Scott R. Sanders

Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection.

PURPOSE (1) To assess the prevalence of rural primary care physician (PCP) bypass, a behavior in which residents travel farther than necessary to obtain health care, (2) To examine the role of community and non-health-care-related characteristics on bypass behavior, and (3) To analyze spatial bypass patterns to determine which rural communities are most affected by bypass. METHODS Data came from the Montana Health Matters survey, which gathered self-reported information from Montana residents on their health care utilization, satisfaction with health care services, and community and demographic characteristics. Logistic regression and spatial analysis were used to examine the probability and spatial patterns of bypass. RESULTS Overall, 39% of respondents bypass local health care. Similar to previous studies, dissatisfaction with local health care was found to increase the likelihood of bypass. Dissatisfaction with local shopping also increases the likelihood of bypass, while the number of friends in a community, and commonality with community reduce the likelihood of bypass. Other significant factors associated with bypass include age, income, health, and living in a highly rural community or one with high commuting flows. CONCLUSIONS Our results suggest that outshopping theory, in which patients bundle services and shopping for added convenience, extends to primary health care selection. This implies that rural health care selection is multifaceted, and that in addition to perceived satisfaction with local health care, the quality of local shopping and levels of community attachment also influence bypass behavior.

Giant cells in pyoderma gangrenosum

It has been claimed that pyoderma gangrenosum (PG) lesions may contain granulomatous foci when associated with Crohn’s disease. To test this assertion, we obtained clinical histories and archived cutaneous biopsies from 34 PG patients. Thirteen of these patients had inflammatory bowel disease (IBD). Immunostaining with PGM1, a macrophage marker, revealed well‐formed giant cells with three or more nuclei in biopsies from 6 of 13 patients with IBD. Five of the 6 biopsies came from patients with Crohn’s disease and one from a patient with ulcerative colitis. Two were peristomal. In the 21 patients who had PG without IBD, no giant cells were seen. Thus, PGM1+ histiocytic giant cells within a PG lesion may be indicative of associated IBD (p=0.006), particularly Crohn’s disease.

Periappendageal lichen nitidus: report of a case

Background:  The histology of lichen nitidus has been described previously but a follicular variant has not been emphasized.

America's Working Poor Conceptualization, Measurement, and New Estimates

This article addresses measurement challenges that have stymied contemporary research on the working poor. The authors review previously used measurement schemes and discuss conceptual assumptions that underlie each. Using 2013 March Current Population Survey data, the authors estimate national- and race-specific rates of working poverty using more than 125 measures. The authors then evaluate the association between each measure and a latent construct of working poverty using factor analysis and develop a working poverty index derived from these results. Finally, the authors estimate multivariate regression models to identify key social and demographic risk factors for poverty among workers. The authors’ national estimates of working poverty range from 2% to nearly 19% and are highly sensitive to alternative assumptions. The authors’ analyses find that the latent construct is most highly correlated with empirical measures of working poverty that include part-time or part-year employment and that use poverty income thresholds that include both the poor and near poor. Crude rates and conditional risks of poverty among workers vary considerably among racial groups. This article provides a conceptual and empirical baseline for decisions about how best to estimate the magnitude and composition of Americas working poor population.

Middle-Aged and Older Adult Health Care Selection Health Care Bypass Behavior in Rural Communities in Montana

This study assesses the prevalence of primary-care physician (PCP) bypass among rural middle-aged and older adults. Bypass is a behavior where people travel beyond local providers to obtain health care. This article applies a precise Geographic Information System (GIS)-based measure of bypass and examines the role of community and non-health-care-related characteristics on bypass. Our results indicate that bypass behavior among rural middle-aged and older adults is multifaceted. In addition to the perceived quality of local primary care, dissatisfaction with local services, such as shopping, creates an effect that increases the likelihood of bypass, whereas strong community ties decrease the likelihood of bypass. The results suggest that the “outshopping theory,” where respondents select services in larger regional economic centers rather than local “mom and pop” providers, now extends to older adult health care selection.

Born Poor? Racial Diversity, Inequality, and the American Pipeline

The authors examine racial disparities in infants’ exposure to economic disadvantage at the family and local area levels. Using data from the 2008–2014 files of the American Community Survey, the authors provide an up-to-date empirical benchmark of newborns’ exposure to poverty. Large shares of Hispanic (36.5 percent) and black (43.2 percent) infants are born poor, though white infants are also overrepresented among the poor (17.7 percent). The authors then estimate regression models to identify risk factors and perform decompositions to identify compositional factors underlying between-race differences. Although more than half of the black-white poverty gap is explained by differences in family structure and employment, these factors account for less than one quarter of white-Hispanic differences. The results also highlight the unmet need for social protection among babies born to poor families lacking access to assistance programs and the safety net. Hispanic infants are particularly likely to be doubly disadvantaged in this manner. Moreover, large and disproportionate shares of today’s black (48.3 percent) and Hispanic (40.5 percent) babies are born into poor families and places with poverty rates above 20 percent. These results raise important questions about persistent and possibly growing racial inequality as America makes its way to a majority-minority society as early as 2043.

A Demographic Deficit? Local Population Aging and Access to Services in Rural America, 1990–2010†

Population aging is being experienced by many rural communities in the U.S., as evidenced by increases in the median age and the high incidence of natural population decrease. The implications of these changes in population structure for the daily lives of the residents in such communities have received little attention. We address this issue in the current study by examining the relationship between population aging and the availability of service-providing establishments in the rural U.S. between 1990 and 2010. Using data mainly from the U.S. Census Bureau and the Bureau of Labor Statistics, we estimate a series of fixed-effects regression models to identify the relationship between median age and establishment counts net of changes in overall population and other factors. We find a significant, but non-linear relationship between county median age and the total number of service-providing establishments, and counts of most specific types of services. We find a positive effect of total population size across all of our models. This total population effect is consistent with other research, but the independent effects of age structure that we observe represent a novel finding and suggest that age structure is a salient factor in local rural development and community wellbeing.

Overcoming Geographic Penalties of Inequality: The Effects of Distance-Demolishing Technologies on Household Well-Being in Vietnam

Geographic isolation and spatial inequality are growing issues for most countries. However, distance-demolishing technologies have been proposed as a solution of overcoming geographic barriers associated with geographic penalties. This research uses the rapid and widespread adoption of inexpensive motorcycles in Vietnam as a case study of how distance-demolishing technologies can improve household well-being. Utilising panel data from the 2004, 2006 and 2008 Vietnamese Household Living Standard Surveys, this research uses propensity score matching to isolate the effect that the introduction of a motorcycle has on household income. Our results show that new motorcycle ownership reduces spatial isolation penalties and significantly improves household well-being in Vietnam. In addition, marginalised populations, such as female-headed households and rural households, receive relatively larger returns from a new motorcycle. Our findings suggest that distance-demolishing technologies can contribute to the reduction of spatial inequality by helping households overcome both geographic and social barriers.