Andrew F. Coburn PhD

Predictors of prenatal care utilization

Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive inadequate or less than adequate care. The study reported here examined the predictive power of a set of variables describing the type of financial coverage available to the mother, attributes of the mother, father and family and characteristics of the health care system. A stratified random sample of mothers was generated from state birth certificate files and surveyed through the use of a mailed questionnaire. Stratification was designed to assure adequate representation of subgroups expected to receive less adequate prenatal care. The study findings indicate that there were deficiencies in prenatal care utilization and that these deficiencies were concentrated in specific areas and subpopulations within the state. While the majority of women in the study started prenatal care in the recommended first trimester, most did not maintain the recommended schedule of visits with their care provider. The following conditions were found to reduce the likelihood of receiving adequate care after controlling for service need: younger women (particularly adolescents); less educated (particularly those without a high school education); low income; longer travel time; Medicaid recipient; and rural resident. In addition, it was found that where one lives is a significant predictor of the adequacy of prenatal care even after controlling for all of the above variables. The authors conclude that it is important in assessing potential policy and program options for reducing differentials in prenatal care use to distinguish between economic and noneconomic barriers to utilization. Receipt of Medicaid does not assure adequate prenatal care use.(ABSTRACT TRUNCATED AT 250 WORDS)

Access to rural mental health services: service use and out-of-pocket costs.

PURPOSE To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services. METHODS The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type. FINDINGS Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services. CONCLUSIONS These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.

Rural Models for Integrating Primary Care and Mental Health Services

This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Uninsured Rural Families

CONTEXT Although research shows higher uninsured rates among rural versus urban individuals, prior studies are limited because they do not examine coverage across entire rural families. PURPOSE This study uses the Medical Expenditure Panel Survey (MEPS) to compare rural and urban insurance coverage within families, to inform the design of coverage expansions that build on the current rural health insurance system. METHODS We pooled the 2001 and 2002 MEPS Household Component survey, aggregated to the family level (excluding households with all members 65 and older). We examined (1) differences in urban, rural-adjacent, and rural nonadjacent family insurance coverage, and (2) the characteristics of rural families related to their patterns of coverage. FINDINGS One out of 3 rural families has at least 1 uninsured member, a rate higher than for urban families-particularly in nonadjacent counties. Yet, three fourths of uninsured rural families have an insured member. For 42% of rural nonadjacent families, this is someone with public coverage (Medicaid/SCHIP or Medicare); urban families are more likely to have private health insurance or a private/public mix. CONCLUSIONS Strategies to expand family coverage through employers may be less effective among rural nonadjacent than urban families. Instead, expansions of public coverage or tax credits enabling entire families to purchase an individual/self-employment plan would better ensure that rural nonadjacent families achieve full coverage. Subsidies or incentives would need to be generous enough to make coverage affordable for the 52% of uninsured rural nonadjacent families living below 200% of the federal poverty level.

The Health of the Chronically Mentally Ill: A Review of the Literature

This paper reviews three areas of research on the health of the chronically mentally ill: (1) epidemiological studies on this population, (2) studies exploring the clinical interface of physical and psychiatric disorder, and (3) studies illuminating barriers to adequate health care for this population. Its purpose is to increase our understanding of the unique health problems facing the chronically mentally ill so that appropriate interventions can be developed. The review suggests that greater attention to this area should result in improved physical health as well as improved psychiatric intervention. The implications for policy, practice, and research are discussed.This paper reviews three areas of research on the health of the chronically mentally ill: (1) epidemiological studies on this population, (2) studies exploring the clinical interface of physical and psychiatric disorder, and (3) studies illuminating barriers to adequate health care for this population. Its purpose is to increase our understanding of the unique health problems facing the chronically mentally ill so that appropriate interventions can be developed. The review suggests that greater attention to this area should result in improved physical health as well as improved psychiatric intervention. The implications for policy, practice, and research are discussed.

URBAN-RURAL DIFFERENCES IN EMPLOYER-BASED HEALTH INSURANCE COVERAGE OF WORKERS

Prior research indicates that rural workers are less likely than urban workers to obtain health insurance coverage through their employer. The reasons for this differential in coverage rates are not well understood. This study uses data from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey to measure differences in the proportion of rural and urban workers who are offered insurance coverage and in their rates of participation in offered plans, and to assess the effects of firm size, wages, and other factors in explaining the residential differences. Both offer rates and participation rates are lower in rural areas, but the probability of employer-based coverage among rural workers rises to the level of that of urban workers when we adjust rural firm size and wages to urban levels. Rural firms and workers are not behaviorally different from urban firms and workers; they are, however, at a greater disadvantage because of their smaller size and lower wages.

Patterns of health insurance coverage among rural and urban children.

Despite the potential for the State Children’s Health Insurance Program to improve the health care coverage of rural children, the expansion of public health insurance to children in rural areas may be hampered by a lack of understanding about the patterns of insurance coverage they experience. This study uses the Census Bureau’s 1993-1996 panel of the Survey of Income and Program Participation to evaluate differences in the duration of, and in their entry into and exit from, uninsured spells. While the average duration of newspells was shorter for rural children and most regained coverage quickly, rural children were also more likely than urban children to experience protracted spells of uninsurance. Moreover, rural children were more likely than urban children to move between public and private coverage. These findings have important implications for designing insurance expansion programs and outreach strategies to effectively enroll and retain rural children.

Models for integrating and managing acute and long-term care services in rural areas

States and the federal government are searching for new managed-care strategies, such as capitated financing and coordinated case management, that integrate the financing and delivery of primary, acute, and long-term care services. For rural communities, the development of organizational and delivery systems, which better integrate and manage primary, acute, and long term care services, may help address long-standing problems of limited access to long-term care services. This article discusses the concept of integrated acute (medical) and long-term care service networks; model programs; challenges that health care providers, state policymakers, and others have faced in developing these new integrated structures; and the future of service-integration and coordination approaches in rural areas.

Satisfaction With Practice in a Rural State: Perceptions of Nurse Practitioners and Nurse Midwives

&NA; Data from nurse practitioners and certified nurse midwive are used to explore contributions to primary care in a rural state and how regulatory restrictiveness and other factors affect satisfaction with practice (N= 151). Satisfaction is high, especially with home communities and professional aspects of work, including collaboration with physicians. However, many feel limited by regulations and are less satisfied, especially those with a masters degree and those in organizational versus office practice sites. Reducing restrictive regulations, reevaluating practice structures, and providing for full scope of practice and other incentives consistent with rising educational levels can increase access to care.

Prioritizing Patient Safety Interventions in Small and Rural Hospitals

BACKGROUND A study was conducted in 2004 to determine if 26 interventions--distributed among nine patient safety areas and as recommended by an expert panel as relevant to rural hospitals--would be validated in terms of relevance and implementability for small and rural facilities. METHODS The chief executive officers (CEOs) and/or key managers responsible for patient safety activities in a diverse group of 29 small and rural hospitals assessed the potential effectiveness and feasibility of the 26 interventions. Representatives of 25 hospitals participated in structured, follow-up phone discussions. RESULTS Adverse drug events were the highest-priority area for 14 hospitals, followed by patient falls (selected by 5 hospitals). Some hospitals had already implemented intervention 1 (use at least two patient identifiers) and intervention 6 (read back of verbal orders) and thus ranked them highly, especially for implementability. Intervention 3 (24-hour pharmacist coverage) was ranked low, especially on implementability. Interventions involving health information technology were ranked lower by the hospitals than by the expert panel. DISCUSSION Safety interventions should reflect the general state of the science of safe practices while incorporating relevant contextual issues unique to rural hospitals. The results have important implications for survey and accreditation activity, and the focus of technical assistance and research efforts.