Online training could help rural doctors offer better mental health care

More than half of all U.S. mental health care takes place at the primary-care level, and that percentage is even higher in rural areas, where mental-health doctors are often hundreds of miles away, reports Newswise, a research-reporting service. A new online training program could help rural primary-care doctors better treat patients with mental health issues, and that could be important in Kentucky.

The Behavioral Health Education Center of Nebraska, a part of the University of Nebraska Medical Center, designed the program. Educational Director Howard Liu said primary care doctors are overwhelmed by the amount of mental health care they must provide. Newswise reports "the goal is to help primary care providers get more comfortable as they prescribe medications and refer patients to psychiatrists and therapists." The adolescent version of the program was released last fall and is being used by doctors worldwide. The adult and geriatric version will be released this spring.

Primary care doctor Angie Brennan estimates 35 percent of all visits to her practice have been mental health related. She said there are specific rural challenges to treatment, including "reluctance to see a counselor and a lack of mental health insurance coverage – combined with an intensified fear that someone in the community will find out a patient has mental health issues." (Read more)

Sept. 13 forum in Somerset will explore how rural communities can get healthier and get better care at lower cost

"In an era of tight budgets and strained resources, Kentucky and its rural communities can no longer afford 'business as usual' in the delivery of health care services," write Susan Zepeda and Amy Watts of the Foundation for a Healthy Kentucky. "As health care costs increase and health status declines, the question becomes: How can we ensure rural Kentuckians get better health care at lower costs?"

Zepeda, the foundation's president, and Watts, is senior program officer, see "promising opportunities" for rural communities to reshape health care, such as working with local health departments and civic leaders to "create communities that support healthy behaviors" and better integrate the health system, with special attention for the chronically ill.

These and other issues and ideas for rural health are on the agenda of the foundation's ninth annual Howard L. Bost Memorial Health Policy Forum, to be held Tuesday, Sept. 13 at the Center for Rural Development in Somerset. The forum will include state and national leaders. "Rather than wait for solutions from Washington, forum speakers will share strategies Kentucky’s civic leaders can put into place at the local, state and regional levels. Many will share ways that Kentucky is already doing this," Zepeda and Watts write in an op-ed article distributed to Kentucky newspapers.

The keynote speaker will be Dr. Len Nichols, who founded and directed Health CEOs for Health Reform, a group that helped policymakers see that reform of health insurance and health-care can be reformed together. Dr. Kavita Patel, a physician and former RAND Corp. researcher now at the Brookings Institution, will bring insights on how to achieve better care and better health at lower costs. Other experts from Kentucky, Virginia, Tennessee and North Carolina will share "practical policy strategies for positive health change in these challenging times," and smaller sessions will allow participants to engage with the speakers, Zepeda and Watts write, saying the forum's goal is to "provide accessible, safe and effective health care to nearly half of Kentucky’s citizens who call rural Kentucky home." More information is available on the foundation’s website, http://www.healthy-ky.org/.

Patients in isolated rural areas have higher rates of death from chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease living in isolated rural areas "seem to be at greater risk" of death from COPD than those living in urban areas, even when "hospital rurality and volume" are taken into account, says a new study published in the latest issue of the Annals of Internal Medicine.

Researchers from Iowa City Veterans Affairs Medical Center collected data from COPD patients at 129 veterans' hospitals measuring first, 30-day mortality and then adusting for patient rurality, hospital volume, and hospital rurality. The results indicate "mortality was significantly elevated in patients living in isolated rural areas compared with those living in urban areas," regardless of patient and hospital characteristics, reports Doctors Lounge, an online medical resource for physicians, students and allied clinical professionals. (Read more)

Defenders of small, rural hospitals take issue with study that found poor patient outcomes

A recent study that concluded small, rural "critical access hospitals" have poorer patient outcomes and lower quality of care is making waves in the medical community. A federally funded monitoring team from three universities issued a response noting certain weaknesses of the study, which was published in the Journal of the American Medical Association earlier this month.

It's not news that critical-access hospitals "have room for improvement," the team wrote. "What the JAMA authors fail to report is how much CAH scores on the process of care measures have improved over time," it writes. "Our most recent trend analysis, for example, shows that CAH scores on each of the pneumonia measures increased between 9 and 22 percentage points between 2005 and 2009."

The analysis in question was performed by researchers at the Harvard School of Public Health. It focused on nearly 1,300 critical access hospitals and looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. Patients at CAHs were more likely to die, and the facilities were behind in implementing electronic health records. It also found CAHs had a smaller number of specialists like cardiologists working at them than at non-CAHs. "That doesn't sound like news to us, either," said Al Cross, director of the Institiute for Rural Journalism and Community Issues.

"Issues such as the limited supply of primary care providers, home health and hospice services, rather than the supply of specialists, should be the focus of interventions to improve rural health quality," said the Flex Monitoring Team, named after its assignment, to evaluate the Medicare Rural Hospital Flexibility Grant Program. The team is made up of researchers from the University of Southern Maine, the University of Minnesota and the University of North Carolina-Chapel Hill. (Read more)

Writing for the Daily Yonder, Dr. Robert C. Bowman, family-medicine professor at the A.T. Still University School of Osteopathic Medicine in Arizona, also took issue with the study, in part because its findings ran counter to an article that was also published in JAMA last year. That article concluded that "greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary-care physicians," Bowman quotes.

"Now JAMA has an article this year claiming lower quality of care in certain types of rural hospitals that are completely different in location, population, funding, and workforce," Bowman writes. "So what happened between last year, when patients made the difference in quality, and this year when it was location of the hospital? ... Why do sophisticated researchers, reviewers, and editors maximize the context of care sometimes (in 2010) and minimize it at other times (in 2011)?"

Bowman, founder of the Rural Medical Educators Group of the National Rural Health Association, took a jab at the researchers. "Do Harvard University researchers associated with hospitals with the most sources of income and the highest reimbursement rates even have the perspective to write about hospitals with the least lines of funding and the lowest reimbursement in each line?"

Though he takes issue with the article, Bowman said the topic "about high and lower quality critical access hospitals" is worthy of research. "Perhaps one of the problems with attempting such research is that there is little variation across rural hospitals. Perhaps that's because the system is designed to spend uniformly less on health care across rural America. . . . The end result is less care and less economic impact from health care in 30,000 zip codes with 65 percent of the U.S. population. And more care delivered in 3,400 zip codes in 4 percent of the land area." (Read more)

Small, rural hospitals with 'critical access' designation have poorer patient outcomes and lower quality of care, study finds

A study has found that small, rural hospitals with the "critical access" designation have poorer patient outcomes and lower quality of care.

The analysis, performed by researchers at the Harvard School of Public Health, focused on nearly 1,300 critical access hospitals, a designation is given to facilities that have 25 or fewer acute-care beds and are more than 35 miles away from another hospital. In return for such concessions as limiting patient stays, CAHs get extra Medicare and Medicaid reimbursements. The Rural Assistance Center reports there are 30 CAHs in Kentucky.

The study looked at the outcomes of Medicare patients who have congestive heart failure, heart attacks and pneumonia. For all three conditions, CAHs performed at a lower standard. For patients treated for heart attacks, CAHs provided care in keeping with Hospital Quality Alliance standards 91 percent of the time, compared to 98 percent at other hospitals. The difference was even larger for patients with congestive heart failure patients (80.6 percent vs. 93.5 percent) and smaller "but still significant" for pneumonia (89.3 percent vs. 93.7 percent), the report says.

Patients at CAHs were also more likely to die. They had higher 30-day risk-adjusted mortality rates for all three conditions than patients admitted to other hospitals. The study also found CAHs behind in the implementation of electronic health records, 6.5 percent to nearly 14 percent.

"Despite more than a decade of concerted policy efforts to improve rural health care, our findings suggest that substantial challenges remain," the study authors write. "Although CAHs provide much-needed access to care for many of the nation's rural citizens, we found that these hospitals, with their fewer clinical and technological resources, less often provided care consistent with standard quality metrics and generally had worse outcomes than non-CAHs." (Read more)