B, some minorities, such as Native Americans, Hispanics, and African Americans, are more concentrated in rural and frontier areas and have lower health status than other residents of these communities. Information is not available to indicate whether these within-system inequities are greater or lesser in rural than in urban health systems.


The evidence base pertaining to differences in quality between rural and urban health care is highly inadequate, and more research on this issue is clearly needed. In the case of safety and effectiveness, there are so few studies that it is not possible to determine whether there are differences between rural and urban areas. Timeliness is the only aim for which the results are clear and not surprising: access to critical services, such as emergency care, is impeded by geography and scarcity of providers. As for the other aims—patient-centeredness, efficiency, and equity—the evidence is anecdotal at best.


A comprehensive review of the Quality Chasm six aims is beyond the scope of this report; however, this section highlights some of the more salient differences between rural and urban communities in terms of health behaviors and environmental threats—the two areas most amenable to intervention in the short run. Appendix B speaks to differences in the racial and ethnic compositions of rural and urban communities (which influence genetic predispositions to a great extent) and many other socioeconomic factors that influence health.

Although the evidence base pertaining to the quality of health care is lean, there is a good deal of evidence pointing to differences in the health behaviors of rural and urban populations. A recently published document, Health, United States, 2001 with Urban and Rural Chartbook (NCHS, 2001) highlights some of the key differences:

  • Adolescents and adults living in rural counties are more likely to smoke than those in urban areas. In the most remote rural areas, about 19 percent of adolescents smoke, as compared with 11 percent of adolescents in metropolitan central areas. Adults living in the most rural counties are the most likely to smoke (27 percent of women and 31 percent of men), and

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