Rural Healthcare Research

Despite the fact that outcomes are best when treatment is given in the early stages of lung cancer, less than 6% of eligible high-risk people who need medical care participate in LCS, with even lower participation in rural populations. Data from the National Lung Screening Trial (NLST), a multi-institutional randomized controlled study of over 50,000 people, demonstrated the utility of LCS by comparing low-dose computed tomography (CT) with chest X-ray. It found that LCS with low-dose CT was associated with a 20% reduction in lung cancer-specific mortality, as well as an overall mortality reduction of 6.7%.

Many organizations have subsequently published guidelines supporting annual LCS. Nevertheless, 10 years later, despite multiple studies confirming the results of the NLST, and revised guidelines based on continued research into its efficacy, low-dose CT is still underutilized, and a disproportionate number of high-risk people are either not referred or do not undergo screening.

While the reasons for this are multifactorial, the need to better understand the current rural screening landscape, and rural provider and population barriers leading to low participation, is imperative to resolve this public health dilemma. Additionally, given these hard-to-reach locations, the use of a community-based approach is vital to developing an intervention that would be well-utilized.

This study seeks to deliver LCS designed to reduce logistical and psychosocial barriers. In rural areas, a mobile unit should be feasible and acceptable to people who need medical care and to providers, and may serve to supplement traditional hospital or clinic-based screening. Based on the success of mobile breast and cervical cancer screening programs, the research team seeks to determine whether a mobile unit will be more successful in increasing screening in rural areas than a traditional hospital-based approach.

Findings from this study will aid in the development of a scalable, feasible intervention acceptable to people who need medical care and to providers in rural areas to improve LCS. Further, by understanding the needs of rural communities and enhancing opportunities for LCS closer to home, earlier detection, prompter treatment, and improved cancer outcomes can be achieved.

People who need medical care in rural settings have significantly worse outcomes from cardiovascular conditions compared with those in non-rural settings, including treatment of arrhythmias with a CIED, like a pacemaker or defibrillator. These ubiquitous implantable devices store copious amounts of medical information related to device function and disease progression, among other items.

These data are available to treating physicians and other clinicians through RM, which relies on wireless connectivity between people who need medical care, a remote server, healthcare facilities and treating physicians. Monitoring of people who need medical care with a CIED through this RM paradigm as an adjunct to periodic in-person evaluations has been associated with a variety of improved outcomes over in-person evaluations alone, ranging from improvements in individual satisfaction to decreased mortality. Thus, RM is unequivocally recommended in combination with in-person evaluations. While known disparities in RM exist among the uninsured and elderly, the geographic distribution of RM remains unstudied.

A number of factors suggest that RM of CIEDs may be particularly vulnerable to geographic disparities. For one, people who need medical care in rural areas face greater barriers to connectivity, including less access to high-speed internet and less-consistent cell phone coverage. These barriers couple with the challenge of greater geographic distances that must be traveled to access in-person subspecialty services, a necessary aspect of CIED care.

Low-value care, defined as care for which the likely degree of benefit is outweighed by harms or costs, is a critical domain of healthcare waste. Efforts to reduce low-value care have intensified as literature has elucidated the magnitude of associated patient- and system-level harms associated with this care.

In the pediatric hospital setting (inclusive of inpatient and emergency departments), describing the impact of low-value care has been identified as a research priority. Low-value care persists for many conditions commonly cared for in this environment despite increasing evidence of their ineffectiveness. While a growing body of literature describes the prevalence of pediatric low-value care, research on this topic in the United States to date has focused largely on freestanding children’s hospitals, all of which are located in urban regions. Little is known about the prevalence and impact of pediatric low-value care in rural hospitals, which provide the majority of hospital care for children in the US. This is particularly relevant because rural-residing children are under-represented in research and have poorer health outcomes and child mortality than their urban-residing peers. 

This study will use Medicaid data to measure the delivery of 30 low-value pediatric services in the hospital setting in eight rural states. Through application of this tool, we will: 1) measure urban-rural disparities in pediatric low-value care delivery and determine if these disparities are moderated by hospital type and setting; 2) characterize downstream healthcare utilization (hospital revisits, imaging studies and prescription fills) and Medicaid spending associated with low-value care delivery; and 3) using qualitative methods, identify unique deimplementation considerations in rural regions from the perspectives of rural hospital stakeholders. 

Individuals with chronic obstructive pulmonary disease (COPD) who live in rural areas of the United States have worse health outcomes compared with their non-rural counterparts, outcomes not completely explained by higher rates of cigarette smoking. Both ongoing cigarette exposure and environmental exposures other than cigarettes, including particulate matter (PM) air pollution, are associated with worse COPD morbidity. Use of solid fuels (e.g. wood and pellet) for heating is common in rural areas and can generate high concentration of indoor PM. However, there is a common belief is that rural areas are free from air pollution, and rural residents are often not aware of pollution sources within their own homes and communities. There are few studies that assess environmental exposures, their association with COPD morbidity, and the risk perceptions of such exposures in rural areas of the United States. 

Our long-term goal is to identify potentially modifiable environmental risk factors that contribute to greater COPD morbidity in rural US, leading to future targeted interventions designed to improve outcomes. Our overall objective for this application is to determine the association of environmental exposures with respiratory morbidity in individuals with COPD living in rural areas, and to explore the risk perceptions of such exposures. The rationale for this project is that identifying the sources, health effects, and risk perceptions of environmental exposures will inform development of a future comprehensive intervention that is sensitive to the needs and priorities in a population where continued inhalational exposures are associated with disease progression and death. 

We will recruit individuals with COPD living in northern New England (NNE), and comprehensive environmental exposure assessment will be paired with extensive clinical outcomes to address the following aims: 1) To identify individual and community characteristics that are associated with environmental exposures among those with COPD living in NNE; 2) To quantify the relationship between environmental exposures and morbidity in individuals with COPD living in NNE; and 3) To use semi-structured interviews and focus groups to explore risk perceptions, knowledge, attitudes, and behaviors surrounding environmental risk factors and potential strategies to mitigate such exposures among individuals with COPD living in NNE. The proposed research will generate crucial information on the associations between environmental exposures and respiratory morbidity as well as the predictors of such exposures in NNE residents with COPD. Results from this study will lead to future trials designed to mitigate environmental exposures and improve health outcomes for individuals living with COPD in the rural US.