1. Chronic Disease in Rural America Disparities and suggestions
Jan Probst, PhD
Director
NACDD Webinar
July 10, 2018

2. South Carolina Rural Health Research Center
Competitively funded research program of the Federal Office of Rural Health Policy, HRSA
Focus on rural vulnerable populations and problems
What we’ll talk about today
First, the size of the problem

3. Rural and chronic disease
“Rural” covers a lot of the US
Poorer social determinants plus clinical shortages result in higher age-adjusted death rates
Interventions must work within socio-economic and financial constraints
Multi-sectoral partnerships are essential

4. Definitions: the rural US
Map displays the national distribution of counties by metro, and nonmetro-status.

5. Why rural America is important
~20% of Americans (60M people) live in the rural US*
>90% of US is rural
The rural economy is critical to the nation:
Agriculture and related industries account for 5.5% of GDP (2015) and 11.0% of total US employment (2016)**
Only 10% of US physicians are located in rural*** * **
***Rosenblatt, Hart 2000

6. Chronic disease disparities are long-standing
3 of 5 leading causes of death in rural are chronic diseases
Source: Moy et al, SS 6601, 2017

7. Diabetes example Best case (suburbs) versus remote rural:
Diabetes prevalence across the US, : Metro 9.7%, Rural 11.5%.
Source: Author’s analysis of mortality data from CDC Wonder

8. Increasing disparities in diabetes deaths
Source: Author’s analysis of mortality data from CDC Wonder

9. Sources of chronic disease disparities
Prevalence:
Metro counties: 9.7%
Rural counties: 11.5%
Differences in social determinants of health

10. Higher poverty rates
Say why people don’t leave

11. Lower educational attainment
Educational attainment, adults 25 and older, by residence, 2016
51% of rural adults, versus 39% of urban adults, have a high school education or less
Disparities will not end quickly: 17% of rural adults ages lack a high school diploma, versus 13% of similar urban adults
Source: Data from

12. Lack of health insurance

13. Sources of chronic disease disparities
Differences in prevalence
Differences in social determinants of health
Differences in service availability
Fewer preventive services
Fewer practitioners
Reduced care management resources

14. Diabetes prevention
CDC lists 1,787 diabetes prevention programs on its registry
But these are concentrated in urban areas:
Within 20 miles of (Columbia, SC, 11.1% diabetes prevalence in 2013): 12 programs
Within 20 miles of (Barnwell, SC, 17.3% diabetes in 2013): 1 program
Within 50 miles of (Beaver, OK: 13.4% prevalence): 0 programs
Source: Rutledge et al MMWR 66:10

15. Diabetes treatment Primary care physician/population ratio:
Metro counties: 8 physicians per 10,000
Rural counties: 5 physicians per 10,000
Proportion of physicians who are 35 or younger:
Metro: 18.4%
Rural: 8.1%
Similar disparities for RNPs per 10,000: 6 metro, 5 non-metro
And for PA’s: Metro 4, non-metro 3
Source:

16. Rural hospital loss Rural hospital closures Why closures matter:
present: 83 closures
> 600 rural hospitals deemed financially vulnerable
Why closures matter:
Loss of emergency care
Loss of physicians
Loss of pharmacy services

17. Protecting rural providers is vital
Certain facilities receive modestly higher reimbursement from Medicare & Medicaid
Critical Access Hospitals
Rural Health Clinics
Detailed list ….
These policies are a frequent target for budget reduction, but they are critical for rural survival
Be informed…
From more recent RUPRI artice: rural sole independent pharmacy closures (total of 924 from March 2003 to December 2013), which peaked in 2008.
Source: RUPRI, 2013

18. Diabetes patient education
62% of rural counties do not have an ADA or ADEA recognized diabetes self management education (DSME) program.
Existing DSME programs are located in counties with lowest SDOH disparities:
greater proportions of insured persons
lower rates of unemployment
lower proportion population with high school education
Source: Rutledge et al MMWR 66:10

19. How do we improve rural outcomes?
Remember that rural …
Exists (surveillance) and
Is not small urban (adaptation)
Identify best practices for chronic disease management in rural communities
Create multi-institutional approaches within health care
Create multi-sectoral partnerships to address social determinants

20. The golden rule of interventions:
No money, no mission
Interventions that are not billable are not supportable

21. Be cautious of technology solutions
Areas in purple or orange are deemed un- or underserved by the FCC and are eligible for federal support to expand broadband
Areas in purple or orange are deemed un- or underserved by the FCC and are eligible for a federal support fund to expand broadband.
Source:

22. Resources for identifying best practices
Rural Health Information Hub

23. Resources for identifying best practices
State Offices of Rural Health
One in every state
Organization location varies: state health department, university settings, 501.c.3 organizations
Grant funding through the Federal Office of Rural Health Policy, HRSA, USDHHS
Contact information: National Organization of State Office of Rural Health – nosorh.org

24. Multi-institution partnerships
Federal Office of Rural Health Policy
Multiple grant programs
Community-oriented grants require the participation of a minimum of 3 distinct organizations, such as a hospital, an FQHC, and a local health department.

25. Potentials for partnership
USDA: extension and economic development
Grantmakers in Health

26. Wrapping up… “Rural” covers a lot of the US
Social, economic disparities  chronic disease disparities
Evidence-based rural interventions are available
Multi-sectoral partnerships are essential
Make the case for rural!

27. Thanks! Our web site: Core funding from: Contact: rhr.sph.sc.edu
Federal Office of Rural Health Policy, Health Resources & Services Administration, USDHHS
Contact:

28. Sign up for our email alerts!
The Rural Health Research Gateway provides access to all
publications and projects from eight different research centers.
Visit our website for more information.
ruralhealthresearch.org
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ruralhealthresearch.org/alerts
Center for Rural Health
University of North Dakota
501 N. Columbia Road Stop 9037
Grand Forks, ND 58202