Abstract
Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources. Nowhere is this more evident than in central Appalachia. Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues. We report the results of a pilot study designed to explore the need for and appropriateness of a potential intervention placed in an emergency department (ED), with the eventual goal of using the ED to link traditionally underserved patients to preventive services. We used a convenience sample of 49 ED patients to explore their characteristics and health needs and compare them with a sample of 120 case management clients participating in the Kentucky Homeplace Program (KHP), and a general sample of 3,165 Appalachian Kentuckians. The recruited ED patients had low socio-economic status, numerous health conditions, and several unmet health needs, including need for colorectal, cervical, and breast cancer screening. Compared to their KHP counterparts, more ED patients were uninsured. Participants in the ED and KHP groups had particularly low income, were less educated, and had less insurance coverage than an average Appalachian resident. Although case management services, including the KHP, have been successful in increasing access to health care by those in need, certain segments of the population remain underserved and continued to be missed by such programs. Our study suggests the need for and appropriateness of reaching out to such underserved populations in the ED and involving them into potential interventions designed to enhance preventive health services.
Keywords: prevention, community health, emergency department, rural population, Appalachia
Introduction
Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources.1–7 This is rather evident in central Appalachia, which includes 54 of 120 counties in Kentucky and has some of the most adverse socioeconomic status and health indicators in the United States.8 Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues.
To improve the ability of traditionally underserved rural residents to access preventive care, we conducted a pilot study to explore whether the emergency department (ED) of a rural hospital might serve as a useful intervention recruitment venue. A first step in this assessment was to determine whether ED users willing to enroll in an intervention project were similar to a traditionally underserved rural Appalachian population. Thus, we compared characteristics, including unmet health needs of individuals recruited via the ED with those of clients in a case management program (Kentucky Homeplace Program, KHP) and to general Appalachian Kentuckians. Although case management services, including the KHP have been successful in increasing access to medical services by those in need, certain segments of the population still may not receive adequate preventive services.
The ED was considered a potential useful intervention location for several reasons: many traditionally underserved individuals use ED as a regular source of care;9 ED use is higher among persons with family incomes below 200% of poverty,9 and the average ED wait time of approximately four hours allows time to assess needs and devise plans for medical and social services.10 Although projects to connect ED patients to a stable source of preventive services have been documented in urban settings, 11–13 to our knowledge, no published research exists on such connection in rural areas.
Methods
Setting
This was a collaborative project among the Appalachian Community Cancer Network (ACCN), a rural not-for-profit community hospital, and the KHP. All protocols were approved by the university’s institutional review board and conformed to HIPAA regulations. As a regional referral center for eight counties in eastern Kentucky (or approximately 78,000 residents), the hospital is a licensed critical access facility, located in an economically distressed county with approximately 15,000 residents.8
Recruitment and Protocols
Men and women age 18 and older who were not decisionally challenged and who presented at the ED for non life-threatening situations were screened for eligibility and willingness to participate in a research project while they waited to be seen by a health care professional. If they agreed to be screened and were eligible and willing to participate, a trained Family Health Care Advisor (FHCA) made arrangements to meet the patient in the future at a private office close to the hospital, in the patient’s home, or in another convenient location. Approximately thirty percent of those eligible declined participation, suggesting patients felt comfortable with refusal.
The FHCA undertook all the protocols. At the post-hospitalization meeting, the FHCA administered informed consent and answered any questions. Upon completion of informed consent protocols, the FHCA orally completed a standard data collection form with the participant.
Instruments/Data Sources
The standard data collection form was developed by the KHP, which employs FHCAs or lay health workers to link traditionally underserved individuals to medical, social, and environmental services.14 This form consisted of questions on socio-demographic characteristics, health history, and health needs. To compare the ED patients recruited in this study to existing KHP clients and general Appalachian Kentucky residents, we used the KHP data logs and data from the public version of the 2009 Behavioral Risk Factor Surveillance System (BRFSS).15
Data Analyses
Descriptive analyses were conducted to explore the characteristics of three samples. The BRFSS estimates were calculated using weighted data. Bivariate analyses, including one-way ANOVA, chi-square tests of independence, and Fisher’s exact tests, were used to compare socio-demographic and health-related characteristics. All quantitative analyses were conducted using Stata/IC 10.1 for Windows.
Results
Consistent with the overall demographics of the region16, all the ED patients (N=49) were non-Hispanic Whites (see Table 1). The average age was 50.51 (range, 25–89). The majority were female (63.27%) and married or partnered (55.10%). Although 57.14% reported having a high school education or GED as their highest level of educational attainment, 40.82% did not complete high school. The average monthly household income was $1,181.17 (range, $176 – $2,734). The majority reported having no health insurance (73.47%), yet having a family doctor (87.76%).
Table 1.
Description of Socio-Demographic and Health-Related Characteristics of the Emergency Department Patients, Kentucky Homeplace Clients, and General Residents of Appalachian Kentucky
| Characteristics * | ED Patients (N = 49)** |
KHP Clients (N = 120)** |
Appalachian KY Residents (n = 3,165)** |
||||
|---|---|---|---|---|---|---|---|
| Mean age, yrs, [range] | 50.51 | [25 – 89] | 47.29 | [14 – 91] | 47.07 | [18 – 96] | |
| Race/Ethnicity | White (non-Hispanic) | 49 | 100.00% | 119 | 99.17% | 98.03% | |
| 0.83% | |||||||
| Gender | Hispanic | 0 | - | 1 | 1.97% | ||
| Male | 18 | 36.73% | 47 | 39.17% | 46.98% | ||
| Female | 31 | 63.27% | 73 | 60.83% | 53.02% | ||
| Current marital status | Single/never been married | 6 | 12.24% | 19 | 15.83% | 11.18% | |
| Divorced | 11 | 22.45% | 31 | 25.83% | 9.99% | ||
| Separated | 1 | 2.04% | 7 | 5.83% | 3.10% | ||
| Widowed | 4 | 8.16% | 10 | 8.33% | 6.93% | ||
| Married/partnered | 27 | 55.10% | 53 | 44.17% | 68.80% | ||
| Mean number of adults at home, [range] | 1.89 | [1 – 5] | 1.79 | [1 – 5] | 0.71 | [0 – 4] | |
| Mean number of dependents at home, [range] | 0.82 | [0 – 4] | 0.53 | [0 – 4] | 2.23 | [1 – 5] | |
| Education, 3 categories | < High school | 20 | 40.82% | 47 | 39.83% | 19.80% | |
| = High school | 28 | 57.14% | 63 | 53.39% | 34.12% | ||
| > High school | 1 | 2.04% | 8 | 6.78% | 46.08% | ||
| Annual household income (from all sources), $ | <10,000 | 16 | 32.65% | 54 | 47.79% | 8.63% | |
| 10,000–14,999 | 10 | 20.41% | 25 | 22.12% | 7.60% | ||
| 15,000–19,999 | 13 | 26.53% | 19 | 16.81% | 13.57% | ||
| 20,000–24,999 | 5 | 10.20% | 6 | 5.31% | 10.44% | ||
| 25,000–34,999 | 5 | 10.20% | 6 | 5.31% | 13.51% | ||
| 35,000–49,999 | 0 | - | 3 | 2.65% | 13.88% | ||
| ≥ 50,000 | 0 | - | 0 | - | 32.38% | ||
| Insurance | No | 36 | 73.47% | 63 | 52.50% | 21.18% | |
| Yes | 13 | 26.53% | 57 | 47.50% | 78.82% | ||
| Have a family doctor*** | No | 6 | 12.24% | 12 | 10.26% | 18.71% | |
| Yes | 43 | 87.76% | 105 | 89.74% | 81.29% | ||
| BMI status | Underweight | 0 | - | 8 | 6.67% | 1.98% | |
| Normal weight | 13 | 26.53% | 28 | 23.33% | 28.26% | ||
| Overweight | 12 | 24.49% | 39 | 32.50% | 34.19% | ||
| Obese | 24 | 48.98% | 45 | 37.50% | 35.57% | ||
| Current smokers | No | 35 | 71.43% | 87 | 72.50% | 69.87% | |
| Yes | 14 | 28.57% | 33 | 27.50% | 30.13% | ||
| Participate in any physical activity or exercise | No | 30 | 61.22% | 61 | 50.83% | 85.42% | |
| Yes | 19 | 38.78% | 59 | 49.17% | 14.58% | ||
| Diabetes (ever told by a doctors) | No | 41 | 85.42% | 98 | 84.48% | 83.11% | |
| Yes | 7 | 14.58% | 18 | 15.52% | 14.21% | ||
| Heart disease (ever told by a doctor)**** | No | 36 | 73.47% | 91 | 77.12% | 91.96% | |
| Yes | 13 | 26.53% | 27 | 22.88% | 8.04% | ||
| High blood pressure (ever told by a doctor) | No | 33 | 68.75% | 81 | 69.23% | 61.10% | |
| Yes | 15 | 31.25% | 36 | 30.80% | 38.90% | ||
Notes:
Since the BRFSS 2009 data were weighted, only percentages are displayed for the sample characteristics of the residents of Appalachian Kentucky.
The total number of respondents for each variable may differ due sporadically missing or incomplete data.
In the BRFSS 2009, the question is “Do you have one person you think of as your personal doctor or health care provider?”
In the BRFSS 2009, the question is “Has a doctor, nurse, or other health professional ever told you that you had angina or coronary heart disease?”
Nearly half (48.98%) were obese. The majority (71.43%) did not report ever using tobacco products; 5 (35.71%) out of 14 (28.57%) current smokers had tried to quit smoking. Fewer than half reported participating in any physical activity or exercise (38.78%); 7 (14.58%) reported diabetes, 13 (26.53%) heart disease, and 15 (31.25%) high blood pressure (see Table 1).
Of those ED patients age 50 and older, 41.67% reported having never been screened for colorectal cancer (CRC). Half of the sample was in need of CRC screening.17 All the female patients age 21 through 70 reported having had at least one Pap test, but 35.71% were out of compliance with guidelines on cervical cancer screening.17Of those women age 40 and older, 4 (14.29%) never had a mammogram, and 53.57% were in need of screening.17 Other health-related needs of the ED patients are presented in Table 2.
Table 2.
Description of Screening Status and Health-Related Needs of the Emergency Department Patients
| Screening status and needs (N = 49*) | |||
|---|---|---|---|
| Ever had CRC screening if age > 49 | No | 10 | 41.67% |
| Yes | 14 | 58.33% | |
| CRC screening modality | Colonoscopy | 10 | 71.43% |
| FOBT | 2 | 14.29% | |
| Sigmoidoscopy | 1 | 7.14% | |
| Colonoscopy/FOBT | 1 | 7.14% | |
| Patients in current need of CRC screening | No | 12 | 50.00% |
| Yes | 12 | 50.00% | |
| Female patients 21–70 yrs ever had a Pap test | No | 0 | -- |
| Yes | 28 | 100.00% | |
| Female patients in current need of a Pap test | No | 18 | 64.29% |
| Yes | 10 | 35.71% | |
| Female patients 40 yrs & older ever had a mammogram | No | 4 | 14.29% |
| Yes | 24 | 85.71% | |
| Female patients in current need of a mammogram | No | 13 | 46.43% |
| Yes | 15 | 53.57% | |
| Additional services needed** | Diabetes management | 10 | 20.83% |
| Mental health assistance | 12 | 25.00% | |
| Medication assistance | 28 | 58.33% | |
| Substance abuse assistance | 0 | -- | |
| Tobacco cessation | 1 | 2.08% | |
| Other*** | 32 | 66.67% | |
Notes:
The total number of respondents for each variable may differ due sporadically missing or incomplete data.
Respondents were asked to check all that applied, thus, the percentages will not add up to 100%.
Other included cancer care/testing, eye exams, help finding a doctor, assistance acquiring glasses, hearing aids, dentures, help with medical bills, etc.
Although there were some differences in socio-demographic characteristics among the ED patients, KHP clients, and general Appalachian residents, the only statistically significant difference was in insurance status (p-value <0.012): more ED patients had no health insurance (73.47%) than KHP clients (52.50%). In comparison, 21.18% of the general Appalachian residents reported having no health insurance. More ED patients reported having a high school education or GED (57.14%), and fewer reported having more than a high school education (2.04%), than KHP clients (53.39% and 6.78%) and general Appalachian residents (34.12% and 46.08%). Reported annual household income of both the ED and KHP patients was lower than of the general Appalachian population: 8.63% of the BRFSS sample reported having annual income under $10,000, and 32.38% reported having annual income above $50,000; whereas 32.65% and 47.79% of the ED and KHP samples, respectively, reported having annual income under $10,000, and none of the ED and KHP clients reported having annual income above $50,000.
Although not statistically significant, 48.98% of the ED sample was obese, compared to 37.50% of the KHP and 35.57% of the BRFSS samples. All three samples had similar percentages of current smokers. More KHP clients reported participating in physical activity (49.17%) than the ED patients (38.78%) and general Appalachian residents (14.58%). Additional description of socio-demographic and health-related characteristics is presented in Table 1.
Discussion
The individuals recruited in our pilot study via the ED had low SES, numerous health conditions, and several unmet health needs, including need for CRC, cervical, and breast cancer screening. Although BRFSS data demonstrated overall substandard health profiles of Appalachian residents, the KHP and ED participants were particularly disadvantaged, with lower income, less education, and less adequate insurance status than an average Appalachian resident. Compared to their KHP counterparts, more ED patients were uninsured.
To explain the high level of need and higher percentage of uninsured in the ED sample, we speculate that the ED patients might fit into the category of the working poor.18 Although overall the sample of both the ED and KHP participants had incomes lower than an average Appalachian resident, a greater proportion of the ED patients had higher incomes than the KHP clients, possibly earning just enough income to disqualify them for public assistance, yet too little to afford private insurance or higher quality care and procedures.18 Previous research has demonstrated that the working poor are less likely to receive recommended preventive care than working non-poor.19 Our study adds to existing research by suggesting that these working poor may be unaware of case management programs for which they may be eligible. Alternatively, some of the ED patients may earn slightly too much income to qualify them for KHP or other case management programs.
Although the majority of the ED patients reported having a regular physician, the especially high level of need for preventive services suggests that these patients may not receive adequate primary care without intervention through case management or other programs. Coupled with their working poor status and no health insurance, realities of limited primary care access in rural contexts account for this.20
Our study has several limitations, including modest sample size, convenience sampling, use of data based on self-report and the standard form developed for KHP monitoring rather than research purposes, and lack of extensive data allowing to compare preventive services and unmet health needs among the three samples. In addition, although certain health care need, psycho-social, cultural, and behavioral factors have been shown to play a role in willingness to participate in a research project, we lacked the necessary resources to engage participants in a comprehensive, theory-based survey. Yet another limitation is our broad focus on preventive services, limiting our ability to pinpoint which preventive services patients might accept in an intervention project.
Despite these limitations, to our knowledge, this is the first description of the characteristics of rural ED patients and how they compare with an overall Appalachian population. Although case management services such as the KHP have been successful in increasing access to health care by those in need, certain segments of the population still do not receive adequate preventive care services. Our study suggests the need for and appropriateness of reaching out to such underserved populations and involving them into future interventions designed to enhance preventive health services.
Acknowledgements
We are grateful to Samantha Bowman, Fran Feltner, Willie Bates, Carol White, Mark Dignan, and the hospital staff and patients who were instrumental in developing and conducting this research.
Financial Disclosure/Funding
This research was supported by grant funding from The National Institutes of Health/ National Cancer Institute, “Appalachian Community Cancer Network” (PI: Dignan) U01 CA114622-01.
Biographies
Yelena N. Tarasenko, M.P.H., M.P.A., is a third year student of the Doctor of Public Health program at the University of Kentucky College of Public Health.
Nancy E. Schoenberg, Ph.D., is the Marion Pearsall Professor of Behavioral Science at the University of Kentucky College of Medicine.
Keisa L. Bennett, M.D. / M.P.H., is an Assistant Professor of Family and Community Medicine at the University of Kentucky College of Medicine.
Footnotes
Declaration of Conflicting Interest
The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
Contributor Information
Yelena N. Tarasenko, Department of Behavioral Science, College of Medicine, University of Kentucky, Medical Behavioral Science Building, Lexington, KY 40536-0086
Nancy E. Schoenberg, Email: nesch@uky.edu, Department of Behavioral Science, College of Medicine, University of Kentucky
Keisa L. Bennett, Email: keisa.bennett@uky.edu, Department of Family and Community Medicine, College of Medicine, University of Kentucky.
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