External to the People or Medical Practice?

Two other related barriers to rural preventive care de- serve mention: distance and source of preventive care. Long distance from primary care physicians can lead one to postpone or ignore needed care, especially when that care, like prevention, is not urgent. The lack of public transportation systems in rural areas adds to this problem. In some cases, there is no easily accessible source of preventive care. In North Carolina, the only counties without mammogram machines are rural. In frontier counties in the western United States, a number of sparsely settled counties have no health-care resources. Although rural areas are less isolated than they once were, some isolation remains, and the group of people most difficult to reach with medical care (including preventive care) frequently is rural.

Preliminary Observations from the North Carolina Prescribe for Health Project

The North Carolina Prescribe for Health project (Ar- nold Kaluzny, Ph.D., Principal Investigator) is a 4-year randomized, controlled trial funded by the National Cancer Institute to increase cancer prevention and early detection activities in primary care practices. Working through three statewide professional associations (the North Carolina chapter of the American College of Physicians, the North Carolina Academy of Family Physicians, and the Old North State Medical Society) and two local area health education centers, the project will provide a resource for preventive care to 66 ran- domly chosen, mostly rural, primary care practices in North Carolina. This resource consists first of an initial practice survey, in which data about baseline perfor- mance rates and attitudes are collected from chart re- views, physician and staff questionnaires, and patient questionnaires. A random half of the practices then will be offered assistance to develop a tailored system for preventive care, designed to fit the needs and capabili- ties of each practice." After a year, a repeat practice survey will be performed in all 66 practices. At the end of the study, all practices will be invited to a conference to share what has been learned. The professional orga- nizations will support their participating physician members throughout the project and will make available to all their membership those ideas and strategies that were the most successful.

For the past year, as part of the North Carolina Prescribe for Health project, we have visited a large

number of rural primary care practices in 20 North Car- olina counties to discuss the project and preventive care. From these visits, we have several preliminary qualitative observations relevant to the issue of this paper.

First, nearly all rural primary care physicians seem to be working very hard, with long hours spent in direct patient care in the office and large numbers of patients seen. Many physicians see 50 or more patients a day, spending only a limited time with each. They tend to have small on-call groups (often two to three physicians), and thus are on call often. A large number are recruiting new physicians to join them, although only a few have had recent success. These physicians often have small office staffs.

Second, almost all of the physicians we have visited have been interested in preventive care, and some are aware of providing this care in only a haphazard way. Nearly all are interested in improving preventive care in their practices. Few, however, have developed a written policy stating what preventive care they want to provide and for whom.

Third, they are aware of several different groups of patients within their practices. Some patients are interested in preventive care, some are open to suggestions about preventive care, and some have little interest and are not easily persuaded. Many also are aware of people in their area who are isolated and infrequently seek medical care of any kind.

Fourth, many physicians have tried various approaches to preventive care in their offices. Some have used chart forms; others have made posters listing patients who have stopped smoking; others use nurse practitioners or physician assistants to emphasize preventive care; and others review ahead of time the medical records of patients to be seen the following day to identify their preventive care needs. We have found no practice, however, that has a complete system for preventive care.

By complete system for preventive care, we mean an organized and planned approach to carrying out the following five tasks: (1) identify the preventive care needs of patients seen in the office, (2) educate patients about preventive care and encourage them to partici- pate, (3) perform or order the preventive care activity, (4) notify patients of the results of screening tests and follow those that are abnormal or those who have had counseling, and (5) recall patients for routine repeat testing at appropriate intervals. Although each task may be accomplished in a number of ways, we believe it is difficult to accomplish preventive care routinely unless all five are addressed.

Rural Preventive Care/Harris and Leininger 1117

Given the demands on rural primary care physicians and the lack of support from a clear prevention policy and a complete office system, it is not surprising that even the good intentions of these physicians are not sufficient to provide optimal preventive care to a large number of their patients.

What Are the Most Promising Approaches to the Rural Preventive Care Deficit, Both Long- and Short- term?

Certainly one approach to increasing preventive care in rural primary care physicians’ practices is to increase the number of rural primary care physicians or midlevel practitioners. A number of programs have been pro- posed or have tried to accomplish this long-term goal. The recent Office of Technology Assessment report, Health Care in Rural America, summarized these programs into six categories:

1.

2.

3.

4.

5.

6.

educational strategies such as rural preceptorships and residency rotations, and decentralized educational models such as area health education centers; strategies to reduce professional isolation, such as teleconferencing, outreach continuing medical education programs, and networking with medical centers; federal strategies to address economic issues, such as the new resource-based relative value scale for Medicare and proposals for national health insurance; targeted strategies for health manpower shortage areas, such as the National Health Service Corps and loan repayment programs; recruitment and retention in the private sector, including hospital and community recruitment and salary supplementation; and state efforts in health personnel distribution, such as the successful North Carolina Office of Rural Health Services.

A shorter term and complementary approach to the problem of rural preventive care is to maximize the preventive activity of current primary care practices. Realiz- ing the great demands on these practices and their general lack of resources, this could be a formidable task. As previously noted, the North Carolina Prescribe for Health project is attempting to work with rural primary care practices to assist them in developing practice prevention policies and complete systems to implement them. Complete systems might include new roles for

nurses and midlevel practitioners, flowcharts, prompt- ing systems, tracking systems, and outreach to defined patient populations. It likely would not involve increased time and effort from the physician, but rather would have them come to consider preventive care as a practice-wide responsibility. In the end, it also would encourage a population- rather than individual-based approach to medical practice. Although difficult to implement, such complete systems may be more important in stressed rural practices than in suburban practices with more resources and a more prevention- minded patient population.

Conclusions and Research Priorities

This brief review permits us several conclusions.

There is a large preventive care deficit for all Ameri- cans, and the deficit in rural America is likely somewhat greater than that in urban/suburban areas. At least part of the discrepancy between preventive care in rural versus urban/suburban America, is probably due to the characteristics of rural populations. Rural primary care practice is a stressed institution, with great demands, little time, and few resources to perform preventive care on a widespread basis. While recruiting and retaining more physicians and midlevel practitioners to rural primary care may improve preventive care delivery in the long run, complete office systems are essential for short- and long-term improvement. We need better measurement of the terms rural, urban, and suburban and research contrasting primary care practices in the different areas: the demo- graphics, needs, and interests of patients; the per- formance of preventive care; the organization of medical practice; and new ways to organize preventive care within the practice.

In the end, all areas have a preventive care deficit. It may be, however, that the deficit in rural areas differs somewhat from that in other areas and will prove a more difficult problem to solve. Research to better un- derstand the rural preventive care deficit, and to test potential solutions, should be a high priority.

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