People in rural areas have more unnecessary hospital visits and are more likely to die from chronic conditions than people in cities because they have little access to specialists, according to a study by St. Louis researchers.

Researchers from St. Louis University, Washington University and Harvard studied nationwide survey and claims data from thousands of Medicare patients with chronic conditions.

They found patients who saw a specialist such as a cardiologist were 16% less likely to be hospitalized and 17% less likely to die than their urban peers. The researchers also found rural residents have higher preventable hospitalization and mortality rates.

Those two findings indicate access to specialists would prevent many rural deaths, the authors concluded.

“Access to specialist care [has] been a big problem in rural areas for a long time,” said Kenton Johnston, lead author of the study, which appeared in the latest edition of the medical journal Health Affairs. “It has particular negative consequences for people who are the most vulnerable, which are the people who are the sickest.”

Public health officials have long focused on expanding primary care in rural areas and used incentives such as student loan repayments to attract doctors to those communities, said Johnston, an assistant professor of health management and policy at SLU. The results show specialty care is just as important in keeping rural residents healthy.

“I think the medical and research community would agree primary care is important, but for people with chronic conditions, primary care is necessary but not sufficient to treating these conditions,” he said.

Primary care doctors agree there’s only so much they can do for chronically sick residents who need a specialist’s care.

“Being in primary care, we’re like the central hub of where patients go to get all their health care needs,” said Crystal Redman, a family physician at Northeast Regional Medical Center in Kirksville. “They see us first, and then we determine if they need to see a specialist and send them off.”

Patients often need to travel hours or wait for months to see a specialist in Columbia, two hours away, she said.

“The wait list can be six months to a year long,” Redman said. “They’re going to end up having to be referred further out, to St. Louis or Kansas City, which creates even more trouble in terms of transportation, or they’re going to end up in ERs to get the care they need.”

One of her patients has been coming to her for a year with a wound that won’t heal, she said. The woman needs a specialist’s help but doesn’t have reliable transportation to get to the nearest city.

"Really, it needs much more care than I’m able to provide, and she’s not able to get it,” Redman said. “At some point, she will end up in the hospital. ... Will there be a major surgery or some kind of amputation? Only time will tell.”

Doctors often don’t want to work outside cities because they can’t make as much money, Johnston said.

“In the U.S., specialists can make a lot of money, and they‘re going to get the most volume in an urban area,” Johnston said.

The findings suggest that policies such as increasing federal reimbursement rates for rural specialists and increasing the use of telemedicine could help rural patients with chronic conditions live longer, healthier lives, he said.

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