The changing social, cultural, and economic environment of rural America has contributed to an already challenging setting for providing health care education, services, and treatment.

Residents of nonmetropolitan areas account for approximately 25% (62 million) of the United States population, with about one third (20.7 million) in fair to poor health and with 50% suffering from at least one major chronic illness. Rural residents report fewer physician contacts per year as compared to their urban counterparts. Rural residents are more likely to be underinsured;^1,2 19.6% of rural residents are uninsured as compared to 16.0% among urban residents.² The tendency for rural populations to be more elderly creates an added burden on a health care system that is already overburdened.²

Rural populations also exhibit behavioral patterns that intensify poorer health outcomes, including smoking, obesity, and physical inaction that are higher than rates for urban residents.² A poorly developed health care infrastructure, compounded by social, cultural, economic, and demographic trends, promotes a poorer health status as compared to urban residents.^3-5

In spite of barriers, opportunities exist for enhancing rural health care. It is possible to improve access to care; primary care physicians and other health care providers may be made available; newer technologies may be brought to bear; coordination of rural medical services can be enhanced. Language and educational services, and health promotion and disease prevention initiatives, can be introduced or expanded while maintaining consumer choice. Some of the greatest challenges for rural health are in chronic disease treatment and prevention.

Education
A major effort is needed to educate rural Americans in emergency preparedness, nutrition, disease prevention, child and maternal health needs, behavioral health, medical care access, and acute and chronic disease health matters unique to rural America. Technologies have aided us in overcoming barriers such as distance, access to qualified educators, language differences, consistency and quality issues, and community buy-in. Technologic innovation offers opportunities for access. For example, schools, churches, and/or health facilities in rural areas may establish educational links (videoconferencing, Internet, telemedicine, or other emerging technologies) to many different providers. These encounters address general and specific needs of the community, enhancing understanding and compliance with sound medical practices.

There is also a need for coordinated health information delivery. Several states are looking for ways to leverage resources while providing the highest quality educational programming possible. To be successful, a long-term strategy must be established that includes goals, objectives, benchmarks, and ongoing evaluations of effectiveness and needs.

Acute Disease
During the past decade, policy makers have readdressed the need for acute medical access in rural areas. In some communities, rural resources have been pooled, education delivered, and communication infrastructures enhanced to facilitate triage and transport of individuals with acute life-threatening medical conditions. For example, many county employees are now trained in basic cardiopulmonary resuscitation and emergency medical first aid. Their vehicles have been equipped with first-aid kits and radios or cell phones linked to trained emergency medical personnel. Protocols have been established, and mock medical emergencies have helped identify weaknesses and strengthen the system. Enhanced communication infrastructures have facilitated the use of qualified physicians to oversee medical delivery from a distance.

COPD, a rubric term that includes chronic bronchitis, emphysema, and sometimes asthma that does not fully reverse, affects roughly 10% of the population or some 24.8 million Americans. Restrictive diseases are also common in rural America. These can include, but are not limited to, asbestosis, silicosis, sarcoidosis, hypersensitivity pneumonitis, fibrosing alveolitis, carcinoma, collagen disease, tuberous sclerosis, neurofibromatosis, idiopathic pulmonary hemosiderosis, and disease caused by exposure to inhaled organic and inorganic dusts, toxic gas exposure, drugs, poisons, and radiation. Tuberculosis, a major concern in the migrant farm and rural community, requires timely, directed, and long-term therapy for treatment to be effective and to arrest disease transmission. Compliance is not good, especially given side effects. This has prompted some states to initiate visually observed medication delivery.

Many chronic respiratory diseases are characterized by impaired gas exchange, physical deconditioning, poor nutritional status, increased dyspnea, nutritional imbalance, and a reduced quality of life. There is a lack of disability insurance underwritten in the rural sector, and often the individual afflicted by the chronic disease is the major income producer for the family. Patients with chronic respiratory diseases who are hypoxemic require supplemental oxygen. While the pathophysiologies may differ, the underlying impairments in pulmonary function, alveolar-capillary permeability, blood flow, and red cell integrity create the need for supplemental oxygen. Long-term oxygen therapy serves a crucial role in the clinical management of these patients. Some portion of this population may require oxygen for 1 or 2 months while recovering from an acute exacerbation of COPD. The selection of the most beneficial delivery system is determined by several clinical factors, as well as the overall level of activity. Cost and availability in the rural setting also come into play.

The benefits of long-term oxygen administration for the severely hypoxemic patient include improved pulmonary hemodynamics, better exercise performance and training, enhanced psychomotor performance, dyspnea reduction, reduced hospitalizations, and better survival. The survival benefit for those with severe disease does not appear to extend to individuals with mild or moderate disease. Further, the long-term benefits of oxygen delivery during sleep and exercise, while considered to be important, remain less well defined in this area.

Example: Oxygen Delivery
Oxygen is prescribed by a physician and provided by a durable medical equipment (DME) supplier. Billing is directed to private insurance, Medicaid/Medicare intermediary, or the individual. Medicare reimbursement guidelines provide for a fixed rate of reimbursement based on the physician’s prescription. For some private insurance carriers, outright purchase is a consideration. Many Medicare recipients elect to rent their equipment and have oxygen provided as part of the contract. The equipment remains the property of the DME, who is responsible for all upkeep, maintenance, and repairs as well as providing an emergency backup system.

The DME provider should be geographically located to assure the service component of oxygen therapy and anticipate delivery, repair, and emergency needs under a variety of conditions. The system supplied should be one that appropriately meets the liter-flow prescription requirement, portability needs, the ability of the patient and family to operate and care for the equipment, and availability in case the patient requires assistance. Oxygen delivery devices should be adequately tested prior to administering them to the patient. The patient should be tested during a typical exercise activity to adequately determine the exercise or activity setting. Further, oxygen needs during sleep should be evaluated based on medical history and/or complaints. If the patient has cor pulmonale in spite of adequate daytime saturations, nocturnal oximetry may be requested. The patient, caregiver, and/or immediate family should be thoroughly trained regarding use, safety, and emergency procedures to follow in the event of failure or emergency.

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the accrediting body for DME providers and other health care organizations, has renewed its review for quality planning in emergency preparedness. As part of the overall delivery of oxygen, an emergency preparedness plan with backup options should be in place and tested to ensure uninterrupted oxygen service. Typically, the provider may reside 50 to more than 100 miles from the patient, and many natural or other disaster conditions create a potential for interrupted service. Thus, it is essential that each patient have a fail-safe backup system that can provide oxygen for some period of time, allowing a safe margin to give the patient time to seek alternative health care. The amount of oxygen required is determined in part by the liter-flow delivery setting and the equipment used. Secondary considerations include the time frame to resupply oxygen through normal channels, and movement of the patient to another medical delivery point given a disaster.

Access to medical oxygen in an emergency can be problematic in the rural setting, with distance and density of services impacting heavily on decision processes. Providers are now required to identify, plan for, and test emergency preparedness in their delivery area. As part of the initial setup, providers should designate, in written format, emergency services available to the patient. Maps and contact information should be provided.

Oxygen does carry some risk in the areas of fire, explosions, burns, and electrocution. While these risks are minimal with modern equipment, careful inspection and modification of the environment, and education of the patient and family, some potential risk remains. Ongoing education is essential. The DME supplier should thoroughly inspect equipment for normal wear and tear, misuse, insect infestation, location, and other conditions requiring special attention at each home visit. During each visit, the patient and caregiver should be reeducated and deficiencies noted and fully documented for additional follow-up or referral.

A major potential for rural America is loss of electrical service for an extended period of time. This becomes a more important matter when an oxygen concentrator is prescribed. Thus, many companies suggest that the patient and family purchase a self-contained generator capable of delivering sufficient electrical service for medical and other emergency needs. The costs for a generator can range from a few hundred to several thousand dollars depending on needs, service capacity, and sophistication of the generator.

Oxygen Delivery Options
Each DME provider must work with the patient, caregiver, and physician to ensure that the method of delivery selected meets the needs of the patient, that it is affordable and reliable, and that sufficient emergency backup exists. There are three primary oxygen delivery methods and a number of different configurations.

Compressed oxygen. Compressed oxygen is the most expensive alternative, especially when considering delivery distance as a cost driver. Therefore, compressed oxygen is typically reserved to meet emergency needs, at which times the vendor will evaluate liter-flow needs, utility of a physician-ordered conserving device, and time and distance from the closest alternative or the vendor, and build in a margin of error as a safety factor.

Liquid Oxygen. Liquid oxygen is a suitable solution for patients residing at a distance, especially if the residential location is on a route typically covered by the DME supplier. For those not on the route, the location and ability to effectively service the patient must be considered. Since liquid oxygen requires routine periodic deliveries based on liter-flow use, size, and efficiency of the Dewier storage system, the DME provider must plan for contingencies with respect to delivery. These contingencies may include faster bleed-off of liquid oxygen than anticipated, inclement weather, and inability to access the region based on flooding, earthquake, or other disaster. Given that these tendencies are manageable, liquid provides a suitable alternative as a base station. When this delivery system is used in concert with a portable system, the degree of independence for the patient is increased. However, the systems are known to freeze up on occasion. Thus, alternative backups should be provided. This is usually accomplished by the stationary system such as a concentrator or through compressed gas cylinders.

Concentrators. Concentrators have been employed for many patients. These systems have seen technologic innovations over the past several years that lend themselves to more remote placement, including better and more reliable pumps, molecular sieves, circuits, warning indicators, better filtration with auto sensing, and internal diagnostic testing capabilities. Further, some concentrators have remote telephone diagnostics installed that will serve as part of maintenance. Some concentrators have the capability to refill small oxygen cylinders, providing the patient much greater independence and a portable system. A variety of different cylinders are now available, varying from the 20-plus-pound E-cylinder to lightweight cylinders that weigh less than three pounds. These systems have been shown to be safe, reliable, and easy for the patient to operate. The major drawback to standard concentrators is the need for a constant electrical source. In the event of power interruption, sufficient cylinder backups should be on-site to sustain the patient until a replacement can be delivered or power restored. If individuals live in areas prone to blackouts, emergency generators can be used to maintain operation during this period.

Summary
Rural America continues to face challenges especially as related to timely and quality health care. Many positive initiatives address both acute and chronic medical delivery and prevention. Educational efforts, technologies, and community buy-in have contributed greatly to enhancing rural health systems. Yet, many challenges remain. Ongoing education will be required to maintain and expand the knowledge base for the general public. Private and public assistance will need to continue at many levels while a consolidated strategy is formulated and implemented to enhance medical systems, assure qualified providers in underserved areas, and ensure the ongoing ability for emergency services to react to and accommodate disasters from many vantage points. Lastly, we should look for and embrace alternatives to medical delivery by expanding opportunities for certified and/or licensed allied health care providers into nontraditional areas of medicine.

Stuart H. Tedders, PhD, is an assistant professor in the Jian-Ping Hsu School of Public Health and the acting director of the Center for Rural Health and Research at Georgia Southern University, Statesboro. Brian Tiep, MD, is medical director of the Respiratory Disease Management Institute in Pomona, Calif. Rick Carter, PhD, MBA, is chair and professor of the Jian-Ping Hsu School of Public Health and Center for Rural Health and Research.

References
1. American College of Physicians. Rural primary care. Ann Intern Med. 1995;122:380-390.
2. Eberhardt MS. Urban and Rural Health Chartbook. Health, United States, 2001. Hyattsville, Md: National Center for Health Statistics; 2001.
3. Braden JJ, Beauregard K. Health Status and Access to Care for Rural and Urban Populations. National Medical Expenditure Survey Research Findings 18. Rocksville, Md: Public Health Service, Agency for Health Care Policy and Research; 1994. AHCPR Pub No. 94-0031.
4. Mainous AG, Kohrs FP. A comparison of health status between rural and urban adults. J Community Health. 1995;20:423-431.
5. Lowe S, Quill BE. Handbook of Rural Health. New York: Kluwer Academic/Plenum Publishers; 2001.