Rural Health Care Delivery System Research Articles

Acknowledging the Role of Community Health Workers in Providing Essential Healthcare Services in Rural India-A Review.

In underserved communities, the community health worker (CHW) concept has been employed to improve health and lessen unfavourable health consequences. In India's rural healthcare delivery system, auxiliary nurse midwives (ANMs), accredited social health activists (ASHA workers), and Anganwadi workers (AWWs) are the primary field-level frontline officials who come into direct contact with the population. They bear a large portion of the burden of carrying out health services. This review investigated the various contributions made by these CHWs, ANMs, ASHA workers, and AWWs to the advancement of basic healthcare in Indian rural areas. The goal of reviewing this paper was to learn more about what CHWs do to provide the target demographic with high-quality healthcare. A thorough literature search was conducted using crucial databases including PubMed, Google, and Google Scholar. Recent studies were examined to determine how well CHWs perform essential healthcare services in low and middle-income nations. Numerous studies demonstrate how their work has a good effect on society. The length of time CHWs spend at work each day and how well they perform as a whole depends on several variables. This review study showed that, globally, there is a growing interest in CHWs' performance. In terms of incentives, pay, and training expenses, CHWs are thought to be a more affordable option than other types of health workers. They are recognised as the main factors in providing promotive, preventive, curative and rehabilitative healthcare services, achieving enhanced neonatal and maternal health and the development of children and adolescents. The current review also examined previous studies on the work done by CHWs and their potential benefits for enhancing primary healthcare in rural India. It focused on the routine work done by these health workers to increase service accessibility and access to high-quality healthcare, particularly for individuals living in rural areas. Hence, it is necessary to evaluate the functions and general status of community health workers (CHWs), as well as recognise their role, to improve their efficiency in providing basic healthcare services to society and make necessary changes in the future.

An Appraisal of Prevailing Issues in Rural Tribal Health Care System in India

Better health is one of the most important aspect of the overall development and progress of any country. In the context of India, tribals are an integral part, which are 8.6 percent of the total population of the country. Scarce public health care services in India and related issues are currently the most discussed topic with recent outbreak of Covid-19 affecting human life terribly and still persisting. Health care issue affects every individual in the society. In tribal areas health care issues become even more important because as it seems that this section of society is still comparatively in unprivileged condition and not properly exploited the benefits of development process.India's development cannot be imagined without improvement of rural and tribal health. This article highlights major issues prevailing in the rural tribal health care system of India, which arises many barriers to tribal health and the holistic development of the country. Based on the blending results of several multi-factual studies, it is known that there exist many issues prevailingin the rural tribal health care delivery system. Many issues are there which are responsible for poor and complex tribal health status among the tribes, such as, low awareness about health, different religious and cultural beliefs, unrealistic health practices, living in difficult and inaccessible areas, financial problems, various infectious diseases, nutritional deficiencies, and poor public health care facilities, etc. These issues have attracted renewed attention from physicians, health policy experts, various health agencies as well as the general public, particularly tribal societies, which are most affected by these issues. Keywords: Health Status; Health Infrastructure; Rural Health Care Services; Tribal Culture And Practices; Health Policy; Public Involvement And Awareness.

Panchayati Raj and Rural Health Care Delivery System in Karnataka

It is commonly opined that decentralisation through Panchayati Raj Institutions (PRIs) can help in creating greater accountability in the Indian healthcare system. Health decentralisation is specially meant for peoples’ participation, increased transparency and a higher degree of accountability to provide comprehensive and quality health services at the grassroots level. The National Rural Health Mission (NRHM) visualises the provision of decentralised healthcare at the grassroots level. However, this scheme has some lacunas in reaching the needy, especially in the rural parts of India because of an ineffective and non-participatory role of PRIs in decision making. This has been ascribed to a malfunction in creating healthcare awareness and making the procedures complicated and chaotic for the local Panchayats. The article is based on the Indian Council of Medical Research-funded study in the state of Karnataka. It seeks to find out how PRIs are managing the public healthcare system and its success and failure through a qualitative study. The study has shown that some amount of caution is needed in devolving requisite powers to the PRIs within the NRHM. The coordination between Public Health Institute officials and those of PRIs is completely absent and most of the PRI members do not even know about various health schemes.

Time-motion study of auxiliary nurse midwives of a primary health center from Wardha District of Maharashtra

Introduction: In the rural health-care delivery system of India, auxiliary nurse midwife (ANM) is the key frontline field-level functionary who interacts directly with the community. A heavy responsibility of implementation of health programs rests on the shoulders of ANMs. As ANMs are central to the delivery of services under the National Rural health Mission including supervision of the work done by the accredited social health activist, we thought it prudent to analyze their work pattern so that their efficiency could be improved upon. Objective: The objective was to study the workload and work pattern of ANMs and identify the causes for improving work efficiency of ANMs. Materials and Methods: This was an observational cross-sectional study conducted among four purposively chosen ANMs from a primary health center (PHC) in Central India using time-motion study as the tool. An ANM's work pattern and workload were studied by constructing 24-h recall. One ANM was followed for a week, similarly the other ANM for another week so that the activities of entire month were covered. To ensure quality, work schedules reported by the ANMs each day were cross-checked with the concerned supervisor or medical officer PHC. Results: A free-listing and pile-sorting exercise was performed with the ANMs, and the 41 activities reported by them were clubbed in to five major categories. It was found that on meeting day, meeting and record keeping were the most performed tasks, whereas other tasks were hardly performed. On the day of home visits, ANMs performed the disease-related activity for most of their time, and record keeping or supporting tasks were the second most performed activities. Majority of ANM's time spent over the week was on supporting tasks which were not directly related to their job profile. Conclusion: We conclude that clarity about job responsibilities of ANMs is lacking and available working time is not effectively utilized. Time spent on supporting tasks such as travel and waiting is maximum. Training to manage time for priority tasks and to improve skills is required.

Implementation of the MEDFRAT to Promote Quality Care and Decrease Falls in Community Hospital Emergency Rooms

AbstractPurposeTo identify and implement an evidence-based fall-risk assessment tool for use in emergency departments at Essentia Health, a large, primarily rural health care delivery system with 12 emergency departments. MethodsThe Iowa Model of Evidence-Based Practice to Promote Quality Care was used to guide the process. The Memorial Emergency Department Fall-Risk Assessment Tool (MEDFRAT) was programmed into the electronic medical record, along with interventions that could be selected for 2 fall-risk levels. An education session was developed for emergency nurses about falls and MEDFRAT, with planned time for discussion about any concerns in the implementation of MEDFRAT. MEDFRAT was selected for implementation by nursing leadership because it is evidence based and appeared to be conducive to implementation in the diverse emergency departments across 12 sites in 3 states. ResultsEducation sessions were presented to nurses at 11 of 12 emergency departments. Suggestions to support site-specific implementation were programmed into the electronic health record. Nurses expressed appreciation that they were consulted, and their feedback was incorporated into the tool before it was implemented. Resources needed at each site to implement recommended MEDFRAT interventions in the tool were identified. Needed resources were then provided to the emergency departments before implementation of MEDFRAT. ConclusionsThe Iowa Model was a useful framework to select an evidence-based tool and then engage nurses in the process of implementing evidence-based practice changes in emergency departments across a diverse health care system serving a largely rural population. Ongoing follow-up will determine if this process results in fewer falls.Image 1

Health services rendered through Accredited Social Health Activists to rural Uttar Pradesh, India: community’s perception

Background: To reduce infant and maternal mortality in India, the Government of India (GOI), under its flagship program, National Rural Health Mission (NRHM), in 2005, introduced a new village based health functionary named Accredited Social Health Activist (ASHA) to act as a bridge between rural population and health care delivery system. To a large extent the actualization of the goals of NRHM depends on the functional efficacy of ASHA as a grass root health activist.Methods: The Study was conducted in a Chiraigaon Block of District Varanasi, Uttar Pradesh., India from October 2008 to September 2009. A total of 270 beneficiaries comprising of mothers, who have delivered during the study period or within last six months since initiation of the study were enrolled and interviewed. Apart from that, 20 Multi Purpose Health Workers- Female (MPHW-F), 30 elected village Heads and five Medical officers were interviewed independently to know their opinions about work performance of ASHA.Results: This study revealed that 80 % of beneficiaries availed Ante Natal Care (ANC) check up. A total of 97% of the beneficiaries had received 100 tablets of Iron Folic Acid (IFA), 72% of the beneficiaries were counseled for nutrition during pregnancy and the child immunization coverage was more than 80%. About 75% of multi purpose Health Worker-Female (MPHW-F), 83 % of the village heads and 80% of the Medical Officers were of the opinion that the maternal and child health (MCH) services have improved after ASHAs introduction. Conclusions: Overall, ASHA’s impact in the form of counseling on health services utilization by beneficiaries was observed to be statistically significant.

Developing Program Performance Measures for Rural Emergency Medical Services

ABSTRACTBackground: The development of measures to monitor and evaluate the performance and quality of emergency medical services (EMS) systems has been a focus of attention for many years. The Medicare Rural Hospital Flexibility Program (Flex Program), established by Congress in 1997, provides grants to states to implement initiatives to strengthen rural healthcare delivery systems, including better integration of EMS into those systems of care. Objective: Building on national efforts to develop EMS performance measures, we sought to identify measures relevant to the rural communities and hospitals supported by the Flex Program. The measures are intended for use in monitoring rural EMS performance at the community level as well as for use by State Flex Programs and the Federal Office of Rural Health Policy (FORHP) to demonstrate the impact of the Flex Program. Methods: To evaluate the performance of EMS in rural communities, we conducted a literature search, reviewed research on performance measures conducted by key EMS organizations, and recruited a panel of EMS experts to identify and rate rurally-relevant EMS performance measures as well as emergent protocols for episodes of trauma, ST Elevation Myocardial Infarction (STEMI), and stroke. The rated measures were assessed for inclusion in the final measure set. Results: The Expert Panel identified 17 program performance measures to support EMS services in rural communities. These measures monitor the capacity of local agencies to collect and report quality and financial data, use the data to improve agency performance, and train rural EMS employees in emergent protocols for all age groups. Conclusion: The system of care approach on which this rural EMS measures set is based can support the FORHP's goal of better focusing State Flex Program activity to improve program impact on the performance of rural EMS services in the areas of financial viability, quality improvement, and local/regional health system performance.

Abstract B14: Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky

Abstract Introduction. Residents of Appalachian Kentucky experiences significant cancer disparities. The population is characterized, in general, as largely rural with high poverty rates, high unemployment and limited access to health care. Lung and colorectal cancer incidence and mortality rates in this area are among the highest in the nation and although cervical cancer mortality has decreased over recent decades, data from the Surveillance, Epidemiology, and End Results (SEER) program reveals that mortality rates in Kentucky are substantially higher than the national average. In 2003, when this project began, the US cervical cancer mortality rate was 2.7 per 100,000 (95% confidence interval = 2.6-2.7). During the same period, the rate in Kentucky was 3.2 per 100,000 (2.9-3.6). In the 54 Appalachian counties in the state, the rate was even higher, 3.7 per 100,000 (3.5-4.0). Death from cervical cancer is preventable in nearly all cases with screening by the Pap test and adherence with recommendations to obtain follow-up care when abnormalities are detected. Methods. To address the problem of elevated cervical cancer incidence and mortality experienced by rural Appalachian women, a patient navigation intervention program was developed with the goal of increasing adherence with recommendations for follow-up for women with abnormal Pap test results. The intervention was implemented in partnership with county health departments. Intervention effectiveness was evaluated in a quasi-experimental trial that included intervention county health departments (n=13) that provided patient navigation services and a comparison group of county health departments (n=13) that provided usual care. Women with abnormal Pap test results were enrolled in the intervention group county health departments and patient navigation was tailored to the type of follow-up care recommended. Study outcome data were collected from medical records. Participants were enrolled from September 2008 through July 2010. A total of 774 medical record reviews are included in the analysis (230 women in intervention and 544 women in comparison county health departments). Recommendations for follow-up, which were based on the type of abnormality and the age of the patient, included returning to the health department to obtain a repeat Pap test or making an appointment with a community gynecologist under contract with the health department. Key Findings. The proportion of participants that received their recommended follow-up care was greater in the intervention group (91.6%) than in the comparison group (80.8%) (p=.01). The effect of the patient navigation intervention was strongest among women who received follow-up care from the health department as opposed to community gynecologists under contract with the health departments. Conclusions. The results demonstrate the effectiveness of the patient navigation intervention and also provide evidence suggesting that development of policy to promote integration of navigation with rural health care delivery systems has great potential to improve patient outcomes. Citation Format: Mark Dignan, Brent Shelton, Nancy E. Schoenberg, Carol R. White, Stacey A. Slone, Emily Van Meter, Frances J. Feltner, Gretchen Ely, Christopher DeSimone. Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B14.

Bridging the Healthcare Access Divide: A Strategic Planning Model for Rural Telemedicine Network

ABSTRACTBalancing access to healthcare and sustaining operational efficiency is a major issue in strategic planning of rural healthcare delivery systems. In this regard, telemedicine is being adopted as a versatile and low cost mechanism for delivering rural healthcare. This article presents a strategic planning model that incorporates different operational and service elements of the rural telemedicine healthcare network. Real‐world data from the rural Black‐belt region in the United States are used in a case study. A novel statistical approach based on decision trees and logistic regression is used to estimate demand of healthcare at the county level. Key issues such as the location of telemedicine health centers, coverage of health services, configuration of medical equipment, and patient travel policies are explored in light of patient demographics, scale of health coverage, and disease prevalence patterns. Results indicate that telemedicine networks can effectively improve healthcare services in rural areas with requisite operational efficiency.

Effectiveness of an Intervention for Adherence to Follow-up Recommendations for Abnormal Pap Tests in Appalachian Kentucky.

In collaboration with rural county health departments (CHDs), we developed a patient navigation intervention to increase adherence to follow-up recommendations for women with abnormal Pap tests. Local women were recruited, trained and placed in CHDs. Navigation was tailored to the follow-up care recommended. Effectiveness was evaluated in a quasi-experimental trial that included 13 intervention CHDs and 13 comparison group CHDs. Participants were enrolled from September 2008 through July 2010. A total of 478 participants were enrolled. The proportion that received recommended follow-up care was greater in the intervention CHDs (91.6%) than in the comparison group CHDs (80.8%) (p = .01). These results suggest that development of policy to promote navigation with rural health care delivery systems has great potential to improve patient outcomes.

Bottlenecks identified in the Implementation of components of national health programmes at PHCs of Cuttack district of Odisha

Introduction: Primary health care is the nucleus of country's health care delivery system. Bottlenecks in delivery of services at PHC level leads to decreased efficiency of health system and indirectly affects health of the citizens of a country. Keeping these issues in mind a study was carried out with the objectives i)To identify constraints/bottlenecks in implementation of elements of primary health care ii)To find out solutions to address these bottlenecks. Materials and Methods: This cross-sectional study was carried out in Cuttack district during Dec 2010 and January 2011 using a semi-structured pre-tested questionnaire. Data regarding various difficulties faced while delivering health care services at PHC was collected from participants attending district level IMNCI (Integrated Management of Neonatal and Childhood Illness) training after getting verbal consent. All 72 respondents who had attended the training during the above mentioned period were included in this study (Medical officer, AYUSH medical officer, Maternal Child Health co-coordinators and Block Programme Officers). Data were analyzed manually using content analysis. Results: Difficulty in vaccine delivery, inadequate infrastructure and lack of sufficient manpower for smooth functioning of JSY, difficulty in card updation and difficulty in retrieval of defaulter of alcoholic TB patients for Directly Observed Treatment Shortcourse (DOTS) are some of the problems identified in general. Conclusion: The study identified the need for strengthening infrastructure and manpower to provide quality care for institutional delivery. It also emphasized the need for construction of more number of sub centre buildings which forms the backbone of rural health care delivery system. Identification of loop holes and bridging the gap by corrective action will make the journey towards Millenium Development Goal (MDG) easier.

Evaluation of Indian Rural Health Care Centre Programs: By the Application of Data Envelopment Analysis Technique

India's achievements in the field of rural health care delivery have been less than satisfactory and that burden of diseases among the rural Indian population remains high. Recognizing the importance of rural health in the process of economic and social development and necessary architectural correction in the rural health care delivery system to improve the quality of life of the citizens, the government of India has resolved to launch the National Rural Health Mission (NRHM). Indian rural health policies and programs do not address significantly to improve the health status to the desired level due to lack of efficient evaluation system. This study uses Data Envelopment Analysis (DEA) to evaluate relative efficiency of rural health care programs. A typical statistical approach is characterized has a central tendency approach and it evaluates producers relative to an average producer. DEA is commonly used to evaluate the efficiency of a number of producers. In contrast, DEA compares each producer with only the best producers. The technique optimizes the relative efficiency ratio of current inputs over current outputs for each decision-making unit (DMU). The multiple inputs and outputs of heterogeneous rural health programs would be assessed simultaneously and helps to identify whether the programs are performing efficiently or inefficiently when compared to the other existing programs. In this paper, we have focused on the evaluation of programs with particular reference to Chikmagalur District, Karnataka, India.

Epidemiological transition in a rural community of northern India: 18-year mortality surveillance using verbal autopsy

BackgroundInformation on causes of death is vital for planning of health services. However, vital events registration systems are weak in developing countries. Therefore, verbal autopsy (VA) tools were incorporated in...

An assessment of rural health care delivery system in some areas of West Bengal-An overview

A cross sectional observational study was carried out in three districts of West Bengal by following observational, quantitative and qualitative methods during July to December 2006 to find out the extent of utilization, strengths, weaknesses and gap as well as suggest recommendations in connection with health care delivery system for the state of West Bengal, India. A total of 672 episodes of illnesses were reported (2 weeks recall) by the study population of the three selected districts in three geographically separated divisions of West Bengal. None did seek care from any health facilities for treatment in case of 221 (32.89%) episodes; especially from tribal areas where in case of 76.19% none sought any health care from any facilities depended on their home remedies. In rest of episodes the (451), majority preferred government health facilities (38.58%), followed by Unqualified quacks (29.27%) due to low cost as well as living in close proximity, 27.27% preferred qualified Private practitioners and only 4.88% preferred AYUSH, as a first choice. Referral was mostly by self or by close relatives/families (61%) and not by a doctor. Awareness is required to avoid unnecessary referral. Cleanliness of the premises, face-lift, and clean toilet with privacy and availability of safe drinking water facilities could have an improved client satisfaction in rural health care delivery systems. This could be achieved through community participation with the involvement of PRI. However, as observed in the study RCH services including Family Planning as well as immunization services (preventive services) were utilized much better while there was a strong need of improvement of Post Natal Care, otherwise, Neonatal and Maternal mortality and morbidity will continue to be high.

Drexel University College of Medicine

Drexel University College of Medicine

National rural health mission: time to take stock.

The poor performance of the Indian Public Health System is widely acknowledged. Analysts have attributed this failure to a number of factors, which include almost all the components that make a system functional, that is, infrastructure, human resources, logistics, and participation of the community. However, some attribute this failure primarily to low and declining public investment in healthcare and secondarily to structural and managerial weaknesses in the system. After groping with the challenges for decades, the planners have come up with a comprehensive mission-oriented approach to revamp the rural healthcare delivery system, which was aptly named National Rural Health Mission (NRHM) [Box 1]. The mission was launched on 12 April, 2005, to be completed in a time frame of seven years.(1) By the end of 2008, the mission has lived half of its life. It is the right time to take stock of the gains and achievements and critically analyze the failures and lapses. Box 1 National Rural Health Mission Large variations exist in the health system and its performance, which is clearly evident in the fact that some states have been performing better than others in the pre-NRHM period. A need was felt by the Mission to bring the states that had been lagging behind at par. In order to provide an impetus to the primary healthcare infrastructure, so that the delivery of family welfare services could be made more efficient, the Empowered Action Group (EAG) was constituted by order of the Government of India on 20 March, 2001, as an administrative mechanism, for the purpose of closely monitoring the implementation of the family welfare program.(2) Initially it included eight states. In spite of a single window clearance mechanism for approving schemes to finalize strategies and address gaps in the ongoing programs, the states failed to show a desirable improvement in health indicators. Thus the mission focused on 18 poorly performing states, which included eight North Eastern states, eight Empowered Action Group (EAG) states, and the hilly states of Himachal Pradesh and Jammu and Kashmir.(3) The NRHM framework represents a conscious decision to strengthen public health systems and the role of the state as a healthcare provider [Figure 1]. It also recognizes the need to make optimal use of the non-governmental sector to strengthen public health systems and has increased access to medical care for the poor. In order to meet the core objectives of NRHM [Table 1], increasing the public expenditure on healthcare from 0.9% of GDP to 2 – 3% of GDP in an effective manner, through an increase in the central government budgetary outlay on health and ensuring a matching increase of the states' expenditure on health by at least 10% annually is one of the major steps.(3) As a corollary, the state health sector is required to develop capacities to absorb this additional fund flow. Table 1 Statistical targets of NRHM Figure 1 Organizational structure of the National Rural Health Mission The core objective of NRHM is to create fully functional health facilities within the public health system. It is expected to provide a certain service guarantee at each level of the healthcare delivery system starting from a Subcenter (SC) to a District Hospital (DH).(3) The structural correction of the health system under NRHM is based on the following five principles. (1) Setting norms and standards and achieving service guarantees, (2) Innovations in the human resource development for the health sector, (3) Increasing participation and ownership by the community, (4) Improving the management capacity and (5) Flexible financing. In a large country with inter-regional and intra-regional variations and inequalities, it is a challenging task to review the overall scenario of the mission's status in the country. However, the performance of NRHM can be reviewed under the following ten components.

Rural policy development: an NRHA and PACE association collaborative model.

The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model of comprehensive care for frail, elderly people. To date, all of the PACE programs have been located in urban areas. Rural advocates and policymakers, however, believe the program may hold great promise for use in rural areas, which have higher percentages of elderly residents than urban areas. In 2002, the National Rural Health Association and the National PACE Association convened a meeting that brought together PACE experts, policymakers, and rural health care providers to examine PACE and its applicability for rural communities. The meeting participants concluded that there were many rural communities where the PACE model might not only be appropriate but also highly successful in caring for rural, frail, elderly people. This article examines the notion of expanding the PACE model to rural communities, including some of the barriers and some of the possible solutions that might make PACE a viable part of the rural health care delivery system.

Rural hospitals: trends, challenges, and a future research and policy analysis agenda.

Previous reviews of the status of rural hospitals conclude that rural hospitals play a major role in ensuring the provision of health services in rural areas, are an essential part of the social and economic identity of rural communities, have had mixed success in their ability to respond to environmental threats, and are very sensitive to public policies due, in part, to their small size. The evolving hospital paradigm in the United States and a turbulent economic and health care environment have created an uncertain future for the rural hospital. Hospitals are being forced to shift their emphasis from filling acute inpatient care beds to providing a more diversified set of services through linkages with other institutions and provider groups. This presents challenges for rural hospitals, which often serve as the foundation for health care delivery in rural communities yet struggle to overcome the effects of troubled local economies, shortages of health professionals, and public policy inequities. This article reviews key trends and challenges facing rural hospitals from the perspective of their structure and organization, financial sustainability, quality of care provided, and strategic linkages with other entities. It concludes with the presentation of a research and policy analysis agenda that addresses the feasibility of the role of the rural hospital as the hub or coordinator of the rural health care delivery system, the fiscal viability of the rural hospital in the post-Balanced Budget Act period, strategies for measuring and improving the quality of care provided by rural hospitals, and the structure and value of horizontal and vertical linkages of rural hospitals.

Rural-Urban Differences in Depression Treatment and Suicidality

Because there are fewer per capita providers trained to deliver mental health services in rural areas, the authors hypothesized that depressed rural individuals would receive less outpatient treatment and report higher rates of hospital admittance and suicide attempts than their urban counterparts. The authors recruited 74% of eligible participants (n = 470) from a 1992 telephone survey and followed up 95% of subjects for 1 year. The authors collected data from subjects on psychiatric problems and service use and from insurers/providers on treatment and expenditures. Although there were no rural-urban differences in the rate, type, or quality of outpatient depression treatment, rural subjects made significantly fewer specialty care visits for depression. Depressed rural individuals had 3.05 times the odds of being admitted to the hospital for physical problems (P = 0.02) and 3.06 times the odds of being admitted for mental health problems (P = 0.08) during the year. Elevated rates of hospital admittance disappear in models controlling for number of specialty care depression visits in the previous month. Rural subjects reported significantly more suicide attempts during the period of 1 year (P = 0.05). Additional work is warranted to determine how to alter barriers to outpatient specialty care if the rural health care delivery system is to provide cost-effective depression care.

Antitrust Immunity in Rural Washington: A Good Answer, but What's the Question?

Abstract: State action immunity from antitrust liability has been proposed as an important tool for preserving and strengthening fragile rural health care delivery systems. Washington is a leader in the use of state action immunity, having passed a statute and having approved several applications for immunity. This paper summarizes the current status of state action immunity, both in general and in Washington, including a review of the literature and an explication of issues of particular relevance to rural areas. Additionally, a summary is presented of inter‐views with key informants in nine rural Washington communities, including an organization that had received a grant of immunity, one rural community just across a state border, and one other organization with rural operations that was given a grant of immunity. The interviews suggest that antitrust immunity, given the current interpretations of laws and guidelines by the courts, the Federal Trade Commission, and the Department of Justice, is not playing a significant role in the plans and decisions of health care providers in rural Washington. In larger rural areas, it was thought that activities could be structured to avoid antitrust liability without needing to apply for immunity; in smaller areas, there was little knowledge of antitrust issues, few resources to obtain knowledgeable advice, and little activity for which immunity might be useful. Overall, the authors did not find a large role for state action antitrust immunity in health care in rural Washington under current conditions.