viders may face different safety risks. For example, given the more limited services available in rural areas, patients are more likely to be referred or transferred for diagnosis and treatment. The interfaces between personnel at different facilities, the application of standardized protocols, and the transfer of complete and relevant information all require significant attention to minimize the potential for error and ensure seamless transfers.

Effectiveness

Effectiveness refers to care that is evidence-based (IOM, 2001). Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values (Sackett et al., 1996). Such care avoids both overuse, or the provision of services that expose the patient to more potential harm than good, and underuse, or the failure to provide services from which the patient would likely have benefited (Wisconsin Medical Society, 2002).

The evidence pertaining to rural and urban differences in effectiveness is mixed. One study found that rural areas scored higher than urban on the appropriate provision of preventive services related to breast examinations/ family history for breast cancer, influenza immunization, and cholesterol screening; no differences were found in provision of preventive services for blood pressure, tobacco use screening and counseling, and mammography and pap smears (Pol et al., 2001). On the other hand, rural populations tend to be diagnosed at a more advanced stage of cancer, to be less likely to have their cancer staged at the time of diagnosis, and to have less access to state-of-the-art technology (Gamm et al., 2002). A study of elderly diabetic patients found that patients in large remote rural communities (i.e., ones that could support both generalist and specialist physicians) were significantly more likely to receive those services than their urban counterparts, while patients in smaller rural communities were less likely to receive those services than urban patients (Rosenblatt et al., 2001).

One study of interventions for acute myocardial infarction (AMI) found that patients admitted to rural hospitals were less likely to receive aspirin, heparin, intravenous (IV) nitroglycerin, and IV fluids (Baldwin et al., 2004). In another study, Medicare beneficiaries hospitalized for AMI in rural hospitals were found to be less likely than those hospitalized in urban hospitals to receive several recommended interventions (e.g., aspirin, heparin, IV nitroglycerin), and risk-adjusted rates of death within 30 days of an admission for an AMI increased with “rurality” or degree of remoteness of the hospital



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