Rural Primary Care Patients Research Articles

Impact of COVID-19 on MOUD retention in a sample of rural primary care patients: A secondary analysis of electronic health records

IntroductionThere is limited research examining factors impacting MOUD retention in rural settings, especially within the context of the COVID-19 pandemic. Using electronic health records data collected as part of a NIDA Clinical Trials Network study (CTN-0102), this study explored how the onset of the COVID-19 pandemic may have impacted MOUD retention in a sample of 563 rural primary care patients. MethodsCox regression model was applied to examine if COVID-19 was related to treatment retention, controlling for demographics, clinic, insurance type, and other diagnoses. The independent variable was the number of days between the patient’s first MOUD prescription date during the pre-COVID observation period (10/1/2019–3/13/2020) and the start of the COVID-19 pandemic. The dependent variable was retention on MOUD, defined as the time from the first MOUD prescription documented during the pre-COVID observation period to the first break in consecutive MOUD prescriptions (right censored at 180 days). ResultsThe findings demonstrated that there was a reduced risk of a prescription break for every 10-day increase in the time from the first documented MOUD prescription to the onset of the COVID-19 pandemic (HR = 0.96, 95 % CI = 0.92–0.99; p = 0.011). ConclusionsWhile the data did not include complete treatment histories to determine who was new to MOUD treatment, the findings suggest that patients whose first documented MOUD prescription in the dataset was closer to the onset of the pandemic had a greater likelihood of experiencing retention challenges. This underscores the importance for clinics to establish comprehensive contingency plans for future emergencies to ensure uninterrupted MOUD treatment and support, particularly for individuals in the early stabilization phase of their recovery.

W105 - Exploring the Impact of the COVID-19 Pandemic on MOUD Retention in a Sample of Rural Primary Care Patients

W105 - Exploring the Impact of the COVID-19 Pandemic on MOUD Retention in a Sample of Rural Primary Care Patients

Medication treatment for opioid use disorder among rural primary care patients.

To investigate the prevalence of opioid use disorder (OUD) and medication treatment for OUD (MOUD) receipt in rural primary care settings and identify characteristics associated with MOUD among patients with OUD. Secondary analyses based on electronic health records of all adult patients who visited 1 of the 6 rural primary care clinic sites from October 2019 to January 2021. Mixed effects logistic regression was conducted to assess MOUD receipt (Y/N) in relation to patient characteristics (eg, demographics, other substance use disorders [SUDs], mental health disorders, and chronic pain) and the number of MOUD prescribers per clinic. The prevalence of OUD varied from 0.7% to 8.2% (Mean [SD] = 3.3% [95% CI: 0.4, 6.1]) among 36,762 primary care patients across 6 clinic sites. Among 1,164 patients with OUD, on average 50.1% received MOUD (95% CI: 28.0, 72.3). Patients in clinics with more than 3 MOUD prescribers had more than 3 times the odds of receiving MOUD (OR = 3.42; 95% CI, 1.22-9.62) as those in clinics with fewer than 3 prescribers. MOUD was positively associated with younger age (18-30 [OR = 6.97; 95% CI, 3.37-14.42], 31-64 [OR = 5.03; 95% CI, 2.64-9.57], relative to those 65 and older), having other co-occurring SUDs (OR = 3.77; 95% CI, 2.57-5.52), being male (OR = 1.50; 95% CI, 1.12-2.01), and negatively associated with having chronic pain disorders (OR = 0.69; 95% CI, 0.50-0.94). The prevalence of OUD and MOUD are high but vary considerably across rural primary care clinics; primary care MOUD prescribers play a key role on MOUD access in rural settings.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest

ObjectivesWhile primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting. Study designAn anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services. ResultsThe overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement. ConclusionOur findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services. ImplicationsA majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Internet health information seeking by primary care patients.

As patients seek health information more frequently on the internet, the impact on their health status and their relationship with doctors could be a matter of concern. The objective of this study is to know how frequently rural primary care patients seek health information on the internet and the factors associated with it. This cross-sectional study surveyed 850 patients aged over 15 years who attended two rural health centers in Cuenca (Spain). Consecutive case sampling was done. The participants were invited to answer a survey with sociodemographic and clinical aspects, and questions about possible internet searches for health information. The statistical analysis included the description of the variables and a bivariate analysis, and was completed with a logistic regression analysis. Patients' median age was 54 years, interquartile range 39-67 years; 60.9% were female. Of those surveyed, 49.8% (95% confidence interval 46.3-53.2) stated that they used the internet to seek health information. Statistically significant differences were apparent for gender, age, level of education, disease and attendance (p<0.0001). A logistic regression analysis showed an independent relationship with health information seeking on the internet for the variables gender, age, level of education (p<0.0001) and having a chronic disease (p=0.004). Roughly half the primary care patients in the rural area sought health information on the internet. Females, young people, those with a higher level of education and a chronic disease background did so more frequently.

Use of a Poverty Screening Question to Predict Social Determinants

The high correlation of poverty to social determinants of health (SDoH) suggests poverty screening could be a viable first step in SDoH screening. This study examined the relationship of SDoH to poverty and evaluated whether screening revealed needs previously unknown to providers. An SDoH Survey with an embedded poverty screening question was completed by 144 urban and 141 rural primary care patients. Nine of 10 SDoH were correlated with positive poverty screening. Needs previously unknown to providers were identified. Using a poverty screening question to identify patients needing full SDoH screening is supported, with some caveats.

The Differences in the Prevalence of Cardiovascular Disease, Its Risk Factors, and Achievement of Therapeutic Goals among Urban and Rural Primary Care Patients in Poland: Results from the LIPIDOGRAM 2015 Study.

A nationwide cross-sectional study, LIPIDOGRAM2015, was carried out in Poland in the years 2015 and 2016. A total of 438 primary care physicians enrolled 13,724 adult patients that sought medical care in primary health care practices. The prevalence of hypertension, diabetes mellitus, dyslipidaemia, and CVD were similar in urban and rural areas (49.5 vs. 49.4%; 13.7 vs. 13.1%; 84.2 vs. 85.2%; 14.4 vs. 14.2%, respectively). The prevalence of obesity (32.3 vs. 37.5%, p < 0.01) and excessive waist circumference (77.5 vs. 80.7%, p < 0.01), as well as abdominal obesity (43.2 vs. 46.4%, p < 0.01), were higher in rural areas in both genders. Mean levels of LDL-C (128 vs. 130 mg/dL, p = 0.04) and non-HDL-C (147 vs. 148 mg/dL, p = 0.03) were slightly higher in rural populations. Altogether, 14.3% of patients with CVD from urban areas and 11.3% from rural areas reached LDL <70 mg/dL (p = 0.04). There were no important differences in the prevalence of hypertension, diabetes, dyslipidaemia, and CVD, or in mean levels of blood pressure, cholesterol fractions, glucose, and HbA1c between Polish urban and rural primary care patient populations. A high proportion of patients in cities and an even-higher proportion in rural areas did not reach the recommended targets for blood pressure, LDL-C, and HbA1c, indicating the need for novel CVD-prevention programs.

Reach Outcomes and Costs of Different Physician Referral Strategies for a Weight Management Program Among Rural Primary Care Patients: Type 3 Hybrid Effectiveness-Implementation Trial.

BackgroundRural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming.ObjectiveThe purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients.MethodsA total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry–derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ≥25 and approved patients for participation to receive a personalized referral letter via mail.ResultsOut of a potential 991 referrals, 573 (57.8%) referrals were made over 16 weeks, and 98 (9.9%) patients were enrolled in the program (58/98, 59.2% female). Differences based on letter (485/991, 48.9%) versus POC (506/991, 51.1%) referrals were identified for completion (100% vs 7%; P<.001) and for proportion screened (36% vs 12%; P<.001) but not for proportion enrolled (12% vs 8%; P=.10). Patients receiving ATF were more likely to be screened (47% vs 7%; P<.001) and enrolled (15% vs 7%; P<.001) than those not receiving ATF. On the basis of the number of referrals made in each condition, we found variations in the proportion and number of enrollees (POC with ATF: 27/190, 50%; POC no ATF: 14/316, 41%; letter ATF: 30/199; 15.1%; letter no ATF: 27/286, 9.4%). Across all conditions, participants were representative of the racial and ethnic characteristics of the region (60% female, P=.15; 94% White individuals, P=.60; 94% non-Hispanic, P=.19). Recruitment costs totaled US $6192, and the overall recruitment cost per enrolled participant was US $63. Cost per enrolled participant ranged from POC with ATF (US $47), registry-derived letter without ATF (US $52), and POC without ATF (US $56) to registry-derived letter with ATF (US $91).ConclusionsLetter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources.Trial RegistrationClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557

Obesity Prevalence and Potential Comorbidities among Rural Primary Care Patients in East Texas

Objective: This study reports the prevalence of obesity among patients in a primary care clinic at a university teaching hospital in rural East Texas and explores potential disparities and comorbidities. Method: The study was a retrospective review of a deidentified, non-relinkable copy of the electronic health records for 6,955 patients who visited the Family Medicine Clinic of the University of Texas Health Science Center at Tyler North Campus between August 31, 2017, and August 1, 2018. Results: The prevalence of obesity was 43.2% with an increased likelihood of being obese among females compared to males (OR=1.49, 95%CI=1.35, 1.64), among blacks compared to whites (OR=1.24, 95%CI=1.11, 1.38), among patients 40-65 years old compared to those younger than 18 years (OR=8.83, 95%CI=7.31, 10.68) and a reduced likelihood among patients with public insurance/grants (OR=0.88, 95%CI=0.79, 0.98) and self-pay (OR=0.81, 95%CI=0.71, 0.93) compared to those with private insurance. Those who were obese were also more likely to report having hypertension (OR=2.59, 95%CI=2.35, 2.87), and diabetes (OR=3.26, 95%CI=2.85, 3.73). Conclusion: There is a high prevalence of obesity among rural primary care patients in East Texas especially among the female, minority black and 40-65 years age groups as well as among patients with diabetes and hypertension. With this facility being a teaching hospital, these findings suggest the need for increased emphasis in the training of medical Residents on the screening and management of obesity, metabolic syndrome, and associated comorbidities in these groups, with special focus on the root cause.

Forgiveness and suicidal behavior in primary care: Mediating role of future orientation

ABSTRACTForgiveness, a cognitive-emotional and behavioral reduction of negative responses to offenses, is directly related to less suicide risk, but may be indirectly related via its relation with future orientation, the ability to envision a positive future. In 100 rural primary care patients, we examined the association between self-forgiveness, other-forgiveness, and forgiveness by God and suicidal behavior, with future orientation as a mediator. Forgiveness was related to greater future orientation and, in turn, to, less suicidal behavior. Addressing the past may promote adaptive views of the future and reduce suicide risk, results suggesting potential temporal and forgiveness-based points for suicide prevention.

Depressive symptoms and interpersonal needs as mediators of forgiveness and suicidal behavior among rural primary care patients

BackgroundSuicide is the 10th leading cause of death in the US, and rates of suicide are higher in rural than urban areas. As proposed by the Interpersonal-Psychological Theory of Suicide, thwarted belongingness and perceived burdensomeness are risk factors for suicidal behavior, although protective individual-level characteristics such as forgiveness, may indirectly affect suicidal behavior by decreasing the deleterious effect of thwarted interpersonal needs. MethodA sample of uninsured adults recruited from a rural primary clinic (N=101) completed the Brief Multidimensional Measure of Religiousness and Spirituality; Suicidal Behaviors Questionnaire-Revised; Interpersonal Needs Questionnaire; and Center for Epidemiologic Studies Depression Scale. Parallel and serial multivariable mediation analyses were conducted to test for direct and indirect effects of forgiveness on suicidal behavior. ResultsIn parallel mediation, covarying depressive symptoms, forgiveness of self had an indirect effect on suicidal behavior, through perceived burdensomeness. Inclusion of depressive symptoms as a mediator revealed an indirect effect of forgiveness of self and others on suicidal behavior via depression, thwarted belongingness, and perceived burdensomeness in a serial mediation model. LimitationA longitudinal study, with an equal representation of males and diverse populations is needed to replicate our findings. DiscussionOur findings have implications for the role health providers can play in addressing suicide with rural patients. Promoting forgiveness, may, in turn affect interpersonal functioning and decrease risk for suicidal behavior.

Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study

Objective. The goal of this pilot study was to develop and field-test questions for use as a poverty case-finding tool to assist primary care providers in identifying poverty in clinical practice. Methods. 156 questionnaires were completed by a convenience sample of urban and rural primary care patients presenting to four family practices in British Columbia, Canada. Univariate and multivariate logistic regression analyses compared questionnaire responses with low-income cut-off (LICO) levels calculated for each respondent. Results. 35% of respondents were below the “poverty line” (LICO). The question “Do you (ever) have difficulty making ends meet at the end of the month?” was identified as a good predictor of poverty (sensitivity 98%; specificity 60%; OR 32.3, 95% CI 5.4–191.5). Multivariate analysis identified a 3-item case-finding tool including 2 additional questions about food and housing security (sensitivity 64.3%; specificity 94.4%; OR 30.2, 95% CI 10.3–88.1). 85% of below-LICO respondents felt that poverty screening was important and 67% felt comfortable speaking to their family physician about poverty. Conclusions. Asking patients directly about poverty may help identify patients with increased needs in primary care.

Correlates of Self-efficacy among Rural Smokers

Self-efficacy has been related to intent to stop smoking, abstinence success, and risk for relapse. Because limited research exists regarding self-efficacy among rural smokers, the current study examined correlates of self-efficacy among rural primary care patients smoking > or =10 cigarettes per day. Participants completed a telephone survey assessing demographics, smoking history, and psychosocial variables (e.g. motivation, depression). Among the 750 participants, lower self-efficacy was correlated with high depression scores, shorter previous abstinence, lower autonomous motivation, younger age, higher nicotine dependence, readiness to quit, and being female. Future studies should examine the potential to improve self-efficacy by addressing depression and autonomous motivation.

PTSD symptom clusters associated with physical health and health care utilization in rural primary care patients exposed to natural disaster

This study investigated the influence of exposure to a tornado disaster and disaster-related posttraumatic stress disorder (PTSD) symptomatology on physical health complaints and primary health care utilization among rural medical patients. One-hundred five patients completed self-report measures assessing disaster exposure, PTSD symptoms, and self-reported physical health complaints. Objective rates of health care utilization were gathered by a review of medical records. Tornado disaster exposure and generalized psychological distress were associated with physical health complaints one year following the disaster. After controlling for age, gender, and levels of predisaster health care utilization, PTSD Cluster C (avoidance) symptoms were associated with increased rates of postdisaster health care utilization. Implications of these findings for interventions within the medical system are discussed.

Rural-Urban Differences in Hospitalization Rates of Primary Care Patients With Depression

Individuals with depression in rural areas showed greater odds of hospitalization over one year than their urban counterparts in a single-state study; however, differences disappeared in models controlling for recent outpatient specialty care. To investigate whether these results are generalizable to a broader geographic area, the research team analyzed an 11-state database to test whether rural primary care patients with depression had greater odds of hospitalization over two years for physical and emotional problems, compared with their urban counterparts. Hypotheses were tested by conducting a preplanned secondary analysis of data for 1,455 patients with depression in the Quality Improvement for Depression (QID) database. This database was developed in a two-year cooperative trial that evaluated quality initiatives to improve primary care depression treatment. QID studies, including Partners in Care and Quality Enhancement by Strategic Teaming, recruited patients from rural and urban areas. Multivariate analyses demonstrated that compared with their urban counterparts, rural patients with depression had significantly higher odds of being hospitalized for physical problems (13% versus 7%, OR=1.8, 95% confidence interval [CI]=1.2-2.8, p<.01 at six months) and for emotional problems (4% versus 2%, OR=2.3, CI=1.0-5.4, p=.05 at 18 months). Hospitalization differences were not reduced in models controlling for outpatient specialty care in the previous six months. Although national studies report that all-cause hospitalization rates are comparable for rural and urban populations, rural patients with depression in this 11-site study had greater odds of hospitalization for both physical and emotional problems over two years, compared with their urban counterparts, suggesting that the potential for reducing hospitalization rates among rural patients with depression should be addressed by depression care management programs serving this population.

Correlates of Late-Life Major Depression: A Comparison of Urban and Rural Primary Care Patients

The objective of this study was to determine whether factors associated with depression differ between elderly residents of rural and urban areas. The research design was cross-sectional and observational. The study subjects consisted of 926 Medicare primary care patients (650 urban and 276 rural) who were age 65+ and cognitively intact and had enrolled in a randomized, controlled Medicare demonstration. Major depression was identified by the Mini International Neuropsychiatric Interview. A logistic regression model was estimated that included a rural-urban indicator variable, additional independent variables, and interaction terms between the rural-urban indicator and independent variables that were significant at p <0.10. A total of 8.3% of the rural and 14.8% of the urban patients were identified as having major depression. Reporting 0-1 close friends (odds ratio [OR]: 6.86; 95% confidence interval [CI]: 2.18-21.58), 2+ emergency room visits during the past 6 months (OR: 4.00; 95% CI: 1.19-13.43), and more financial strain (OR: 1.50; 95% CI: 1.01-2.23) were associated with significantly higher likelihood of major depression among rural as compared with urban patients. The SF-36 Physical Component Summary score had a curvilinear relationship with major depression and was higher for urban patients. The predicted probability for major depression is lower for the rural patients when financial strain is low, about the same for rural and urban patients when strain is intermediate, and higher for rural patients when strain is high. Clinicians in rural areas should be vigilant for major depression among patients with very few close friends, several recent emergency department visits, and financial strain.

Barriers to colorectal cancer screening in rural primary care

Background. Residents of rural communities may face unique barriers to obtaining colorectal cancer (CRC) screening, including reduced access to services. This study assessed the impact of patient, physician, and practice characteristics on rural primary care patient receipt of CRC screening. Methods. We surveyed patients ( N = 801) over 50 years of age and primary care physicians ( N = 36) in rural practices. Medical students administered surveys to assess patient demographics, self-reported CRC screening, practice features, local availability of endoscopy, and physician screening test preferences. We used multivariable logistic regression analyses to investigate associations between independent variables, and (1) patient CRC screening status and (2) adequacy of CRC discussions between physicians and patients. Results. Fifty-seven percent of patients reported being up-to-date with colorectal cancer screening and most in this group had received FOBT and endoscopy. A minority of patients (39%) reported adequate time to discuss CRC screening, and this was positively associated with being up-to-date with CRC screening in a multivariable analysis. Endoscopy was available in 58% of the practices and 44% of the practices had local gastroenterologists available on at least a monthly basis. The availability of endoscopic procedures and gastroenterological services were not associated with CRC screening or with use of endoscopy as a screening method. Conclusions. CRC screening among rural primary care patients is related to adequacy of physician CRC screening discussions but not access to endoscopic procedures. Efforts to improve CRC screening should focus on improving physician–patient discussions of CRC.

Functional impairment associated with psychological distress and medical severity in rural primary care patients.

The study examined functional impairment associated with psychological distress and severity of medical illness in a rural primary care population and explored how functional impairment varied with psychological distress and chronic medical illness. Fifty-eight patients recruited from three rural primary care clinics completed the 36-item Short Form Health Survey (SF-36) and the Typology of Psychic Distress (PsyDis). The chronic disease score, a measure of the severity of chronic medical illness, was calculated from data on use of prescription medications over a six-month period. T tests were used to determine the level of functional impairment associated with various levels of psychological distress and medical illness. Regression analyses were used to determine the proportion of variance in impairment that was explained by level of psychological distress and severity of medical illness. High levels of psychological distress explained the variance in impairment in several domains measured by the SF-36, including general health, social functioning, emotional role, and mental health, whereas a high level of severity of chronic medical illness explained the variance in impairment in physical functioning. Both high psychological distress and high severity of chronic medical illness explained the variance in impairment in vitality, and neither variable explained variance in impairment in physical role or bodily pain. In this rural outpatient primary care population, functional impairment was explained more by psychological distress than by severity of medical illness. Decreasing the burden of psychological distress among primary care patients may improve functioning.