Rural family physicians in practices that follow model for comprehensive, coordinated care expand patients' access to care

By Melissa Patrick
Kentucky Health News

Rural family physicians who work in patient-centered medical homes generally provide more services and procedures than those in non-PCMH practices, according to a recent study at the University of Kentucky. A PCMH is not just a place, but "a model of the organization of primary care," says the federal Agency for Health Research and Quality.

"The idea of a patient-centered medical home is that you organize your services in a way to better meet the needs of the patient, and that should include being able to do more for the patient," Dr. Lars E. Peterson, lead author of the study, said in an interview. "We've shown that there is evidence that if you are in a patient centered medical home practice, if you structure your care that way, you can actually provide even more services."

Peterson is the director of research at the American Board of Family Medicine and an associate professor of family and community medicine at UK. 

The study, published by UK's Rural & Underserved Health Research Center, used data from more than 3,000 rural family physicians and compared the results according to rurality, measured by population: "large rural" (20,000-250,000), "small" rural (2,500-19,999), and "frontier" (less than 2,500).

Considering a list of 21 clinical services, the study found that rural family physicians in both the large and small rural areas who practiced at PCMHs provided more services than those who did not work in a PCMH. It didn't find much difference in services provided by in the sparsely populated areas.

The other exceptions to the overall finding were inpatient hospital care, major surgery, and nursing home care. They were provided at about the same rate in both the large and small rural areas regardless of PCMH status. Also, physicians in "small" rural areas provided home visits at about the same rate as non-PCMH physicians.

Family physicians in the "large rural" areas didn't show any real differences in obstetrical and prenatal care, but those who practiced in a PCMH in "small" rural areas provided more obstetrical and prenatal care their non-PCMH counterparts.

The study found two areas in which "frontier" PCMH family physicians out-performed their non-PCMH counterparts: chronic disease management and preventive services. All of the frontier PCMH family physicians provided chronic disease management, and 98.3 percent provided preventive care; among non-PCMH physicians, the percentages were 89.3 and 87.4, respectively.

Peterson said it's important for rural communities to find ways to increase access to care, especially in the areas of women's health and mental health, which is often lacking. He added that even with the passage of the Patient Protection and Affordable Care Act and the expansion of Medicaid to people who earn up to 138 percent of the federal poverty line, many still struggle to find health care.

"This is just another way of expanding access to patients," he said. "Within rural areas, physicians who work in practices that have a patient-centered medical home designation tend to be able to do more for their patients than physicians who are not in practices that are organized in that way."

Comparing medical procedures, researchers found that while PCMH family physicians in "large rural" areas had higher rates for eight of 18 procedures, the only two that showed a significant dfference over their non-PCMH counterparts were for in-office skin procedures (92.6 percent and 80.4 percent, respectively) and neonatal circumcisions (33.3 percent and 22.1 percent).

"Consistent with family physicians in rural PCMHs being less likely to provide inpatient care, they were also less likely to provide hospital-based procedures . . . than family physicians in rural non-PCMHs," the study report said.

The PCMH physicians in the "small" rural areas had a higher rate for 12 of the 18 procedures, but only showed significant differences over their non-PCMH counterparts for four of them.

"Family physicians practicing in PCMHs in small rural areas reported over 10 percent higher rates of providing IUD insertion, endometrial biopsies, neonatal circumcision, and office skin procedures than those practicing in non-PCMHs," the report said.

In the sparsely populated "frontier" areas, PCMH physicians had higher rates only for cosmetic procedures, though that rate was not significantly different when compared to the non-PCMH family physicians in such areas.

The report points out that while rural health-care providers tend to offer a broader range of services than their urban counterparts because of their limited health care resources, they often lack the financial and provider infrastructure needed to offer the PCMH model of care.

To that end, the report stresses the importance of creating programs to help rural practices shift to this model of care and in finding financial incentives to encourage rural family physicians already working within the PCMH model to broaden their scope of practice.

"Supporting rural practices that wish to transform to the PCMH model to improve care and access will be essential to meeting patient needs," said the report. "With strong evidence that overall health care costs and hospitalization rates are lower when physicians have a broader scope of practice, including inpatient care, determining how to best structure care by rural family physicians in all care settings will be essential."

Three articles published in The Journal of Rural Health show the importance of integrating oral health and primary-care medicine

By Melissa Patrick
Kentucky Health News

Three studies reported in the autumn edition of The Journal of Rural Health show different ways a regular health care provider can help patients get access to dental care, and all three articles say that integrating oral health and primary care would benefit patients.

The first study, using data from more than 26,000 participants in the 2012 Medical Expenditure Panel Survey, looked at whether having a "usual source of care" makes a difference in whether a person gets preventive dental checkups. A usual source of care, which researchers call a "USC," is a place where a person goes when he or she is sick or needs medical attention – not including an emergency room.

The study found that about 66 percent of individuals with a USC had a preventive checkup, while only 47 percent of individuals without a USC did.

Both rural and urban residents with a USC were 11 percent more likely to have at least one dental checkup per year. "This demonstrated that no matter where people live, having a USC was associated with a higher probability of having at least one preventive dental checkup," the article says.

However, the study also found that rural adults had "significantly lower odds" of getting an annual preventive dental exam that those living in urban areas – 51.5 percent vs. 63.4 percent, respectively.

The researchers said incorporating dental care into primary care "may help mitigate the challenges due to a shortage of oral health care providers in rural areas," and noted that previous research and the World Health Organization have recommended such integration.

The article offers an example of how this might work: "Primary care providers can be trained to provide regular dental screenings and oral health risk assessment, and oral-health care providers can help identify patients with increased risk for developing cardiovascular disease."

The article, "Preventive Dental Checkups and Their Association With Access to Usual Source of Care Among Rural and Urban Adult Residents," added that tele-dentistry and mobile dental clinics could be part of the solution to improve oral health access.

Preventive dental care is least likely in the South, where 58 percent of residents had a preventive dental service in the past year. Southern states, including Kentucky, have "a lower density" of health care providers, including dentists, the researchers noted.

They remind readers of the importance of annual dental exams: "Lack of preventive dental care can result in a higher prevalence of dental caries, periodontal disease, tooth loss, oral cancer, cardiovascular disease and other negative health outcomes, leading to a decreased quality of life."

Having usual source of care doesn't eliminate black-white disparities

The second study examined how having access to a USC affected the oral health of older adults, specifically looking at differences between African Americans and whites. It used data from more than 15,000 adults aged 50 and older from the national Health and Retirement Study.

The research also established that having a USC made dental care more likely, but the association between a USC and tooth loss in rural areas varied greatly by race, with blacks having more tooth loss than whites even if they had a USC.

The study found that 28 percent of rural blacks had lost all their teeth, compared to 18.7 percent of urban blacks, while 17.5 percent of rural whites had complete tooth loss, compared to 11.1 percent of urban whites.

The report found that both races in rural areas have substantially more tooth loss and fewer dental visits when compared to their racial counterparts in urban areas.

The same held true for dental visits, with 34.3 percent of rural blacks reporting having a dental visit in the previous two years, compared to 49.3 percent of urban blacks; 62.4 percent of rural whites had had a dental visit in the prior two years, compared to 73.5 percent of urban whites.

The study also showed sizable differences between the races in reports of a USC in both rural and urban areas. In urban areas, 88 percent of whites reported a USC, compared to 78 percent of blacks; in rural areas, 88 percent of whites reported having a USC, while only 70 percent of blacks did.

The report stressed that having a USC did not completely eliminate the differences in oral health between whites and blacks. It noted that even with a USC, older rural blacks appeared to have more tooth loss and fewer recent dental visits when compared to older rural whites.

"These findings may underscore continued disparities in community access to both health care and dental care and poorer quality of care for rural blacks," says then article, "The Role of Primary Care for the Oral Health of Rural and Urban Older Adults."

It reports that one in four adults age 60 and older have no natural teeth, "with blacks having significantly higher rates of missing teeth when compared to whites." It also found that Appalachia and the Mississippi Delta have higher rates of tooth loss than the U.S. population in general.

These regional disparities could be explained by "rapidly aging populations, a greater proportion of blacks, less fluoride in the water, and lower socioeconomic status" and "older rural populations, and particularly blacks, may also have had limited access to preventive dental care as children," the researchers write.

They conclude, "Access to primary health care was associated with improved oral-health outcomes, but it did not close the gap between whites and blacks in rural areas."

The researchers said an integration of primary and oral health care could particularly benefit older adults who smoke or have diabetes, which increases the risk of poor oral health. They also suggested that primary-care physicians need more oral-health education, and stressed the importance of new models of care, like the medical home, to better integrate geriatric dental care into the primary-care setting.

"These findings are important for public health because missing teeth may contribute to limited food choices, poorer nutritional intake, and lower quality of life," says the report.

Medical-dental referral networks help but aren't always dependable

The third article reports that collaboration between doctors and dentists works in rural areas.

The study looked at rural medical-to-dental referral networks. It involved 559 medical and dental professionals from 44 states who attended one of 10 continuing-education classes about collaboration. It also looked at whether rural health clinics, which get incentives to care for Medicaid and Medicare patients, but otherwise act a private practice, have different medical-to-dental experiences than other types of practices.

The study found that nearly half (48.7 percent) of the participants reported their medical-to-dental referral systems were dependable. A plurality (40.6 percent) said their referral system was bi-directional, meaning medical and dental practices  referred to each other; 25.9 percent reported systems that were one-directional, with medical referring to dental; 33.5 percent reported having no referral system.

The survey found no rural-urban differences. "Our study demonstrates that, in this motivated study population, medical-to-dental referrals can work well, even in rural areas," the researchers wrote.

They also found that accountable-care organizations, which work under a prevention-focused care model, were over five times more likely than rural health clinics to report dependable medical-to-dental referral systems. Federally qualified health centers, which "have long been identified as medical-dental integrators," were just over three times more likely than rural health clinics report dependable referral systems.

Practitioners with electronic health records and the ones who made referrals by way of a "warm hand-off or internal information exchange," which is typical of an ACO or hospital network, were the most likely to report they had a dependable referral system.

The report notes that the federal Health Resources and Services Administration has made recommendations on integration of oral-health and primary-care practices, but both the medical and dental participants reported dissatisfaction with communication between the professions, and better guidelines are needed, says the report.

The article points out that the Patient Protection and Affordable Care Act was written to support collaboration between health professionals through the use of electronic health records, patient-centered medical homes and accountable-care organizations. That said, the researchers said they were surprised that states that expanded Medicaid under the ACA did not report that they had a more dependable medical-to-dental referral system.

"This may reflect previous findings that increasing benefits coverage may not necessarily lead to increased dental-care utilization, especially if certain environmental, social, and economic characteristics are absent," the article says. "When enabling conditions such as reduced administrative burdens, improved oral-health prioritization, dental-care affordability, higher Medicaid reimbursement, and a better understanding of dental benefits by patients are present, effective utilization appears more likely to occur."

The study is titled "An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality."

Eastern Kentucky reluctant to accept HPV vaccination that helps prevent cervical, mouth and throat cancers

By Molly Burchett
Kentucky Health News

New research indicates that HPV, the sexually transmitted human papilloma virus, is now the leading cause of mouth and throat cancers in the United States, ranking above both alcohol use and smoking. This problem has a solution, since some cancers caused by HPV can be easily prevented by vaccination, but many Kentucky women are stiff-arming the solution as researchers found they "literally could not give the vaccine away to young women" in Eastern Kentucky.

In Kentucky, vaccination rates remain low, particularly in the east, where the percentage of women who die from cervical cancer is significantly greater than in the rest of state or the nation, notes Tom Collins in a recent Lexington Herald-Leader article. Collins is the associate director of the University of Kentucky's Rural Cancer Prevention Center, which initiated a project to explore the acceptance of the HPV vaccine.

Read more here: http://www.kentucky.com/2013/06/30/2698240/rural-kentucky-slow-to-embrace.html#storylink=cpy

Since 2000, scientists have known that certain strains of HPV are responsible for nearly all cervical cancer in women, and newer studies link HPV to head and neck cancer for many men too. This year, about 14,000 people in the United States will be diagnosed with oropharyngeal cancer, most of them will be young, between 40 and 50 years old and 75 percent will be male, says a Newswise article. A decade ago, patients with head and neck cancer were smokers or drinkers, but now 80 percent of the cancers are caused by HPV.

About half of all Americans will become infected with HPV at least once their lifetime and it's difficult to recognize the symptoms of the virus, making vaccination even more important. The federal Centers for Disease Control and Prevention now recommends that boys and girls both be vaccinated against HPV between the ages of 11 and 12 and up to the age of 26, says Collins.

Collins writes that Eastern Kentucky is slow to accept the vaccine, even when promoted at community events such as hog roasts. Despite the initial reluctance, "Researchers at the center hope that if a community is engaged in the process and allowed to direct the delivery of the necessary change, outcomes can be achieved that will lead to a healthier population," he Collins.

And, there's still hope. The national prevalence of infection in young women has declined by more than half since the introduction of the HPV vaccine, despite low vaccine usage, says recent findings by the CDC. This decline occurred even though only a third of eligible patients received the vaccine, so imagine the benefits afforded to Kentuckians with efforts to improve vaccination acceptance and usage.

Doctor shortage news: Residencies are filling the pond with primary care doctors, but U.S. and Ky. need an ocean of them

Despite a critical shortage of primary care in the country, only 25 percent of newly educated doctors go into this field, and even worse for the mostly-rural Kentucky, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The report, which was just released in the “Published Ahead-of-Print” section in Academic Medicine,  suggests that not only are we facing a primary care shortage, but also that the problem is not likely to be solved soon. There's been a lot of talk about the need to get primary care doctors to practice in Kentucky, specifically in the state's rural areas, without mention of the underlying issue that the study makes clear: there are not even close to enough doctors being trained as primary care physicians in the first place.

In addition to finding that just 4.8 percent of the graduate medical education system practiced in rural areas, 198 institutions (26 percent) produced no rural physicians and 283 institutions (37 percent) produced no Federally Qualified Health Center or Rural Health Clinic physicians, which were created to enhance the provision of primary care services in underserved communities.

“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said lead study author Dr. Candice Chen, a professor at SPHHS. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

Currently, the U.S. is producing primary care physicians at rates that are “abysmally low” and unless changes are made to the system, the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act ramps up demand for these services, said Chen in a Newswise release. And in Kentucky, the additional need for primary care doctors as a result Medicaid expansion is piled onto the heap of issues.

The study's authors said policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable graduate medical education system. It is critical to find a better balance in medical specialties and more primary care physicians to build an effective, affordable health system.

Oral health care for the poor in Kentucky suffers under managed care as dentists leave Medicaid; how about your county?

Kentucky's serious oral-health problems are getting worse because fewer dentists are participating in the Medicaid program -- a result of "new paperwork issues compounding Medicaid's reputation" for low payments to providers, Laura Ungar reports for The Courier-Journal.

Ungar's source for that is Dr. Raynor Mullins of the College of Dentistry at the University of Kentucky, who told her that only 700 to 800 of the state's nearly 2,500 dentists, about 30 percent, accept Medicaid patients.

That makes now seem like a good time for journalists to ask their local dentists if they accept Medicaid -- and if not, why not; and if so, whether they are considering dropping it.

Ungar notes that 28 of Kentucky's 120 counties are deemed not to have enough dentists to serve the local population. Most if not all of them are rural. You can find out which counties are under-served by physical, dental or mental health providers at this federal Health Resources and Services Administration website.

Experimental concentrated breast cancer radiation therapy offers new options for women who live far away from treatment facilities

A study at the University of Louisville James Graham Brown Cancer Center designed to make  radiation treatment more accessible to women who face obstacles such as distance, transportation problems and time constraints is proving promising. The idea is to cut daily trips to the cancer center to once a week, says Dr. Anthony Dragon, a radiation oncologist at U of L. It also has the added benefit of cutting treatment costs by better than half.

Laura Ungar of The Courier-Journal in Louisville reports that Dragun led a previous study that found that "about a third of Kentucky women with early-stage breast cancer didn’t get recommended radiation treatments after lumpectomy surgery. Among those least likely to get radiation were rural Kentuckians, the elderly, African Americans and women in the Appalachian region of the state. Women who did not get recommended radiation were 60 percent more likely to die during the time they were studied."

Dragun told Ungar that the folks at U of L were not satisfied with just gathering those numbers, they wanted solutions to the problem. Dragun said the new experimental regimen is yielding good results, with women who get weekly radiation reporting similar levels of side effects as those getting radiation every day. Ungar notes that some outside experts say the approach does seems promising, but one critic was concerned about breast appearance results after the once-a-week treatments.

According the National Cancer Institute, more than 3,070 new cases of breast cancer were diagnosed in Kentucky in 2009 and was responsible for 614 deaths.  (Read more) 

Rural teens more likely to abuse prescription meds; Operation UNITE launches 'Accidental Dealer' to guard medicine cabinets

A University of Kentucky study has shown rural teenagers in Kentucky are 26 percent more likely to abuse prescription drugs than those living in urban areas, the Lexington Herald-Leader's Mary Meehan reports. The study concludes 13 percent of teenagers living in rural areas have said they used prescription drugs recreationally. Only 10 percent of urban youths have tried them.

Dr. Jennifer Havens, right, spearheaded the study. She is a professor of epidemiology at UK's Department of Behavioral Science in the College of Medicine. "This is one of the first studies to show that hard data," she said.

Karen Kelly, director of Operation UNITE, a federally funded anti-drug program for Eastern Kentucky, said she was pleased to have the data. "We were excited when we heard about those numbers," she said. "A lot of times in small communities, people don't think there is anything to be concerned about."

The study looked at data from 17,872 participants ages 12 to 17 in the 2008 National Survey on Drug Use and Health. It showed teens are getting pills from medicine cabinets in their home, which has prompted UNITE to launch "Don't Be an Accidental Drug Dealer. The program, which Meehan reports started in Knox, Clay and Wolfe counties last week, will inform communities about prescription drug abuse through town hall-style meetings and public service announcements. (Read more)

The program has also started in Breathitt County, with a training meeting last Thursday to make volunteers and key personnel "aware about keeping the lid locked on prescription and over-the-counter medications," Jeff Noble reports for the Jackson Times-Voice. "For some that attended, the session was more than just basic information – it was an eye-opener that mirrored their concerns," Noble writes, citing a statement from Kelly: “In Eastern Kentucky, the average age of first-time drug abuse is 11 years old, so this is a particularly critical issue.” Karen Bunn, chair of the Breathitt UNITE Coalition, told Noble that the program needs volunteers to work. (Read more)