Chartbook on Rural Health Care: Slide Presentation

Contents

Introduction
Summary of Trends
Access to Health Care
Patient Safety
Person-and Family-Centered Care
Communication and Care Coordination
Prevention and Treatment of Leading Causes of Morbidity and Mortality
Healthy Living
Affordability

Introduction

Slide 1

National Healthcare Quality and Disparities Report

Chartbook on Rural Health Care August 2015

Slide 2

Organization of the Chartbook on Rural Health Care

• Part of a series related to the National Healthcare Quality and Disparities Report (QDR).
• Contents:
  
  • Overview of the QDR.
  • Overview of residents of rural areas, one of the priority populations of the QDR.
  • Summary of trends in health care quality and disparities for rural populations.
  • Tracking of access and quality measures for rural populations:
    
    • Access to Health Care.
    • Patient Safety.
    • Person- and Family-Centered Care.
    • Communication and Care Coordination.
    • Prevention and Treatment of Leading Causes of Morbidity and Mortality.
    • Healthy Living.
    • Affordability.

Slide 3

National Healthcare Quality and Disparities Report

• Annual report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129).
• Provides a comprehensive overview of:
  
  • Quality of health care received by the general U.S. population.
  • Disparities in care experienced by different racial, ethnic, and socioeconomic groups.
• Assesses the performance of our health system and identifies areas of strengths and weaknesses along three main axes:
  
  • Access to health care.
  • Quality of health care.
  • Priorities of the National Quality Strategy.

Slide 4

National Healthcare Quality and Disparities Report

• Based on more than 250 measures of quality and disparities covering a broad array of health care services and settings.
• Data generally available through 2012.
• Produced with the help of an Interagency Work Group led by the Agency for Healthcare Research and Quality and submitted on behalf of the Secretary of Health and Human Services.

Slide 5

Changes for 2014

• New National Healthcare Quality and Disparities Report (QDR):
  
  • Integrates findings on health care quality and health care disparities into a single document to highlight the importance of examining quality and disparities together.
  • Focuses on summarizing information over the many measures that are tracked.

Slide 6

Key Findings of the 2014 QDR

• Demonstrates that the Nation has made clear progress in improving the health care delivery system to achieve the three aims of better care, smarter  spending, and healthier people, but there is still more work to do, specifically to address disparities in care.
  
  • Access improved.
  • Quality improved for most National Quality Strategy priorities.
  • Few disparities were eliminated.
  • Many challenges in improving quality and reducing disparities remain.

Slide 7

2014 Chartbooks

• 2014 QDR supported by a series of related chartbooks that:
  
  • Present information on individual measures.
  • Are updated annually.
  • Are posted on the Web (https://archive.ahrq.gov/research/findings/nhqrdr/2014chartbooks/).
• Order and topics of chartbooks:
  
  • Access to care.
  • Priorities of the National Quality Strategy.
  • Access and quality of care for different priority populations.

Slide 8

Six Chartbooks Organized Around Priorities of the National Quality Strategy

1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family is engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Slide 9

Other Chartbooks Organized Around AHRQ's Priority Populations

• AHRQ's priority populations, specified in the Healthcare Research and Quality Act of 1999 (Public Law 106-129):
  
  • Racial and ethnic minority groups.
  • Low-income groups.
  • Women.
  • Children (under age 18).
  • Older adults (age 65 and over).
  • Residents of rural areas.
  • Individuals with special health care needs, including:
    
    • Individuals with disabilities.
    • Individuals who need chronic care or end-of-life care.

Slide 10

Chartbook on Rural Health

• This chartbook includes:
  
  • Summary of trends in health care quality and disparities for rural populations.
  • Figures illustrating select measures of Access to Health Care and 6 NQS Priorities for rural populations.
• Introduction and Methods contains information about methods used in the chartbook.
• Appendixes include information about measures and data.
• A Data Query tool (http://nhqrnet.ahrq.gov/inhqrdr/data/query) provides access to all data tables.

Slide 11

Residents of Rural Areas

• Approximately 17% of Americans live in a nonmetropolitan, or rural, area.
• Although rural residents make up less than one-fifth of the U.S. population, 65% of all U.S. counties are classified as nonmetropolitan (Meit, et al., 2014).
  
  • This includes 445 "frontier" counties (U.S. Census Bureau, 2010) that have a population density of fewer than 7 people per square mile.

Slide 12

Health Issues in Rural Areas

• Compared with their urban counterparts, residents of rural counties are:
  
  • Older.
  • Poorer.
  • Sicker (a higher percentage of residents has activity limitations due to chronic health conditions) (Meit, et al., 2014).

Slide 13

Life Expectancy in Rural Areas

• The life expectancy for U.S. residents decreases as the level of rurality increases:
  
  • In 2005-2009, those living in large metropolitan areas had a life expectancy of 79.1 years compared with 76.7 years for those living in rural areas.
  • This disparity widened over time.
  • Causes of death contributing most to lower life expectancy in rural areas include:
    
    • Heart disease.
    • Unintentional injuries.
    • Chronic obstructive pulmonary disease.
    • Lung cancer.
    • Stroke.
    • Suicide.
    • Diabetes (Singh & Siahpush, 2014).

Slide 14

Health Care Providers in Rural Areas

• Metropolitan, or urban, counties tend to have a greater supply of health care providers per capita than nonmetropolitan counties.
  
  • This is especially true for specialists such as neurologists, anesthesiologists, and psychiatrists.
  • The same is true for the supply of dentists, which decreases per capita as the level of rurality increases.
• Rural residents often live farther away from health care resources, which can add to the burden of accessing care (Meit, et al., 2014).
• Nonphysician practitioners, such as nurse practitioners and physician assistants are also an important part of the health care landscape in rural communities.

Slide 15

Hospitals in Rural Areas

• Many rural residents depend on small rural hospitals for their care.
  
  • There are approximately 2,300 rural hospitals throughout the country; 71% have 50 or fewer beds.
  • Most of these hospitals are critical access hospitals that have 25 or fewer beds and must meet certain distance requirements or be declared a necessary provider by the State.

Slide 16

Services Provided by Hospitals in Rural Areas

• Although rural hospitals vary widely, the typical rural hospital offers inpatient care that includes:
  
  • Surgical services.
  • Obstetric services.
  • Swing bed services.
• Rural hospitals typically do not include:
  
  • Intensive care unit.
  • Skilled nursing facility.
  • Psychiatric unit.
  • Rehabilitation unit.
• The typical rural hospital also offers outpatient care, such as surgical services.

Note:

• The typical rural hospital also offers outpatient care that includes outpatient surgical services and breast cancer screening/mammography but does not offer hospice services, home health services, chemotherapy services, dental services, or outpatient drug/alcohol abuse care (Freeman, et al., 2015).

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Slide 17

Challenges Faced by Hospitals in Rural Areas

• Rural hospitals face unique challenges due to their size and case mix.
  
  • During the 1980s, many were forced to close due to financial losses.
  • The rate of closures slowed in the late 1990s and early 2000s but in recent years there has been an uptick in rural hospital closures, with at least 54 closures between January 2010 and July 2015 (North Carolina Rural Health Research Program, 2015).

Slide 18

NCHS Urban-Rural Classification Scheme

• This chartbook compares residents of nonmetropolitan (rural) areas with residents of large fringe metropolitan (suburban) areas:
  
  • Residents of suburban areas tend to have higher quality health care and better outcomes.
• The National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme is used to guide analyses involving geographic location.
  
  • This scheme includes six urbanization categories, including four metropolitan and two nonmetropolitan county designations.

Note:

• The 2013 NCHS classification system is derived from data gathered from three sources: the OMB metropolitan and nonmetropolitan designations, the Rural-Urban Continuum and Urban Influence coding systems, and the U.S. Census.

Slide 19

2013 NCHS Urban-Rural Classification System

Metropolitan
Large central metropolitan	Counties in a metropolitan statistical area of 1 million or more population: That contain the entire population of the largest principal city of the metropolitan statistical area, or Whose entire population resides in the largest principal city of the metropolitan statistical area, or That contain at least 250,000 of the population of any principal city in the metropolitan statistical area.
Large fringe metropolitan	Counties in a metropolitan statistical area of 1 million or more population that do not qualify as large central
Medium metropolitan	Counties in a metropolitan statistical area of 250,000 to 999,999 population
Small metropolitan	Counties in a metropolitan statistical area of 50,000 to 249,999 population
Nonmetropolitan
Micropolitan	Counties with urban population of 10,000-49,999, adjacent to metropolitanarea
Noncore	Counties that are neither metropolitan nor micropolitan

Source: Ingram D, Franco S. 2013 Rural-Urban Classification Scheme for Counties. CDC, NCHS, 2013. www.cdc.gov/nchs/data_access/urban_rural.htm

Slide 20

Map Applying NCHS Urban-Rural Classification Scheme

Image: Map of the United States shows the NCHS Urban-Rural Classification Scheme applied at the county level.

Source: 2013 NCHS Urban-Rural Classification Scheme for Counties.

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Summary of Trends

Slide 21

Chartbook on Rural Health Care

Summary of Trends

Slide 22

Disparities in measures of quality between large fringe metropolitan and micropolitan and noncore areas, 2011-2012

Image: Chart shows disparities in measures of quality between large fringe metropolitan and micropolitan and noncore areas. Micropoliitan (n=138): Worse - 35, Same - 97, Better - 6; Noncore (n=139): Worse - 43, Same - 88, Better - 8.

Key: n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.
Note: For each measure, the most recent data year available was analyzed. These data represent 2011-2012.

• Residents living in micropolitan areas received:
  
  • Better quality of care for 4% (6 out of 138) of the measures, compared with those living in large fringe metropolitan areas.
  • Worse quality of care for 25% (35 out of 138) of the measures, compared with those living in large fringe metropolitan areas.
  • The same quality of care for 71% (97 out of 138) of the measures, compared with those living in large fringe metropolitan areas.
• Residents who live in noncore areas received:
  
  • Better quality of care for 6% (8 out of 139) of the measures, compared with those living in large fringe metropolitan areas.
  • Worse quality of care for 31% (43 out of 139) of the measures, compared with those living in large fringe metropolitan areas.
  • The same quality of care for 63% (88 out of 139) of the measures, compared with those living in large fringe metropolitan areas.

Slide 23

Disparities in quality of care measures for micropolitan areas by 4 NQS priorities and Access

Image: Chart shows disparities in quality of care measures for micropolitan areas. Patient Safety (n=19): Worse - 4, Same - 11, Better - 4; Person-Centered Care (n=15): Same - 15; Effective Treatment (n=44): Worse - 13, Same - 31; Healthy Living (n=27): Worse - 11, Same - 15, Better -1; Access (n=24): Worse - 10, Same - 14.

Key: n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Overall: Residents of micropolitan areas are doing worse than residents of large fringe metropolitan areas on Effective Treatment, Healthy Living, and Access measures compared with Person-Centered Care measures.
• Patient Safety: Residents of micropolitan areas received better care for 21%, same care for 58%, and worse care for 21% of the measures compared with residents of large fringe metropolitan areas.
• Person-Centered Care: Residents of micropolitan areas received the same care for 100% of the measures as residents of large fringe metropolitan areas.
• Effective Treatment: Residents of micropolitan areas received the same care for 70% and worse care for 30% of the measures compared with residents of large fringe metropolitan areas.
• Healthy Living: Residents of micropolitan areas received better care for 4%, the same care for 56%, and worse care for 40% of the measures compared with residents of large fringe metropolitan areas.
• Access: Residents of micropolitan areas received the same care for 58% and worse care for 42% of the measures compared with residents of large fringe metropolitan areas.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

Slide 24

Disparities in quality of care measures for noncore areas by 4 NQS priorities and Access

Image: Chart shows disparities in quality of care measures for noncore areas. Patient Safety (n=19): Worse - 4, Same - 13, Better - 2; Person-Centered Care (n=16): Same - 14, Worse - 2; Effective Treatment (n=44): Worse - 17, Same - 25, Better - 2; Healthy Living (n=27): Worse - 11, Same - 15, Better -1; Access (n=25): Worse - 9, Same - 16.

Key: n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Overall: Residents of noncore areas are doing worse than residents of large fringe metropolitan areas on Effective Treatment, Healthy Living, and Access measures compared with Person-Centered Care measures.
• Patient Safety: Residents of noncore areas received better care for 11%, the same care for 68%, and worse care for 21% of the measures compared with residents of large fringe metropolitan areas.
• Person-Centered Care: Residents of noncore areas received the same care for 88% and worse care for 12% of the measures compared with residents of large fringe metropolitan areas.
• Effective Treatment: Residents of noncore areas received better care for 4%, the same care for 57%, and worse care for 39% of the measures compared with residents of large fringe metropolitan areas.
• Healthy Living: Residents of noncore areas received better care for 3%, the same care for 56%, and worse care for 41% of the measures compared with residents of large fringe metropolitan areas.
• Access: Residents of noncore areas received the same care for 64% and worse care for 36% of the measures compared with residents of large fringe metropolitan areas.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

Slide 25

Change in disparities in measures of quality between large fringe metropolitan and micropolitan and noncore areas, 2011-2012

Image: Chart shows change in disparities in measures of quality between large fringe metropolitan and micropolitan and noncore areas. Micropolitan (n=116): Improving - 9, No Change - 100, Worsening - 7; Noncore (n=117): Improving - 6, No Change - 101, Worsening - 10.

Key: n = number of measures.
Improving = Disparity is getting smaller at a rate greater than 1% per year.
No change = Disparity is not changing or is changing at a rate less than 1% per year.
Worsening = Disparity is getting larger at a rate greater than 1% per year.
Note: For each measure, the earliest and most recent data year available were analyzed through 2011-2012.

• For residents of micropolitan areas:
  
  • Disparities were getting smaller for 8% (9 out of 116) of the measures, compared with residents of large fringe metropolitan areas.
  • Disparities were getting larger for 6% (7 out of 116) of the measures, compared with residents of large fringe metropolitan areas.
  • Disparities did not change for 86% (100 out of 116) of the measures, compared with residents of large fringe metropolitan areas.
• For residents of noncore areas:
  
  • Disparities were getting smaller for 5% (6 out of 117) of the measures, compared with residents of large fringe metropolitan areas.
  • Disparities were getting larger for 9% (10 out of 117) of the measures, compared with residents of large fringe metropolitan areas.
  • Disparities did not change for 86% (101 out of 117) of the measures, compared with residents of large fringe metropolitan areas.

Slide 26

Change in disparities for micropolitan areas by 4 NQS priorities and Access

Image: Chart shows change in disparities for micropolitan areas. Patient Safety (n=19): No Change - 18, Worsening - 1; Person-Centered Care (n=15): No Change - 15; Effective Treatment (n=31): Improving - 2, No Change - 28, Worsening - 1; Healthy Living (n=21): Improving - 1, No Change - 19, Worsening - 1; Access (n=22): Improving - 2, No Change - 19, Worsening - 1.

Key: n = number of measures.
Improving = Disparity is getting smaller at a rate greater than 1% per year.
No change = Disparity is not changing or is changing at a rate less than 1% per year.
Worsening = Disparity is getting larger at a rate greater than 1% per year.

• Overall: There is no clear pattern in the reduction of disparities between people living in micropolitan areas and people living in large fringe metropolitan areas.
• Patient Safety: Disparities got larger for 5% of the measures and there was no change in 95% of the measures.
• Person-Centered Care: There was no change in disparities for 100% of the measures.
• Effective Treatment: Disparities got smaller for 7% of the measures, there was no change in 90%, and disparities got larger for 3% of the measures.
• Healthy Living: Disparities got smaller for 5% of the measures, there was no change in 90%, and disparities got larger for 5% of the measures.
• Access: Disparities got smaller for 9% of the measures, there was no change in 86%, and disparities got larger for 5% of the measures.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

Slide 27

Change in disparities for noncore areas by 4 NQS priorities and Access

Image: Chart shows change in disparities for noncore areas. Patient Safety (n=19): No Change - 18, Worsening - 1; Person-Centered Care (n=15): No Change - 15; Effective Treatment (n=32): Improving - 3, No Change - 26, Worsening - 3; Healthy Living (n=21): No Change - 19, Worsening - 2; Access (n=23): No Change - 22, Worsening - 1.

Key: n = number of measures.
Improving = Disparity is getting smaller at a rate greater than 1% per year.
No change = Disparity is not changing or is changing at a rate less than 1% per year.
Worsening = Disparity is getting larger at a rate greater than 1% per year.

• Overall: There is no clear pattern in the reduction of disparities between people living in noncore areas and people living in large fringe metropolitan areas.
• Patient Safety: Disparities got larger for 5% and did not change for 95% of the measures.
• Person-Centered Care: There was no change in disparities in 100% of the measures.
• Effective Treatment: Disparities got smaller for 9% of the measures, there was no change in 82%, and disparities got larger for 9% of the measures.
• Healthy Living: Disparities got larger for 10% and did not change for 90% of the measures.
• Access: Disparities got larger for 4% and did not change for 96% of the measures.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

Slide 28

Trends in measures of quality for micropolitan and noncore areas

Image: Chart shows trends in measures of quality for micropolitan and noncore areas. Micropolitan (n=119): Improving - 55, No Change - 52, Worsening - 12; Noncore (n=131): Improving - 62, No Change - 58, Worsening - 11.

Key: n = number of measures.
Improving = Quality is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Quality is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Quality is going in a negative direction at an average annual rate greater than 1% per year.
Note: For each measure, the earliest and most recent data year available were analyzed through 2011 to 2012.

• The quality of care for residents living in micropolitan areas:
  
  • Improved for 46% (55 out of 119) of the measures.
  • Worsened for 10% (12 out of 119) of the measures.
  • Did not change for 44% (52 out of 119) of the measures.
• The quality of care for residents living in noncore areas:
  
  • Improved for 48% (62 out of 131) of the measures.
  • Worsened for care for 8% (11 out of 131) of the measures.
  • Did not change for 44% (58 out of 131) of the measures.

Slide 29

Trends in measures of quality for micropolitan areas by 4 NQS priorities and Access

Image: Chart shows trends in measures of quality for micropolitan areas. Healthy Living (M = 1.13), Effective Treatment (M = 2.24), Patient Safety (M = 2.08), Person-Centered Care (M = 2.31), Access (M = 0.22). All show slight improvement.

Key: M = median.

• Each point represents one measure. The large red diamonds indicate median values. Quality of health care has improved steadily but the median pace of change varies across National Quality Strategy (NQS) priorities and Access.
• Median change in quality for residents of micropolitan areas was:
  
  • 1.13% per year among measures of Healthy Living.
  • 2.24 per year among measures of Effective Treatment.
  • 2.08% per year among measures of Patient Safety.
  • 2.31% per year among measures of Person-Centered Care.
  • 0.22% per year among measures of Access.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

Slide 30

Trend in measures of quality for noncore areas by 4 NQS priorities and Access

Image: Chart shows trend in measures of quality for noncore areas. Healthy Living (M = 1.38), Effective Treatment (M = 1.97), Patient Safety (M = 2.31), Person-Centered Care (M = 2.92), Access (M = 0.57). All show slight improvement.

Key: M = median.

• Each point represents one measure. The large red diamonds indicate median values. Quality of health care has improved steadily but the median pace of change varies across National Quality Strategy (NQS) priorities and Access.
• Median change in quality for residents on noncore areas was:
  
  • 1.38% per year among measures of Healthy Living.
  • 1.97 per year among measures of Effective Treatment.
  • 2.31% per year among measures of Patient Safety.
  • 2.92% per year among measures of Person-Centered Care.
  • 0.57% per year among measures of Access.
• There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

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Access to Health Care

Slide 31

Chartbook on Rural Health

Access to Health Care

Slide 32

People with a specific source of ongoing care, by residence location, 2009-2012

Image: Graph shows people with a specific source of ongoing care:

Residence Location	2009	2010	2011	2012	2013
Total	85.5	85.5	86.8	85.9	86.6
Large Central Metro	83.4	83.4	84.4	83.4	83.7
Large Fringe Metro	88.9	87.7	89.1	87.9	88.1
Medium Metro	85.0	85.3	86.9	85.9	87.8
Small Metro	84.7	85.1	85.3	85.4	86.3
Micropolitan	84.4	86.1	88.2	86.9	87.6
Noncore	87.3	87.0	88.7	87.9	88.5

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2009-2012.

• Importance: People with a usual source of care have better health outcomes and fewer disparities and costs (Healthy People 2020). Having a usual place of care and a usual provider are associated with an increased likelihood of receiving preventive services and recommended screenings compared with having no usual source of care (Blewett, et al., 2008).
• Overall Rate: In 2012, the percentage of people with a specific source of ongoing care was 85.9%.
• Change Over Time: From 2009 to 2012, the percentage of people with a specific source of ongoing care improved for residents of small metropolitan areas.
• Groups With Disparities:
  
  • In 2012, the percentage of people with a specific source of ongoing care was lower for residents of large central metropolitan, medium metropolitan, and small metropolitan areas compared with residents of large fringe metropolitan areas.
  • In all years, the percentage of people with a specific source of ongoing care was lower for residents of large central metropolitan, medium metropolitan, and small metropolitan areas compared with residents of large fringe metropolitan areas.

Slide 33

People who identified a hospital, emergency room, or clinic as a source of ongoing care, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows People who identified a hospital, emergency room, or clinic as a source of ongoing care:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	22.0	14	27.9	32.1
Large Fringe Metro	13.6	11.3	14.5	22.3
Medium Metro	19.1	14.3	23.7	32.9
Small Metro	24.8	23.4	26.1	28.6
Micropolitan	26.6	24.8	27.9	34.7
Noncore	35.8	32.8	30.4	54.8

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.
Note: For this measure, lower rates are better. White and Black are non-Hispanic. Hispanic includes all races

• Overall Rate: In 2012, the percentage of people who identified a hospital, emergency room, or clinic as a source of ongoing care was higher for residents of large central metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas.
• Groups With Disparities:
  
  • In 2012, the percentage of people who identified a hospital, emergency room, or clinic as a source of ongoing care was higher for residents of large central metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas among non-Hispanic Whites and non-Hispanic Blacks.
  • In 2012, the percentage of people who identified a hospital, emergency room, or clinic as a source of ongoing care was higher for residents of large central metropolitan, medium metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas among Hispanics.
  • In 2012, more than half of Hispanics living in noncore areas identified a hospital, emergency room, or clinic as a source of ongoing care.

Slide 34

Emergency department visits with a principal diagnosis related to dental conditions per 100,000 population, by residence location, 2010-2012

Image: Graph shows emergency department visits with a principal diagnosis related to dental conditions per 100,000 population:

Residence Location	2010	2011	2012
Large Central Metro	228.8	229.7	255.9
Large Fringe Metro	212.7	236.1	244.0
Medium and Small Metro	403.5	360.7	374.1
Micropolitan and Noncore	476.3	455.8	446.8

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, National Emergency Department Sample, 2010-2012.
Denominator: U.S. resident population.
Note: For this measure, lower rates are better.

• Importance: Patients with limited access to community dental providers may seek dental care in emergency departments.
• Overall Rate: In 2012, the rate of emergency department visits for dental conditions was 447 per 100,000 population among residents of micropolitan and noncore areas.
• Groups With Disparities: In all years, use of emergency departments for dental conditions was higher among residents of micropolitan and noncore areas and of medium and small metropolitan areas than among residents of large fringe metropolitan areas (suburbs).

Slide 35

Trauma center utilization for severe injuries, by residence location, 2012

Image: Chart shows trauma center utilization for severe injuries:

Residence Location	Trauma Level I/II	Trauma Level III	Nontrauma
Large Central Metro	69.2	2.2	28.6
Large Fringe Metro	67.0	2.5	30.6
Medium Metro	67.6	6.7	25.6
Small Metro	51.6	19.3	29.1
Micropolitan	49.1	8.2	42.7
Noncore	56.6	6.9	36.5

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, National Emergency Department Sample, 2012.
Denominator: Patients with an emergency department visit for severe injuries.
Note: Injuries with an Injury Severity Score of 16 or greater were considered severe.

• Importance: Most patients with severe injuries are treated in Level I or II trauma centers, but access to trauma centers may be more difficult for residents of rural areas.
• Overall Rate: In 2012, 63% of all patients with severe injuries were treated in Level I or II trauma centers (data not shown).
• Groups With Disparities: Residents of micropolitan and noncore areas with severe injuries were less likely to be treated in Level I or II trauma centers and more likely to be treated in nontrauma emergency departments compared with residents of large fringe metropolitan areas (suburbs), but some of these difference were not statistically significant due to small sample sizes.

Slide 36

People with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends, by residence location, 2005-2012

Image: Graph shows people with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2005	43.9	45.4	52.7	40.4	46.6	32.2	29.8
2006	42.9	45.8	52	39.5	40.1	31.1	31.5
2007	42.5	46.1	49.6	39.5	38.9	30.2	35
2008	42.6	45.8	49.2	39.5	40.1	34.7	29.2
2009	43.1	44.8	49.3	42.4	39.4	37.6	26.8
2010	43.7	46.4	52.4	39.9	36.5	38.5	26.9
2011	41.5	44.1	49.7	38.6	34.1	37	25.7
2012	42.5	44.1	51	39.5	39	35.7	26.5

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005-2012.

• Overall Rate: In 2012, 42.5% of people had a usual source of care, excluding hospital emergency rooms, with office hours at night or on weekends.
• Change Over Time: From 2005 to 2012, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends, improved for people living in micropolitan areas and worsened for those living in small metropolitan areas.
• Groups With Disparities:
  
  • In 2012, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for people living in large central metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas compared with those living in large fringe metropolitan areas.
  • In all years, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for people living in medium metropolitan, micropolitan, and noncore areas compared with those living in large fringe metropolitan areas.
  • In 7 of 8 years, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for people living in small metropolitan areas compared with those living in large fringe metropolitan areas.
  • In 5 of 8 years, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or one weekends was lower for people living in large central metropolitan areas compared with those living in large fringe metropolitan areas.

Slide 37

People with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends, by residence location, stratified by income, 2012

Image: Chart shows people with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends:

Residence Location	Total	Poor	Low Income	Middle Income	High Income
Large Central Metro	44.1	40.4	38.1	47.7	46.3
Large Fringe Metro	51	47.1	47.2	51.2	52.8
Medium Metro	39.5	40.3	38.4	40.4	38.9
Small Metro	39	39.4	36.7	39	40.3
Micropolitan	35.7	35.8	32.5	34.5	39.1
Noncore	26.5	17.5	27.2	32.5	23.8

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.

• Overall Rate: In 2012, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for residents of large central metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas.
• Groups With Disparities:
  
  • In 2012, among people with middle and high income, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for residents of medium metropolitan, small metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas.
  • In 2012, among people with low income, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for residents of large central metropolitan, small metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas.
  • In 2012, among poor people, the percentage of people with a usual source of care, excluding hospital emergency rooms, who had office hours at night or on weekends was lower for residents of large central metropolitan, micropolitan, and noncore areas compared with residents of large fringe metropolitan areas.

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Patient Safety

Slide 38

Chartbook on Rural Health Care

Patient Safety

Slide 39

Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure, by hospital location, 2008-2012

Image: Graph shows postoperative sepsis per 1,000 adult discharges with an elective operating room procedure:

Hospital Location	2008	2009	2010	2011	2012
Large Central Metro	16.3	17.7	17.8	17.5	14.0
Large Fringe Metro	15.3	18.3	17.3	17.4	14.1
Medium Metro	16.7	14.6	14.8	15.9	13.8
Small Metro	13.9	14.3	15.2	13.1	13.6
Micropolitan	11.8	12.6	16.6	15.1	11.4
Noncore	9.8	7.7	16.4	10.3	12.2

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, 2008-2011 Nationwide Inpatient Sample and 2012 State Inpatient Databases quality analysis file, and AHRQ Quality Indicators, modified version 4.4.
Denominator: All elective surgical discharges from community hospitals for patients age 18 years and over with length of stay of 4 or more days, excluding patients admitted for infection, those with cancer or immunocompromised states, those with obstetric conditions, and admissions specifically for sepsis. Discharges from critical access hospitals are typically included while discharges from rehabilitation and long-term acute care hospitals are excluded.
Note: For this measure, lower rates are better. Rates are adjusted by age, sex, age-sex interactions, comorbidities, major diagnostic category, diagnosis-related group, and transfers into the hospital.

• Importance: Infections acquired during hospital care—also known as nosocomial infections—are among the most common complications of hospital care. Patients are particularly vulnerable to healthcare-associated infections after surgery. Hospitals in more rural areas may refer patients to hospitals in urban areas for complex surgeries.
• Change Over Time: From 2008 through 2012, the rate of postoperative sepsis did not change overall (data not shown) or for any hospital location group.
• Groups With Disparities: From 2008 to 2011, hospitals in noncore, micropolitan, and small metropolitan areas had lower rates of postoperative sepsis than hospitals in large fringe metropolitan areas (suburbs), but differences were often not statistically significant.
• Achievable Benchmark:
  
  • The 2011 top 4 State achievable benchmark was 11.3 per 1,000 discharges. The top 4 States were Alaska, Minnesota, Montana, and Wisconsin.
  • At current rates of improvement, the benchmark could be met in 5 to 10 years by hospitals in most metropolitan areas.
  • While having lower rates, hospitals in noncore and micropolitan areas show no movement toward the benchmark.

Slide 40

Adults age 65 and over who received potentially inappropriate prescription medications during the calendar year, by residence location, 2002-2012

Image: Graph shows Adults age 65 and over who received potentially inappropriate prescription medications during the calendar year:

Residence Location	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Large Central Metro	17.1	16.3	14.4	19.1	13.5	12.8	9.6	12.9	11.4	9.8	10.1
Large Fringe Metro	20.1	17.5	13.7	14.1	14.9	13.2	11.7	11.6	13.1	13.0	12.8
Medium Metro	19.4	20.1	18.8	18.4	17.2	17.1	16.4	13.9	11.4	11.3	12.7
Small Metro	19.7	17.6	17.6	15.0	13.2	17.9	15.5	14.2	18.5	16.0	14.6
Micropolitan	22.8	21.2	21.3	18.3	17.9	17.7	14.8	16.6	18.1	17.5	14.2
Noncore	18.0	19.6	17.1	23.0	21.2	19.3	15.1	12.3	18.4	13.3	13.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002–2012.
Note: For this measure, lower rates are better. Prescription medications received include all prescribed medications initially purchased or otherwise obtained as well as any refills. For more information on inappropriate medications, see the American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012 Apr;60(4):616-31.

• Importance: Some drugs that are prescribed for older patients are known to be potentially harmful for this age group.
• Change Over Time: From 2002 to 2012, the percentage of adults age 65 years and over who received potentially inappropriate prescription medications decreased overall (data not shown) and for all residence location groups except residents of small metropolitan areas.
• Groups With Disparities: In almost all years, the percentage of adults age 65 years and over who received potentially inappropriate prescription medications was higher among residents of noncore, micropolitan, and small metropolitan areas than among residents of large fringe metropolitan areas (suburbs), but these difference were often not statistically significant due to small sample sizes.

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Person-and Family-Centered Care

Slide 41

Chartbook on Rural Health Care

Person-and Family-Centered Care

Slide 42

Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by residence location, 2002-2012

Image: Graph shows adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers:

Residence Location	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Large Central Metro	12.8	11.3	10.8	11.2	10.8	10.8	10.1	9.5	8.6	9.2	9.1
Large Fringe Metro	10.6	9.8	9.3	8.9	9.3	8.1	8.7	8.2	7.4	7.2	6.8
Medium Metro	9.7	9.2	7.8	9.0	9.7	8.7	9.8	9.0	8.4	8.2	7.3
Small Metro	9.9	7.4	10.0	9.9	8.7	8.5	10.3	10.1	9.1	9.4	8.3
Micropolitan	8.9	8.8	10.0	9.4	10.1	10.3	9.5	9.4	7.9	8.8	7.5
Noncore	10.9	10.3	9.6	8.0	8.7	8.5	7.0	8.5	6.5	6.4	8.8

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.
Denominator: Civilian noninstitutionalized population age 18 and over who had a doctor's office or clinic visit in the last 12 months.
Note: For this measure, lower rates are better. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

• Importance: Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers need to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.
• Change Over Time: From 2002 to 2012, the percentage of adults who reported poor communication with health providers decreased overall and for all residence location groups except residents of micropolitan and small metropolitan areas.
• Groups With Disparities: In almost all years, the percentage of adults who reported poor communication with health providers was higher among residents of micropolitan and large central metropolitan areas than among residents of large fringe metropolitan areas (suburbs), but these difference were often not statistically significant due to small sample sizes.

Slide 43

People with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by residence location, 2002-2012

Image: Graph shows people with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions:

Residence Location	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Large Central Metro	25.6	21.2	19.8	18.8	19.0	16.8	16.9	14.9	14.5	16.1	13.2
Large Fringe Metro	21.1	17.4	17.8	16.4	17.5	14.9	16.3	14.5	11.7	13.4	13.0
Medium Metro	20.5	18.7	16.1	18.3	15.9	17.7	14.5	15.9	13.4	13.3	11.5
Small Metro	20.1	17.9	18.4	14.9	14.9	16.4	17.4	18.9	14.7	14.2	13.4
Micropolitan	18.6	17.8	16.9	16.4	18.1	14.2	12.9	14.5	12.1	13.6	13.3
Noncore	20.7	18.3	13.5	13.9	14.5	12.7	12.9	16.5	12.3	14.8	9.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.
Note: For this measure, lower rates are better.

• Importance: The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment.
• Change Over Time: From 2002 to 2012, the percentage of people whose health care providers sometimes or never asked them to help make treatment decisions decreased overall and for all residence location groups.
• Groups With Disparities: In almost all years, the percentage of people whose health care providers sometimes or never asked them to help make treatment decisions was higher among residents of large central metropolitan areas than among residents of large fringe metropolitan areas (suburbs), but these difference were often not statistically significant due to small sample sizes.

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Communication and Care Coordination

Slide 44

Chartbook on Rural Health Care

Communication and Care Coordination

Slide 45

Potentially avoidable hospitalizations for all conditions per 100,000 population, by residence location, 2005-2012

Image: Graph shows Potentially avoidable hospitalizations for all conditions per 100,000 population:

Residence Location	2005	2006	2007	2008	2009	2010	2011	2012
Total	1941.2	1873.5	1814.3	1814.5	1756.5	1658.3	1669.3	1582.4
Large Central Metro	1948.3	2005.7	1831.9	1885.8	1789.9	1610.9	1779.3	1542.8
Large Fringe Metro	1842.4	1648.7	1715.0	1758.0	1712.7	1725.6	1641.1	1427.1
Medium Metro	1795.8	1666.1	1615.4	1587.3	1552.7	1515.9	1324.2	1583.3
Small Metro	1600.9	1632.7	1803.2	1563.8	1560.4	1484.8	1611.1	1649.8
Micropolitan	2261.2	2200.8	2042.7	2092.3	1981.8	1727.7	1765.8	1706.5
Noncore	2582.8	2475.7	2274.2	2282.0	2267.7	2157.8	2268.2	1979.1

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, 2005-2011 Nationwide Inpatient Sample and 2012 State Inpatient Databases quality analysis file and AHRQ Quality Indicators, version 4.4.

• Importance: Hospitalizations due to ambulatory care-sensitive conditions (ACSCs) such as hypertension and pneumonia should be largely prevented if ambulatory care is provided in a timely and effective manner. Evidence suggests that effective primary care is associated with lower ACSC hospitalization (also referred to as avoidable hospitalization) (Gao, et al., 2014).
• Overall Rate: In 2012, the overall rate of potentially avoidable hospitalizations for all conditions was 1,582 per 100,000 population.
• Change Over Time:
  
  • From 2005 through 2012, the overall rate of potentially avoidable hospitalizations for all conditions improved from 1,941 per 100,000 population to 1,582 per 100,000 population.
  • The rate of potentially avoidable hospitalizations for all conditions improved for all residence locations except small metropolitan: large central metropolitan, large fringe metropolitan, medium metropolitan, micropolitan, and noncore areas.
  • The disparity between residents living in micropolitan and large fringe metropolitan areas narrowed.
• Groups With Disparities:
  
  • From 2005 to 2012, the rate of potentially avoidable hospitalizations for all conditions was higher for people living in noncore areas compared with those living in large fringe metropolitan areas.
  • In 5 of 8 years, the rate of potentially avoidable hospitalizations for all conditions was higher for people living in micropolitan areas compared with those living in large fringe metropolitan areas.
  • In 2012, the rate of potentially avoidable hospitalizations for all conditions for people living in noncore (1,979 per 100,000) and micropolitan (1,707 per 100,000) areas was higher than for residents living in large fringe metropolitan areas (1,427 per 100,000).
• Achievable Benchmark:
  
  • The 2010 top 4 State achievable benchmark was 938.6. The top 4 States that contributed to the achievable benchmark are Hawaii, Oregon, Utah, and Washington.
  • At current rates of improvement, it would take 13 years for the total population to reach the achievable benchmark.
  • The benchmark for residents of micropolitan, large central metropolitan, large fringe metropolitan, medium metropolitan, and noncore areas could be achieved in 9, 10, 14, 15, and 16 years, respectively. Residents of small metropolitan areas are not making progress toward the benchmark.

Slide 46

Potentially avoidable hospitalizations for all conditions per 100,000 population, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows potentially avoidable hospitalizations for all conditions per 100,000 population:

Residence Location	Total	White	Black	API	Hispanic
Large Central Metro	1528.5	1224.4	2930.5	651.1	1546.2
Large Fringe Metro	1524.0	1436.2	2552.1	558.8	1293.6
Medium Metro	1340.4	1249.7	2262.5	512.7	1271.2
Small Metro	1508.7	1410.4	2542.1	641.8
Micropolitan	1653.3	1584.2	2470.3		1565.7
Noncore	1846.9	1812.6	2508.2	937.7	1432.5

Key: API = Asian or Pacific Islander.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, 2012 State Inpatient Databases disparities analysis file and AHRQ Quality Indicators, version 4.4.
Note: White, Black, and API are non-Hispanic. Hispanic includes all races. Data for micropolitan areas for APIs and small metropolitan areas for Hispanics did not meet criteria for statistical reliability.

• Overall Rate: In 2012, the rate of potentially avoidable hospitalizations for all conditions per 100,000 population was 1,529 for large central metropolitan, 1,524 for large fringe metropolitan, 1,340 for medium metropolitan, 1,509 for small metropolitan, 1,653 for micropolitan, and 1,847 for noncore areas.
• Groups With Disparities:
  
  • In 2012, the rate of potentially avoidable hospitalizations for all conditions was higher for Whites living in noncore areas (1,813 per 100,000 population) compared with those living in large fringe metropolitan areas (1,436 per 100,000 population).
  • In 2012, the rate of potentially avoidable hospitalizations for all conditions was higher for Asians and Pacific Islanders (APIs) living in noncore areas (938 per 100,000 population) compared with those living in large fringe metropolitan areas (559 per 100,000 population).

Slide 47

Admissions for immunization-preventable influenza per 100,000 population, age 65 and over, by residence location, 2000-2012

Image: Graph shows admissions for immunization-preventable influenza per 100,000 population, age 65 and over:

Residence Location	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Total	77.53	13.39	38.41	69.15	45.12	102.33	59.59	22.00	94.55	45.07	12.90	56.59	54.17
Large Central Metro	49.96	8.96	24.90	39.34	31.47	73.20	40.52	19.22	68.66	44.97	12.76	61.33	54.03
Large Fringe Metro	62.84	10.43	25.91	58.54	57.34	98.39	64.68	20.31	92.51	45.40	12.46	51.75	49.15
Medium Metro	69.03	9.93	33.71	72.25	35.44	107.55	59.28	20.13	94.51	41.75	13.56	40.33	51.72
Small Metro	91.30	14.49	55.44	81.90	42.38	95.72	64.58	20.02	87.22	37.59	10.81	56.20	52.96
Micropolitan	104.09	19.84	52.86	90.44	51.26	120.01	59.73	26.21	118.52	43.32	12.50	59.65	57.49
Noncore	169.52	33.10	83.50	135.02	74.21	174.73	101.32	36.87	156.75	64.71	16.04	92.48	71.82

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, 2000-2011 Nationwide Inpatient Sample and 2012 State Inpatient Databases quality analysis file and AHRQ Quality Indicators, version 4.4.

• Importance: Immunization is a cost-effective strategy for reducing illness, death, and disparities associated with influenza.
• Overall Rate: In 2012, the rate of admissions for immunization-preventable influenza in patients age 65 and over was 54 per 100,000 population.
• Change Over Time: From 2000 to 2012, there was no clear geographic pattern in the rate of admissions for immunization-preventable influenza among people age 65 and over.
• Groups With Disparities: In 11 of 13 years, admissions for immunization-preventable influenza per 100,000 population age 65 and over was higher for people living in noncore areas compared with those living in large fringe metropolitan areas.
• Achievable Benchmark:
  
  • The 2011 top 4 State achievable benchmark was 26.3 per 100,000 population. The top 4 States that contributed to the achievable benchmark are Hawaii, Nevada, New Jersey, and Oregon.
  • The total population and residents of large central metropolitan and small metropolitan areas are moving away from the benchmark. Residents of large fringe metropolitan areas are not making progress toward the benchmark.
  • Residents of micropolitan, noncore, and medium metropolitan areas could not achieve the benchmark for more than 20 years.

Slide 48

All emergency department visits per 100,000 population, adults age 18 and over, by residence location, 2008-2011

Image: Graph shows all emergency department visits per 100,000 population, adults age 18 and over:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2008	3818.7	3402.6	3398.2	4047.6	4034	4561.9	4956.7
2009	3835	3639.1	3253.2	4000.4	3916.2	4535.4	5093
2010	3865.3	3670.5	3193.8	3991.6	4238.9	4668	4972.9
2011	3865.3	3718.3	3429.8	4040.4	3686.8	4578.8	4853.3

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, 2008-2011 Nationwide Emergency Department Sample and AHRQ Quality Indicators, version 4.4.

• Importance: Emergency department (ED) visits are costly. Because some visits are potentially avoidable, they may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries (Dowd, et al., 2014). ED visits for conditions that are preventable or treatable with appropriate primary care lower health system efficiency and raise costs (Enard & Ganelin, 2013). An estimated 13% to 27% of ED visits in the United States could be managed in physician offices, clinics, and urgent care centers, saving $4.4 billion annually (Weinick, et al., 2010).
• Overall Rate: In 2011, the rate of all ED visits was 3,865 per 100,000 population.
• Change Over Time: There were no statistically significant changes over time in the rate of ED visits overall or by residence location.
• Groups With Disparities: In 2011, the rate of ED visits per 100,000 population was higher for residents of noncore areas (4,853) and micropolitan areas (4,579) compared with residents of large fringe metropolitan areas (3,430).

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Prevention and Treatment of Leading Causes of Morbidity and Mortality

Slide 49

Chartbook on Rural Health Care

Prevention and Treatment of Leading Causes of Morbidity and Mortality

Slide 50

Adults age 40 and over with diagnosed diabetes who received all four recommended services for diabetes in the calendar year, United States, 2012

Image: Chart shows adults age 40 and over with diagnosed diabetes who received all four recommended services for diabetes. Total - 26.6, Large Central Metro - 27.2, Large Fringe Metro - 26.0, Medium Metro - 25.8, Small Metro - 32.6, Micropolitan - 24.7, Noncore - 21.4.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: All four recommended services include 2 or more hemoglobin A1c measurements, dilated eye examination, foot examination, and flu shot in the calendar year.

• Importance: Diabetes is one of the leading causes of hospitalization in the United States, with more than 600,000 discharges in 2009 (CDC, 2011). With appropriate and timely ambulatory care, it may be possible to prevent many hospitalizations for diabetes and related complications.
• Overall Rate: In 2012, 26.6% of adults diagnosed with diabetes received all four recommended services for diabetes.
  
  • The percentage of adults diagnosed with diabetes who received all four recommended services for diabetes was highest in small metropolitan areas (32.6%) and lowest in noncore areas (21.4%).
  • The percentage of adults with diagnosed diabetes who received all four recommended services was 27.2% in large central metropolitan areas, 26.0% in large fringe metropolitan areas, 25.8% in medium metropolitan areas, and 24.7% in micropolitan areas.

Slide 51

Hospital admissions for uncontrolled diabetes without complications per 100,000 population, age 18 and over, by residence location, 2001-2012

Image: Graph shows hospital admissions for uncontrolled diabetes without complications per 100,000 population, age 18 and over:

Residence Location	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Large Central Metro	34.1	32.9	32.8	27.8	26.9	31.5	28.5	30.8	31.8	23.2	25.6	19.4
Large Fringe Metro	23.2	22.5	21.5	18.3	16.7	17.2	18.0	20.1	18.9	20.3	17.9	15.2
Medium Metro	20.0	19.9	14.8	15.8	16.6	14.9	15.5	17.1	16.6	15.5	13.7	15.6
Small Metro	19.9	19.7	19.5	19.7	14.2	15.2	17.8	17.2	17.1	18.0	16.0	18.0
Micropolitan	33.7	28.2	28.3	28.9	24.0	25.5	23.7	22.6	23.1	17.3	19.6	18.3
Noncore	41.6	37.7	34.5	35.7	32.8	30.9	29.0	27.4	28.1	26.1	27.5	20.8

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2001-2011 Nationwide Inpatient Sample and 2012 State Inpatient Databases quality analysis file and AHRQ Quality Indicators, version 4.4.
Denominator: U.S. resident population age 18 and over.
Note: For this measure, lower rates are better.

• Importance: Individuals who do not achieve good control of their diabetes may develop symptoms that require correction through hospitalization. Admission rates for uncontrolled diabetes may be reduced by better outpatient treatment and patients' tighter adherence to diet and medication.
• Trends: From 2001 to 2012, the rate of hospital admissions for uncontrolled diabetes decreased overall and for all residence location groups.
• Groups With Disparities: In almost all years, the rates of hospital admissions for uncontrolled diabetes were higher among residents of noncore, micropolitan, and large central metropolitan areas and lower among residents of medium metropolitan areas compared with residents of large fringe metropolitan areas (suburbs), but these differences were often not statistically significant due to small sample sizes.
• Achievable Benchmark:
  
  • The 2008 top 4 State achievable benchmark was 5 admissions per 100,000 population age 18 and over. The top 4 States that contributed to the achievable benchmark were Colorado, Hawaii, Utah, and Vermont.
  • At the current rates, residents of noncore and micropolitan (nonmetropolitan) areas should reach the benchmark in about 10 years, sooner than residents of metropolitan areas, whose rates are not decreasing as quickly.

Slide 52

Suicide deaths per 100,000 population, 2008-2011

Image: Graph shows suicide deaths per 100,000 population:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2008	14	12.3	12.7	14.8	15.7	16.9	18.4
2009	14.2	12.1	12.9	14.9	16.3	17.6	18.8
2010	14.6	12.3	13.5	15.4	16.6	17.8	20
2011	14.9	12.3	13.8	15.8	17.4	18.5	20.2

2008 Achievable Benchmark: 9.0 per 100,000 Population.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System–Mortality, 2008-2011.
Note: The 2009 data include ages 12 and over. Other years included all ages.

• Importance: Suicide may be prevented when its warning signs are detected and treated. Identification of suicidal ideas and plans among individuals being treated for depression is expected to increase with the growing use of standardized screening instruments and electronic medical records.
• Overall Rate: In 2011, the total suicide rate was 14.9 per 100,000 population.
• Trends:
  
  • From 2008 to 2011, the overall suicide rate and rates for residents of large fringe metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas got worse.
• Groups With Disparities:
  
  • In 2011, residents of medium and small metropolitan, micropolitan, and noncore areas had higher rates of suicide than residents of large fringe metropolitan areas.
  • Residents of large central metropolitan areas had lower rates than residents of large fringe metropolitan areas.
• Achievable Benchmark:
  
  • The 2008 top 5 State achievable benchmark was 9.0 per 100,000 population. The top 5 States that contributed to the achievable benchmark were and Connecticut, District of Columbia, Massachusetts, New Jersey, and New York.
  • No group showed progress toward the benchmark.

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Healthy Living

Slide 53

Chartbook on Rural Health Care

Healthy Living

Slide 54

Children ages 2-17 for whom a health provider gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have, by residence location, 2002-2012

Image: Graph shows children ages 2-17 for whom a health provider gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2002	30	32.2	35.4	29.4	22.5	21.9	22.2
2003	29.3	30.8	33.8	30.9	18.3	21.6	25.1
2004	31	35.2	37.2	27.4	24.5	21.8	20.5
2005	31.9	34.3	35.7	31.9	28.6	21.2	26
2006	34.6	39.1	36.1	33.9	34.2	24.3	25
2007	36.2	40.5	42.2	34.5	28.2	25.6	26.3
2008	33.5	38.4	34.2	33.7	28.5	26.4	27.2
2009	34.7	37.7	40.2	30.8	31.9	27.1	28.3
2010	39.7	43.3	45.5	37.1	33.2	33.2	26.8
2011	40.2	41.1	46.6	39.5	34.7	36.5	24
2012	41.8	43.8	47.2	40.5	42.8	30.6	31.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.

• Importance: Childhood is often a time when people establish healthy lifelong habits. Physicians can play an important role in encouraging healthy behaviors from a young age. For example, they can educate children and parents about the importance of regular exercise.
• Overall Rate: In 2012, 41.8% of children ages 2-17 received advice about exercise, sports, or physically active hobbies.
• Trends:
  
  • From 2002 to 2012, the overall percentage of children who received about exercise improved from 30.0% to 41.8%.
  • Children residing in all geographic locations showed improvement.
• Groups With Disparities: In 2012, children in medium metropolitan, micropolitan, and noncore areas were less likely to receive advice about exercise, sports, or physically active hobbies than children in large fringe metropolitan areas.

Slide 55

Children ages 2-17 for whom a health provider gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows children ages 2-17 for whom a health provider gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	43.8	40.2	42.9	47
Large Fringe Metro	47.2	46.3	42.4	56.3
Medium Metro	40.5	40.1	40	42.1
Small Metro	42.8	47.9	34.1	38.6
Micropolitan	30.6	27.5	36.5	43.9
Noncore	31.6	27.6		62.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: Data unavailable for Blacks in noncore areas

• Groups With Disparities:
  
  • Among Hispanic children, residents of large central metropolitan, medium metropolitan, and small metropolitan areas were less likely than residents of large fringe metropolitan areas to have a health care provider give advice about the amount and kind of exercise, sports, or physically active hobbies they should have.
  • Among White children, residents of micropolitan and noncore areas were less likely than residents of large fringe metropolitan areas to have a health care provider give advice about the amount and kind of exercise, sports, or physically active hobbies they should have.

Slide 56

Children ages 2-17 for whom a health provider gave advice within the past 2 years about eating healthy, by residence location stratified by race/ethnicity, 2012

Image: Chart shows children ages 2-17 for whom a health provider gave advice within the past 2 years about eating healthy:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	60.6	58.5	60.2	62.2
Large Fringe Metro	62.4	62.4	59.1	67.4
Medium Metro	56.8	56.6	59.7	56.8
Small Metro	59.2	63.9	55.8	52.5
Micropolitan	40.1	37.8	42.5	52.8
Noncore	42.9	39.8		67.4

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: Data not available for Black children in noncore areas. White and Black are non-Hispanic. Hispanic includes all races.

• Importance: It is essential for physicians to emphasize to patients the importance of consuming foods from all food groups, including whole grains and fibers, lean proteins, complex carbohydrates, fruits, and vegetables, as well as providing education about balancing energy intake and energy expenditure.
• Overall Rate: In 2012, 57.1% of children ages 2-17 received advice about healthy eating (data not shown).
• Groups With Disparities:
  
  • Overall, in 2012, children residing in micropolitan and noncore areas were less likely to receive advice about healthy eating than children in large fringe metropolitan areas.
  • Among Hispanic children, residents of medium and small metropolitan areas were less likely than children in large fringe metropolitan areas to receive advice about healthy eating.
  • Black children in micropolitan areas were less likely than children in large fringe metropolitan areas to receive advice about healthy eating.
  • White children residing in micropolitan and noncore areas were less likely than children in large fringe metropolitan areas to receive advice about healthy eating.

Slide 57

Children ages 2-17 who had a dental visit in the calendar year, by residence location, 2002-2012

Image: Graph shows Children ages 2-17 who had a dental visit in the calendar year:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2002	49.1	41.8	53.5	54.1	49	52.5	43.5
2003	50.9	42.2	58.2	53.2	55.1	51	48.2
2004	51.6	44.6	57.9	56.3	55.8	45.1	49.3
2005	50.7	45	55.7	54.6	56.1	46.4	45.7
2006	52.2	48.3	58	52.5	52.6	50.2	49.3
2007	52.2	49.3	55.3	50.9	54.9	51.6	54.1
2008	49.3	46	54.4	51	47	48.9	40.5
2009	50.9	45	56.4	53.6	51.7	48.2	48.5
2010	50.6	46.1	57	52.7	55.6	42.8	42.8
2011	50.5	43.5	56.7	53.1	57.1	46.6	43.1
2012	52.8	46.9	56.5	55.6	56.6	51.6	49

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.

• Importance: According to the National Institute of Dental and Craniofacial Research, presence of dental caries is the single most common chronic disease of childhood, occurring five to eight times as frequently as asthma (NIDCR, 2000), the second most common chronic disease in children. Regular dental visits help to improve overall oral health and prevent dental caries.
• Overall Rate: In 2012, 52.8% of children ages 2-17 had a dental visit in the calendar year.
• Trends: From 2002 to 2012, there were no statistically significant changes in the overall rate nor among children residing in any geographic location.

Slide 58

Children ages 2-17 who had a dental visit in the calendar year, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows children ages 2-17 who had a dental visit in the calendar year:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	46.9	58	39.2	42.2
Large Fringe Metro	56.5	61.9	44.2	50.8
Medium Metro	55.6	62.3	43.4	45.6
Small Metro	56.6	58.1	52.7	51.2
Micropolitan	51.6	52.6	50.8	41.5
Noncore	49	52.3		47.5

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: Data unavailable for Black children in noncore areas. White and Black are non-Hispanic. Hispanic includes all races.

• Groups With Disparities:
  
  • Hispanic children living in large central metropolitan areas were less likely to have a dental visit than children in large fringe metropolitan areas.
  • Among White and Black children, there were no statistically significant differences between those living in large fringe metropolitan areas and those in other geographic locations in the percentage who had a dental visit.

Slide 59

Children age 17 and under with a wellness checkup in the past 12 months, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows children age 17 and under with a wellness checkup in the past 12 months:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	81.7	82.5	87.6	79
Large Fringe Metro	82.9	82.5	88.8	79.8
Medium Metro	80.9	82.4	86.8	74.9
Small Metro	77.7	77.3	86.8	76.9
Micropolitan	76.2	77.6	75.7	69.7
Noncore	68.7	70.6	76.9	57.4

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2012.

• Groups With Disparities:
  
  • Overall in 2012, children residing in small metropolitan, micropolitan, and noncore areas were less likely to have a wellness visit than children in large fringe metropolitan areas.
  • Hispanic children living in micropolitan and noncore areas were less likely to have a wellness visit than children in large fringe metropolitan areas.
  • White children living in small metropolitan, micropolitan, and noncore areas were less likely to have a wellness visit than children in large fringe metropolitan areas.
  • Black children living in micropolitan areas were less likely to have a wellness visit than children in large fringe metropolitan areas.

Slide 60

Children for whom a health provider gave advice within the past 2 years about how smoking in the house can be bad for a child, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows children for whom a health provider gave advice within the past 2 years about how smoking in the house can be bad for a child:

Residence Location	Total	White	Black	Hispanic
Large Central Metro	44.2	38.2	44.9	50.3
Large Fringe Metro	38.5	36.7	37	50.1
Medium Metro	38.4	32.1	48	48.8
Small Metro	44.3	46.4	50.3	37.9
Micropolitan	35	32	40.6	49.8
Noncore	38	32.9	35.1	61.1

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.

• Importance: Secondhand smoke can cause serious health problems in children. Studies show that older children whose parents smoke get sick more often. Their lungs grow less than children who do not breathe secondhand smoke, and they get more bronchitis and pneumonia.
• Groups With Disparities:
  
  • Among Hispanic children who received advice about how smoking in the home can be bad, there were no statistically significant differences between residents of large fringe metropolitan areas and other geographic areas.
  • White and Black children living in small metropolitan areas were more likely to receive advice about how smoking in the home can be bad than children living in large fringe metropolitan areas.

Slide 61

Women ages 50-74 who received a mammogram in the last 2 years, by residence location, stratified by income, 2010

Image: Chart shows women ages 50-74 who received a mammogram in the last 2 years:

Residence Location	Total	Poor	Low Income	Middle Income	High Income
Large Central Metro	74.1	65	61	70.2	84.8
Large Fringe Metro	71.6	56.3	55.9	67.5	79.9
Medium Metro	73.8	51.9	60.1	73.4	84
Small Metro	71.1	33.6	59.2	75.1	83.9
Micropolitan	72.9	60	51.3	75.6	86.1
Noncore	64.6	48.7	59	67.1	75.8

2008 Achievable Benchmark: 88.0%.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2010.

• Importance: Early detection of cancer allows more treatment options and often improves outcomes. Mammography, the most effective method for detecting breast cancer at its early stages, can identify malignancies before they can be felt and before symptoms develop.
• Groups With Disparities:
  
  • In 2010, there were no statistically significant differences between women overall and from large central metropolitan, medium metropolitan, micropolitan, and noncore areas and women from large fringe metropolitan areas in the percentage who received a mammogram.
  • Among poor women, those from small metropolitan areas were less likely to receive a mammogram than those living in large fringe metropolitan areas.
• Achievable Benchmark:
  
  • The 2008 top 5 State achievable benchmark was 88%. The top 5 States that contributed to the achievable benchmark were Connecticut, Delaware, Massachusetts, New Hampshire, and Rhode Island.
  • No group had reached the benchmark by 2010.

Slide 62

Adults 50-75 years who reported any type of colorectal test use, by residence location, 2005-2010

Image: Graph shows adults 50-75 years who reported any type of colorectal test use:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2005	45	40.5	50.3	44.9	49.3	45.1	38.2
2008	52.2	47	56.2	56.2	54.6	50.2	46.6
2010	59.2	56.9	63.6	60.3	59.3	56.4	51.3

2010 Achievable Benchmark: 73%.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005-2010.

• Importance: Colorectal cancer is the third most common cancer in adults. Prevention of colorectal cancer includes modifying risk factors such as weight, physical activity, smoking, and alcohol use, as well as screening for early disease.
• Overall Rate: In 2010, 59.2% of adults ages 50-74 received any type of colorectal cancer screening.
• Trends:
  
  • In 2010, 56.4% of adults in micropolitan areas received colorectal cancer screening compared with 45.1% in 2005.
  • In 2010, 51.3% of adults in noncore areas received colorectal cancer screening compared with 38.2% in 2005.
• Groups With Disparities:
  
  • In 2010, adults in large central metropolitan, micropolitan, and noncore areas were less likely to receive colorectal cancer screening than residents of large fringe metropolitan areas.
• Achievable Benchmark:
  
  • The 2010 top 5 State achievable benchmark was 73%. The top 5 States that contributed to the achievable benchmark were Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island.
  • Data are insufficient to assess progress toward the benchmark.

Slide 63

Women ages 21-65 who received a Pap smear in the last 3 years, United States, 2005-2010

Image: Graph shows women ages 21-65 who received a Pap smear in the last 3 years:

Residence Location	2005	2008	2010
Total	85.3	84.5	82.8
Large Central Metro	84.2	83.1	82.6
Large Fringe Metro	87.1	86.2	83.3
Medium Metro	84.6	86.2	83.1
Small Metro	88.4	83.6	83.5
Micropolitan	84.6	83.1	82.8
Noncore	82.7	81.4	80.5

2010 Achievable Benchmark: 90%.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005-2010.

• Overall Rate: In 2010, 82.8% of women ages 21-65 received a Pap smear.
• Trends:
  
  • In 2010, 82.8% of women in micropolitan areas received a Pap smear compared with 84.6% in 2005.
  • In 2010, 80.5% of women in noncore areas received a Pap smear compared with 82.7% in 2005.
• Groups With Disparities: In 2010, there were no statistically significant geographic differences in the percentages of women who received cervical cancer screening.
• Achievable Benchmark:
  
  • The 2010 top 5 State achievable benchmark was 90%. The top 5 States that contributed to the achievable benchmark were Delaware, District of Columbia, Massachusetts, Rhode Island, and Vermont.
  • Data are insufficient to assess progress toward the benchmark.

Slide 64

Adult current smokers with a checkup in the past year who received advice in the last 12 months to quit smoking, by residence location, 2002-2012

Image: Graph shows adult current smokers with a checkup in the past year who received advice in the last 12 months to quit smoking:

Year	Total	Large Central Metro	Large Fringe Metro	Medium Metro	Small Metro	Micropolitan	Noncore
2002	63.1	64.9	63.8	62.4	60.3	62.7	59.5
2003	65.3	64.8	62.1	69.4	61.2	67.8	67.7
2004	63.1	63.2	64.1	65	61.5	62.4	57
2005	63.4	64.3	63.6	61.8	67.8	57.2	69.3
2006	62.7	60.4	63.8	68	63	57.7	60.3
2007	65.1	68.7	67.5	66.5	56.1	62.5
2008	64.5	59.7	70.7	64.6	66.2	64.3	55.7
2009	67.6	66.2	73.9	67.5	59.3	69.4
2010	65.7	69.5	69.3	61.9	59.2	67.9
2011	68.2	68.9	64.2	71.5	64.1	71.1	68.4
2012	66.5	64.6	61.2	68.5	65.1	73.4	73

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.
Note: Data unavailable for noncore in 2007, 2009, and 2010.

• Importance: Smoking harms nearly every organ of the body and causes or exacerbates many diseases. Since the first Surgeon General's report on smoking and health in 1964, there have been more than 20 million premature deaths attributable to smoking and exposure to secondhand smoke (OSH, 2014). In 2012, 25.6% of residents of nonmetropolitan areas age 18 and over were current smokers compared with 15.4% of residents of large metropolitan areas (Blackwell, et al, 2014).
• Overall Rate: In 2012, 66.5% of current smokers received advice to quit smoking.
• Trends:
  
  • From 2002 to 2012, the overall percentage of adults who received advice to quit smoking increased from 63.1% to 66.5%.
  • Among current smokers in both micropolitan and noncore areas, there were significant improvements. Micropolitan residents improved from 62.7% in 2002 to 73.4% in 2012 and percentages for noncore residents improved from 59.5% to 73.0%.
  • Residents of large central metropolitan, large fringe metropolitan, and medium metropolitan areas showed no statistically significant changes.

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Affordability

Slide 65

Chartbook on Rural Health Care

Affordability

Slide 66

People under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income, by residence location, 2006-2012

Image: Graph shows people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income:

Residence Location	2006	2007	2008	2009	2010	2011	2012
Total	17.5	16.3	17.3	17.4	17.6	17.5	17.9
Large Central Metro	14.3	14.0	16.2	14.7	15.1	15.6	16.4
Large Fringe Metro	15.5	14.9	16.2	16.8	17.1	17.4	16.6
Medium Metro	20.0	16.9	17.9	18.5	19.4	19.2	20.4
Small Metro	18.5	18.2	18.9	18.1	18.3	19.3	18.3
Micropolitan	22.1	21.8	20.3	21.4	18.4	17.4	18.6
Noncore	24.4	19.7	17.6	22.3	24.3	18.9	20.9

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2012.
Note: For this measure, lower rates are better.

• Importance: Health care expenses that exceed 10% of family income are a marker of financial burden for families. These numbers predate the Affordable Care Act.
• Overall Rate: In 2012, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was 17.9%.
• Trends:
  
  • From 2006 to 2012, there was no statistically significant change in the rate of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of their total family income.
  • From 2006 to 2012, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income improved for people living in micropolitan and noncore areas.
  • From 2006 to 2012, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income worsened for people living in large central metropolitan and large fringe metropolitan areas.
  • The disparity between residents of micropolitan and large fringe metropolitan areas narrowed.
• Groups With Disparities:
  
  • In 2012, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was worse for residents living in medium metropolitan and noncore areas compared with large fringe metropolitan areas.
  • In 5 of 7 years, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was worse for residents living in noncore areas compared with large fringe metropolitan areas.
  • In 4 of 7 years, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was worse for residents living in micropolitan areas compared with large fringe metropolitan areas.

Slide 67

People under age 65 whose family health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income, by residence location, stratified by race/ethnicity, 2012

Image: Chart shows people under age 65 whose family health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income:

Residence Location	Total	Non-Hispanic White	Non-Hispanic Black	Hispanic
Large Central Metro	16.4	17.5	13.6	13.9
Large Fringe Metro	16.6	17.5	12.2	11.3
Medium Metro	20.4	20.9	18.6	18.0
Small Metro	18.3	19.3	17.7	11.7
Micropolitan	18.6	18.9	22.6	14.2
Noncore	20.9	22.0	21.5	13.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: For this measure, lower rates are better.

• Overall Rate: In 2012, the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was worse for residents living in medium metropolitan and noncore areas compared with large fringe metropolitan areas.
• Groups With Disparities:
  
  • In 2012, among non-Hispanic Black residents, the percentage of people under age 65 whose family health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income was higher for those who live in medium metropolitan, micropolitan, and noncore areas compared with those who live in large fringe metropolitan areas.
  • In 2012, among Hispanic residents, the percentage of people under 65 whose family health insurance premiums and out of pocket medical expenditures were more than 10% of total family income was higher for those who live in medium metropolitan areas compared with those who live in large fringe metropolitan areas.

Slide 68

Among people unable to get or delayed in getting needed medical care, dental care, or prescription medicines, those who cite financial or insurance reasons, United States, by residence location, 2002-2012

Image: Graph shows, among people unable to get or delayed in getting needed medical care, dental care, or prescription medicines, those who cite financial or insurance reasons, United States, by residence location:

Residence Location	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012
Total	61.2	63.7	63.8	65.6	65.2	64.6	65.2	69.2	71.4	68.7	69.3
Large Central Metro	61.1	61.8	64.7	66.8	66.4	61.8	62.7	70.3	71.3	69.4	72.4
Large Fringe Metro	55.8	60.8	58.7	61.9	63.6	60.4	61.8	68.4	66.8	68.7	68.2
Medium Metro	64.5	65.2	64.6	65.2	64.4	71.0	68.4	70.6	75.0	68.2	68.3
Small Metro	66.7	69.9	68.1	69.4	69.2	67.5	64.5	65.3	70.5	65.3	63.3
Micropolitan	59.5	65.1	64.9	65.8	65.6	65.9	70.4	68.9	71.1	67.1	72.8
Noncore	65.8	65.8	68.8	68.2	62.4	65.3	69.7	69.7	77.7	78.6	66.7

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.

• Importance: Some Americans cannot afford all the care they need.
• Overall Rate: In 2012, among people unable to get or delayed in getting needed medical care, dental care, or prescription medicines, 69.3% cited financial or insurance reasons. These numbers predate the Affordable Care Act.
• Trends:
  
  • From 2002 to 2012, the percentage of people unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons worsened overall and for residents of large central metropolitan, large fringe metropolitan, micropolitan, and noncore areas.
  • The disparity narrowed between residents of small metropolitan and large fringe metropolitan areas.

Slide 69

People without a usual source of care who indicate a financial or insurance reason for not having a source of care, by education, 2012

Image: Chart shows people without a usual source of care who indicate a financial or insurance reason for not having a source of care, by education:

Residence Location	Total	<High School	High School Grad	Any College
Large Central Metro	25.9	36.6	28.1	20.9
Large Fringe Metro	19.8	33.7	23.2	14.2
Medium Metro	20.4	31.0	25.6	14.4
Small Metro	18.0	21.0	22.2	14.3
Micropolitan	16.2	23.0	15.1	13.6

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2012.
Note: For this measure, lower rates are better. Data do not meet the criteria for statistical reliability, data quality or confidentiality for Noncore areas.

• Overall Rate: In 2012, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was 21%.
• Groups With Disparities:
  
  • In 2012, overall, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was higher for people living in large central metropolitan areas compared with those living in large fringe metropolitan areas.
  • In 2012, among people who had less than a high school education, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was lower for people living in small metropolitan and micropolitan areas compared with those living in large fringe metropolitan areas.
  • In 2012, among high school graduates and people with any college, the percentage of people without a usual source of care who indicated a financial or insurance reason for not having a source of care was higher for people living in large central metropolitan areas compared with those living in large fringe metropolitan areas.

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Slide 70

References

• Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 2014;10(260). http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf (3.581 KB).
• Blewett LA, Johnson PJ, Lee B, et al. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med 2008 Sep;23(9):1354-60. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518015/. Accessed August 25, 2015.
• Centers for Disease Control and Prevention, National Center for Health Statistics. Number (in thousands) of hospital discharges with diabetes as first-listed diagnosis, United States, 1988-2009. Last updated: August 5, 2011. http://www.cdc.gov/diabetes/statistics/dmfirst/fig1.htm. Accessed August 25, 2015.
• Dowd B, Karmarker M, Swenson T, et al. Emergency department utilization as a measure of physician performance. Am J Med Qual 2014;29(2):135-43. http://ajm.sagepub.com/content/29/2/135.long
• Enard KR, Ganelin DM. Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. J Healthc Manag 2013;58(6);412-28. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142498/. Accessed August 25, 2015.
• Freeman VA, Thompson K, Howard HA et al. The 21st century rural hospital: a chartbook; 2015. http://www.shepscenter.unc.edu/wp-content/uploads/2015/02/21stCenturyRuralHospitalsChartBook.pdf (3.928 MB). Accessed July 17, 2015.
• Gao J, Moran E, Li YF, et al. Predicting potentially avoidable hospitalizations. Med Care 2014 Feb;52(2):164-71. PMID: 24374413.

Slide 71

References

• Healthy People 2020. Access to Health Services. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services. Accessed October 14, 2014.
• Meit M, Knudson A, Gilbert T, et al. The 2014 update of the rural-urban chartbook; 2014. https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf  (3.572 MB). Accessed July 17, 2015.
• Office on Smoking and Health. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-by-section.html.
• Rural hospital closures: January 2010-present. North Carolina Rural Health Research Program. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures. Accessed July 17, 2015.
• Singh GK, Siahpush M. Widening rural-urban disparities in life expectancy, U.S., 1969-2009. Am J Prev Med 2014 Feb;46(2):e19-29. PMID: 24439358. 
• U.S. Bureau of the Census; 2010. http://www.census.gov/2010census/data/. Accessed July 17, 2015.
• Weinick RM, Burns RM, Mehrotra A. How many emergency department visits could be managed at urgent care centers and retail clinics? Health Aff 2010;29(9):1630-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3412873/. Accessed August 25, 2015.

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