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Publications

To receive a hard copy of an Upper Midwest Rural Health Research Center publication, please call (701) 777-3848.

  • The Use of Hospitalists in Small Rural Hospitals
    The use of hospitalists has spread to smaller rural hospitals, but no studies in the peer-reviewed literature have examined their use in these settings. This project will begin to fill the gaps in existing knowledge by examining why and how hospitalists are being used in rural hospitals and the impact of their use on the provision of inpatient and primary care in rural communities.
  • Effect of Outpatient Visits and Discharge Destination on Potentially Preventable Readmissions for Congestive Heart Failure and Bacterial Pneumonia
    This report and policy brief explores the relationship between potentially preventable readmissions (PPRs) and (a) use of outpatient follow-up care, (b) discharge destination, (c) rural versus urban residence of the patient, and (d) time to follow-up care. These factors were examined in a large population of Medicare patients with a hospital stay for one of these prevalent diagnoses: congestive heart failure or bacterial pneumonia. Differences in readmission risk associated with outpatient visits and discharge destinations were calculated. Outpatient follow-up appears to be strongly influential in reducing PPRs, though fewer than half of the patients in the study had evidence of any kind of outpatient follow-up within 30 days. Home health care appeared to have less of an effect on reducing PPRs in rural areas relative to urban areas. Swing bed destination was associated with higher PPR risk, especially for pneumonia patients. Additional research should be done on encouragement of post-discharge follow-up care and types of outpatient interventions, access to outpatient and home health care, and use of swing beds in rural areas.
  • Will Bundling Work in Rural America? Analysis of the Feasibility and Consequences of Bundled Payments for Rural Health Providers and Patients
    This report and policy brief will (1) assess the financial and quality challenges—and potential unintended consequences for rural providers and patients—of implementing bundled payments for acute and post-acute care episodes; (2) explore the possible impact on quality of care delivered under a facility-physician bundled payment system; and (3) describe potential modifications to current bundling proposals and additional steps CMS could take that will help address rural-specific issues.
  • Developing Quality Measures and Communication Strategies for Rural Patient Transfers - This report and policy brief look at care coordination with a focus on the transitions from inpatient care back to the rural community. It suggests ways of measuring the quality of care coordination on discharge from the hospital.

  • Nurse Staffing and Rural Hospital Performance Improvement - This policy brief examines the impact of nurse staffing on rural hospital performance improvement in the CMS/Premier Inc. Hospital Quality Incentive Demonstration project. Higher RN staffing hours per patient day are associated with higher scores on composite quality measures for pneumonia, heart failure, acute myocardial infarction and a hospital-wide composite score.

  • Geographic Differences in Potentially Preventable Readmission Rates in Rural and Urban Hospitals - Potentially preventable hospital readmissions (PPRs) among Medicare patients are examples of inefficiencies in the health care system. Policymakers are considering efforts to measure and publicly report preventable readmission rates and target hospitals with high rates for improvement by means of payment policy and technical assistance. To help inform the policy debate about readmissions of rural patients, this study estimated PPRs in three types of acute care hospitals: urban prospective payment system (PPS) hospitals, rural PPS hospitals and Critical Access Hospitals (CAHs).

  • The Impact of Freestanding Ambulatory Surgery Centers on Rural Community Hospital Performance - This study uses a retrospective analysis of data on rural hospital, ambulatory surgery center (ASC), and market characteristics for the years 1997 through 2006 to assess the impact of freestanding ASCs on rural hospital performance.

  • Patient Assessments and Quality of Care in Rural Hospitals - This report and policy brief analyze the relationships between rural patients' perspectives of hospital quality of care and key hospital characteristics that may influence patients' experiences of hospital care; and assess whether rural patients' perspectives of hospital quality of care are related to quality measures focused on the provision of recommended care for medical conditions.
  • Potentially Preventable Readmissions in Rural Hospitals - A hospital's potentially preventable readmission rate is a quality indicator receiving considerable attention from policymakers and payers. Using 3-M algorithm software and Medicare inpatient claims data from five states, this brief examines potentially preventable readmission rates for rural and urban hospitals, and discusses the rural implications of policy initiatives to reduce readmission rates.
  • Rural Issues Related to Comparative Effectiveness Research and Dissemination - Comparative effectiveness research, which compares the costs and benefits of different treatments for specific diseases or conditions, has the potential to improve the quality and reduce the costs of health care. This brief describes strategies for expanding clinical research in rural environments; implementing practice guidelines in rural settings; and improving access to current evidence-based information for rural health professionals and patients.

  • Health Information Technology Policy and Rural Hospitals - Health information technology (HIT) is a key component of plans to reform the health care system. HIT adoption among smaller rural providers has lagged behind larger urban providers, and the vast majority of research on HIT has focused on its adoption and impact in urban institutions. This brief summarizes the implementation status of key HIT applications in Critical Access Hospitals and other rural hospitals, and discusses policies for encouraging HIT adoption in rural hospitals.

  • Rural Issues Related to Bundled Payments for Acute Care Episodes - Bundling Medicare payments, i.e., providing a fixed payment for a set of acute and post-acute services, has been proposed as a way of encouraging providers to find innovative, cost reducing strategies to provide better coordinated care. This brief describes challenges to implementing bundled payments in rural settings and discusses potential contracting and reimbursement strategies to address these challenges.

  • Implementation of Telepharmacy in Rural Hospitals: Potential for Improving Medication Safety - Findings from this new report and policy brief describe successful telepharmacy activities being implemented in rural hospitals and analyze policy issues related to the implementation of telepharmacy projects in rural hospitals.

  • Far From the City: Community Orientation and Responsiveness of Rural Hospitals - A new report from the Upper Midwest Rural Health Research Center reports the findings of a national study focused on variation in hospital community orientation and responsiveness across differing rural contexts. Study findings suggest that measures of community orientation and responsiveness differ between urban and rural hospitals, and further research is needed to develop an improved, context specific, model for community benefits.

  • Health Insurance Coverage and Access to Health Care for American Indian and Alaska Native Elders - This project examines health insurance coverage and access to health care among American Indian and Alaska Native elders (Native elders) -- defined as 55 years or older. Young elders, 55 to 64 years of age, are most likely to be uninsured with one-third reporting having no insurance, while 15% of older elders, 65 years of age and over, report they are uninsured. Uninsured Native elders are about twice as likely as insured Native elders to indicate they have no regular provider. In addition, one out of 10 Native elders report they were not able to get care when they needed it during the preceding 12 months. Reasons cited for not getting health care when it was needed included long waiting times, transportation problems, and cost. The authors conclude it is essential to develop policies that address the financial, geographical, and cultural aspects that negatively impact access to culturally appropriate healthcare.
  • Implementing Patient Safety Initiatives in Rural Hospitals: An Evaluation of the Tennessee Rural Hospital Patient Safety Demonstration - The Tennessee Rural Hospital Patient Safety Demonstration project included: 1) the implementation of three patient safety initiatives in eight rural Tennessee hospitals using a collaborative model and 2) an evaluation of the process and tools used in the implementation to inform future rural patient safety initiatives. Staff from the Tennessee Hospital Association, Q-Source (the state quality improvement organization), BlueCross BlueShield of Tennessee and the University of Southern Maine all provided technical assistance and resources to the hospitals. The Upper Midwest Rural Health Research Center evaluated the project.
  • Rural Emergency Department Staffing: Implications for the Quality of Emergency Care Provided in Rural Areas - The purpose of this project was to describe rural emergency department staffing nationally and to assess the potential implications of staffing for the quality of emergency care provided in rural areas. A national telephone survey of a random sample of rural hospitals with less than 100 beds was conducted in June to August 2006. The study found that the majority of rural hospitals use more than one type of staffing to cover their Emergency Department (ED), including combinations of physicians on their own medical staff, contracts with emergency physician management groups and with individual physicians, and physician assistants and nurse practitioners. The study concluded that it is important to ensure that the family physicians, internists, PAs, NPs and nurses who staff rural EDs have the expertise and technical skills needed to provide optimal ED care, and that rural ED staff may benefit from additional continuing education opportunities, particularly in terms of specialized skills to care for pediatric emergency patients and trauma patients and training in working effectively in teams.

    • Policy Brief
    • Request a copy of the full report at: raasc001@umn.edu
    • Casey, M., Wholey, D. and Moscovice, I. “Rural Emergency Department Staffing and Participation in Emergency Certification and Training Programs.” Journal of Rural Health, 24(3):253-262, 2008.
  • Ambulatory Care Sensitive Condition Hospitalizations Among Rural Children - Ambulatory care sensitive conditions (ACSCs) are conditions for which inpatient hospital admissions could potentially be avoided through better outpatient care. Using hospital inpatient discharge data from six states, this study examined the relationships between children’s inpatient hospitalizations for ACSCs, rural residence, poverty, health insurance, and physician supply. Admission rates for five conditions were examined: asthma, diabetes short-term complications, gastroenteritis, urinary tract infection and perforated appendix. Hospitalization rates for four of the five conditions are significantly higher for children living in rural areas than in urban areas. Condition-specific ACSC hospitalization rates for children also vary significantly across states, even after adjusting for rurality, poverty, uninsurance, and physician supply.
  • Hospital Size, Uncertainty and Pay-for-Performance - Examines whether hospital size impacts the ability to identify hospitals' performance in a pay-for-performance demonstration project based on hospital rankings. Using data from the Premier Hospital Quality Incentive Demonstration and the Centers for Medicare and Medicaid Services' Hospital Compare, the report found that the smallest hospitals would, on average, experience five to seven times more uncertainty than the largest hospitals concerning their true relative performance for heart failure, pneumonia, and acute myocardial infarction. The authors conclude that all estimates of rank need to include adequate measures of uncertainty of those estimates.

    • Policy Brief
    • Full Report
    • Davidson, G., Moscovice, I., Remus, D. “Hospital size, uncertainty and pay-for-performance.” Health Care Financing Review, 29(1):45-57, 2007.

  • The Implementation of Pay-For Performance in Rural
    Hospitals: Lessons from the Hospital Quality
    Incentive Demonstration Project     - A new report from the Upper Midwest Rural Health Research Center reports the findings of a national study designed to identify institutional, organizational, and environmental factors that influence the experience of rural hospitals in the HQID project. Implications of those findings for future pay-for-performance (P4P) program development and strategies for helping program participants are also discussed.
  • Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety - Assesses the capacity of rural hospitals to implement medication safety practices. The study found that many small rural hospitals have limited hours of on site pharmacist coverage. About three-quarters of the hospitals are using pharmacy computers, but a significant proportion either do not have a pharmacy computer or are not using it for clinical purposes. Hospital financial status is significantly related to pharmacist staffing, the use of technology, and implementation of medication safety practices, supporting a continuation of Medicare policies to help ensure financial stability for small rural hospitals. This publication is available in two formats:

    • Press Release
    • Policy Brief
    • Working Paper
    • Casey, M., Moscovice, I., and Davidson, G. “Pharmacist Staffing, Technology Use and Implementation of Medication Safety Practices in Rural Hospitals.” Journal of Rural Health, 24(4), 321-330, 2006.

Other related working papers, monographs, and publications can be found at: