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Coast to Coast

Primary care physicians, whether rural or urban, are committed to quality improvement

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Full implementation of the Patient Protection and Affordable Care Act (ACA) is expected to escalate the demand for visits to primary care practitioners. That demand may be strongly felt in rural primary care practices. Although studies have found that the quality of care delivered to patients in rural areas is as good or better than care provided in urban areas, the belief persists that top-quality primary care is available only in big cities.

A study published in the February 16 online issue of The Journal of Rural Health found that, regardless of location, physicians held similar attitudes on key measures of professionalism, including the value of participating in quality improvement.

“In terms of professional beliefs and behaviors, we found that rural and urban doctors are more alike than different,” says study leader Eric Campbell, an HMS professor of medicine at Massachusetts General Hospital and director of research at the Mongan Institute for Health Policy at the hospital. “Despite our results and other evidence, the perception still exists that rural primary care is not as good as that available in cities.” Campbell and his colleagues decided to learn more about the factors driving that misperception, and the role it may play in the continuing shortage of rural physicians in this country.

The study was designed to determine whether there were differences between rural and urban primary care physicians in their professional beliefs and in their interest and participation in quality improvement activities.

For the study, a survey was sent to nearly 3,000 practicing physicians randomly selected from an American Medical Association database; slightly more than 1,800 responded. Of those who responded, 840 were family practitioners, internists, or general pediatricians. Based on zip code data, 127 respondents practiced in rural communities and 713 in urban areas.

There were no significant differences between rural and urban physicians’ attitudes regarding participation in quality-improvement activities and the importance of open communication with patients, including reporting medical errors. Rural physicians were more likely to participate in error-reduction and other quality-improvement initiatives in their practices and hospitals and in reviews of other physicians’ records, and they felt prepared to contribute to quality-improvement efforts. They also were more likely to agree that physicians should discuss the costs of care with their patients. In addition, rural physicians were more likely than their urban counterparts to have added Medicaid or uninsured patients to their practices during the preceding year.

In states that have not accepted the Medicaid expansion offered by the ACA, say the researchers, adding Medicaid or uninsured patients to a practice will place greater cost burdens on rural providers compared with those borne by urban doctors.

The researchers note that while smaller rural communities may have fewer training options, rural primary care physicians are more likely to have personal as well as professional relationships with their patients. This latter attribute, note the authors, may give the physicians a better sense of the environmental and lifestyle factors that affect their patients’ health. That same attribute also could lead to challenges when professional responsibilities conflict with patients’ expectations and perceptions.

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