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The rural health care system has changed dramatically over the past decade because of a general transformation of health care financing, the introduction of new technologies, and the clustering of health services into systems and networks. Despite these changes, resources for rural health systems remain relatively insufficient. Many rural communities continue to experience shortages of physicians, and the proportion of rural hospitals under financial stress is much greater than that of urban hospitals. The health care conditions of selected rural areas compare unfavorably with the rest of the nation. The market and governmental policies have attempted to address some of these disparities by encouraging network development and telemedicine and by changing the rules for Medicare payments to providers. The public health infrastructure in rural America is not well understood but is potentially the most fragile aspect of the rural health care continuum.

There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care. [PUBLICATION ABSTRACT]

The delivery of pediatric surgical care for gallbladder (GB) and biliary disease involves both General Surgeons (GS) and Pediatric Surgeons (PS). There is a lack of data describing how surgeon specialty impacts practice patterns and healthcare charges. We performed a retrospective review of the North Carolina Inpatient Hospital Discharge Database (2013–2017) on pediatric patients (≤18 years) undergoing surgery for biliary pathology. We performed multivariate linear regression comparing surgeons with surgical charge. 12,531 patients had GB or biliary pathology and 4023 (32.1%) had cholecystectomies. The most common procedure for PS and GS was cholecystectomy for cholecystitis (n = 509, 54.0% and n = 2275, 76.4%, p < 0.001), respectively. The hospital ($26,605, IQR $18,955–37,249, vs. $17,451, IQR $13,246–23,478, p < 0.001) and surgical charges ($15,465, IQR $12,233–22,203, vs. $10,338, IQR $6837–14,952, p < 0.001) were higher for PS than GS. Controlling for pertinent variables, surgical charges for PS were $4192 higher than for GS (95% CI: $2162–6122). The cholecystectomy charge differential between PS and GS is significant and persisted after controlling for pertinent covariates. •The delivery of pediatric surgical care for gallbladder (GB) and biliary disease involves both General surgeons and Pediatric Surgeons.•There is a lack of data describing how surgeon specialty impacts practice patterns and healthcare charges.•The most common procedure for both specialties was cholecystectomy for cholecystitis (54.0% vs. 76.4%, p < 0.001).•After controlling for pertinent variables, surgical charges for PS were $4,192 higher than for GS (95% CI: $2,162–6,122).

Health human resource (HHR) ratios are a measure of workforce supply and are expressed as a ratio of the number of health care practitioners to a subset of the population. Health human resource ratios for physical therapists have been described for Canada but have not been fully described for the United States. In this study, HHR ratios for physical therapists across the United States were estimated in order to conduct a comparative analysis of the United States and Canada. National US Census Bureau data were linked to jurisdictional estimates of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and 2005. These results then were compared with the results of a similar study conducted by the same authors in Canada. The national HHR ratio across the United States in 1995 was 3.8 per 10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The aggregated results indicated that HHR ratios across the United States increased by 61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. Although there were wide variations across jurisdictions, the data indicated that HHR ratios across the United States increased more rapidly than overall population growth in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios surpassed population growth in only 7 of 10 jurisdictions (70.0%). Despite their close proximity, there are differences between the United States and Canada in overall population and HHR ratio growth rates. Possible reasons for these differences and the policy implications of the findings of this study are explored in the context of forecasted growth in demand for health care and rehabilitation services.

Among epidemiologists, there has been increasing interest in the characteristics of communities that influence health. In the United States, the rural health disparity has been a recent focus of attention and made a priority for improvement. While many standardized definitions of urban and rural exist and are used by social scientists and demographers, they are found in sources unfamiliar to health researchers and have largely not been used in public health studies. This paper briefly reviews some available definitions of urban and rural for American geographic subunits and their respective strengths and weaknesses. For example, some definitions are better suited than others for capturing access to health care services. The authors applied different definitions to breast cancer incidence rates to show how urban/rural rate ratio comparisons would vary by choice of definition and found that dichotomous definitions may fail to capture variability in very rural areas. Further study of the utility of these measures in health studies is warranted.

Rural America has always included a wide range of economic activity beyond farming and timber and mining: many rural communities are fundamentally low-density industrial and manufacturing centers, some devoted primarily to services and others to recreation. Death rates have risen in recent years for White, lower-income and middle-income people, especially women living in rural places, as the work of Anne Case and Angus Deaton tells us.\\n National ideology has replaced the policy preferences of \"place\" If the nation is divided to maximize the separation of progressives and conservatives even in its smallest communities, who will knit up the ravelld sleeve of rural America in response to its needs?

Rural communities in the United States are served by relatively fewer health care professionals than urban or suburban areas. I review the geographic distribution of 6 classes of health professionals and describe the multiple government and private policies and programs intended to affect their geographic distribution. These programs can be classified into 3 categories--coercive, normative, and utilitarian--that characterize the major policy levers used to influence practice location decisions. Health workforce policies must be normative to ensure equity for rural communities, but goals in this area can be achieved only through a balance of utilitarian and coercive mechanisms.

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the America's Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.

Geographic information systems (GIS) and analyses based on GIS have become widespread and well accepted. GIS is not the complete solution to understanding the distribution of disease and the problems of public health but is an important way in which to better illuminate how humans interact with their environment to create or deter health.