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Script:
Most people think of race and poverty when thinking of healthcare inequities, but there also exists a divide between rural and urban health care access. This divide exists not only within parts of the United States, but in rural areas of North Carolina as well. With further travel times, many rural communities are not able to manage chronic diseases as well as their urban counterparts and also experience higher mortality rates following traumatic injury.
One of the main barriers to care access for rural communities is the distance that must be traveled to receive care. Many rural communities must travel outside their communities for even primary care appointments (Arcury et al., 2005, p. 36), making access to consistent care difficult. The management of chronic illnesses requires frequent medical appointments, so the inconsistent access makes management of these conditions harder. A study from 2005 found that both rural patients and practitioners reported a higher number of barriers to care than those in urban settings when being treated for HIV/AIDS, a chronic condition (Reif et al., 2005, p.564).
Rurality is not only a barrier to primary care access, but a barrier to emergency care access as well. In one study, car accidents were shown to have a higher mortality in rural areas (Beck et al., 2017, p.1). This could be because of the longer EMS response times because response times are, on average, twice as long in rural areas as in urban ones. The delayed arrival of EMS on scene can have negative consequences for patients, as it delays the start of necessary procedures as well.
In recent years, telehealth visits have started to bridge the gap in care but are not a perfect substitution for an in person visit. While simple check-ins may be able to be performed online, treatments like dialysis—which has to be performed multiple times a week—are not able to be performed in the setting of telehealth visits, leaving patients with a continued gap in care.
North Carolina faces the same gaps in rural care as other parts of the United States, and whether through the use of community paramedics that check in on patients in their houses—a practice that is already being implemented in Durham County—or small clinics that doctors of different specialties rotate between so that many people are able to receive care even with fewer practitioners willing to work in a rural setting, there are ways to bridge these gaps in care. With some rethinking of the way care is delivered to rural communities, there are solutions that can be implemented to better provide for these populations and decrease the health inequities felt by rural communities.
Explication of Research:
Healthcare inequities and differences in healthcare access have been the subject of conversation more frequently recently because of the ongoing Covid-19 pandemic. The difference between case and vaccination rates of different populations has helped to bring these issues to light. Most people think of race and poverty when thinking of these health inequities, but there also exists a divide between rural and urban health care access. This divide exists not only within parts of the United States, but in rural areas of North Carolina as well. With further travel times compounded by higher poverty rates, many rural communities are not able to manage chronic diseases as well as their urban counterparts and also experience higher mortality rates in both acute medical cases and following traumatic injury as well. Telehealth visits have been posed as a solution, but are not effective for most conditions, leaving a gap in consistent care access. There needs to be a renewed awareness of this gap for new solutions to emerge and changes to occur.
One of the main barriers to care access for rural communities is the distance that must be traveled to receive care. Many rural communities must travel outside their communities for even primary care appointments (Arcury et al., 2005, p. 36). Such travel distances make taking time off of work or out of busy schedules to get to appointments difficult and even lowers appointment frequency within rural populations. To further complicate the issue, a study from 2005 found that because of the long distances patients must travel to receive care, those without cars went to, on average, half the number of appointments as those who own one (Arcury et al., 2005, p. 35). This observation creates an intersection point between rurality and poverty, suggesting that those who live in poverty and rural areas have an even harder time gaining access to healthcare.
In addition to location being a barrier to primary care access, it also poses an issue regarding emergency care access. Car accidents that occur in rural areas have a higher mortality than those that occur in urban ones (Beck et al., 2017, p.1). This could be because of the longer dispatch times before EMS assistance arrives, or rural population’s lower rate of seatbelt/restraint usage. One study found that in 2015 across the US, it took EMS an average of 7 minutes to get on scene to a call in urban and suburban areas, but greater than 14 minutes on average in rural areas (Mell et al, 2017, pg. 984). The delayed arrival of EMS on scene can have negative consequences for patients, as it delays the start of necessary procedures as well. In North Carolina specifically, there are six hospitals—level one trauma centers—that can treat severe traumatic injuries. Of the six, three are within 45 minutes of any point within the triangle; however, in the rural areas of western North Carolina, it can take hours to receive the same medical care that those in the triangle are able to receive in less than 20 minutes. Disparities can even be seen in Orange County specifically with the rural areas of the northern portions of the county experiencing much longer response times than those in Chapel Hill or Carrboro, leading to greater care barriers.
Management of chronic conditions is also made difficult by a rural setting where conditions such as diabetes, HIV/AIDS, and CHF (congestive heart failure) are not able to be managed closely by a doctor. When treating a chronic condition like HIV/AIDS, many clinical visits and exams are needed to ensure drug compliance and efficacy in the patient, so the harder it is to find that access every time its needed, the worse the disease outcome for the patient. A study from 2005 found that both rural patients and practitioners reported a higher number of barriers to care than those in urban settings when being treated for HIV/AIDS (Reif et al., 2005, p.564). Such barriers make disease management more difficult for rural patients. Aside from distance, rural patients reported poverty, insurance access, and even lack of adequate care as barriers to consistent treatment.
In recent years, telehealth visits have started to bridge the gap in care but are not a perfect substitution for an in person visit, as all the same procedures and tests cannot be done (CDC, 2020, paras 2-8). Major healthcare systems, such as UNC, have begun to offer these services when appropriate within North Carolina to reduce rural care inequities (UNC Health, paras 1-4), but while simple check-ins may be able to be performed online, treatments like dialysis—which has to be performed multiple times a week—are not able to be performed in the setting of telehealth visits. Management of chronic conditions such as renal failure must be done in person, and, thus, telehealth visits aren’t able to help the rural patients suffering from them.
Patients from rural populations face many barriers to seeking all types of care (primary care, care for chronic conditions, and emergency care), and while telehealth has started to make care more accessible for rural patients, but these patients will not have the same access as urban ones until there are more clinics and practitioners working in rural settings. North Carolina faces the same gaps in rural care as other parts of the United States, and whether through the use of community paramedics that check in on patients in their houses—a practice that is already being implemented in more urban counties in North Carolina such as Durham County—or small clinics that doctors of different specialties rotate between so that many people are able to receive care even with fewer practitioners willing to work in a rural setting there are ways to bridge these gaps in care. With some rethinking of the way care is delivered to rural communities, there are solutions that can be implemented to better provide for these populations and decrease the health inequities felt by rural communities.
References:
Arcury, T. A., Preisser, J. S., Gesler, W. M., & Powers, J. M. (2005). Access to Transportation and Health Care Utilization in a Rural Region. The Journal of Rural Health, 21(1), 31–38. Retrieved from https://doi.org/10.1111/j.1748-0361.2005.tb00059.x
Beck, L. F., Downs, J., Stevens, M. R., & Sauber-Schatz, E. K. (2017). Rural and Urban Differences in Passenger-Vehicle–Occupant Deaths and Seat Belt Use Among Adults. MMWR. Surveillance Summaries, 66(17), 1–13. Retrieved from https://doi.org/10.15585/mmwr.ss6617a1
Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to health care access in the rural USA. Public Health, 129(6), 611–620. Retrieved from https://doi.org/10.1016/j.puhe.2015.04.001
Mell H.K., Mumma S.N., Hiestand B., Carr B.G., Holland T., Stopyra J. (2017) Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas. JAMA Surg, 152(10), 983–984. Retrieved from https://jamanetwork.com/journals/jamasurgery/fullarticle/2643992
Reif, S., Golin, C. E., & Smith, S. R. (2005). Barriers to accessing HIV/AIDS care in North Carolina: Rural and urban differences. AIDS Care, 17(5), 558–565. Retrieved from https://doi.org/10.1080/09540120412331319750
Telehealth in Rural Communities. (2020, August 21). CDC. Retrieved from
Virtual Care (n.d.). UNC Health. Retrieved from https://www.unchealthcare.org/patient-care/virtual-care/
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