title: Bypass of local primary care in rural counties: effect of patient and community characteristics.
abstract: OBJECTIVE
  This national study sought information from rural patients (1) to assess the prevalence of bypass, a pattern of seeking health care outside the local community; (2) to examine the impact of locally available primary care physicians (PCPs) and hospital size on the odds of bypass; and (3) to identify patient demographic and geographic factors associated with bypass. This study also ascertained the reasons patients give for bypass and their suggestions for how hospitals can retain patients locally.
  
  
  METHODS
  We analyzed data from a 2005 telephone survey of 1,264 adults, aged 18 years or older, who lived within 20 miles of 25 randomly selected Critical Access Hospitals and were linked with a Health Professional Shortage Area and 2004 census data. Respondents were asked about demographic characteristics, travel time and distance to local hospitals, and insurance status, as well as for suggestions of what local hospitals could do to retain patients.
  
  
  RESULTS
  Overall, 32% of respondents bypassed local primary care; the rate ranged from 9% to 66% across the Critical Access Hospital service areas. Factors associated with bypass included age, education, marital status, satisfaction with the local hospital, admission to a hospital in the past 12 months, hospital size, and local density of PCPs. Compared with residents in areas with a higher density of PCPs (=3,500 residents per PCP), residents in areas with a low density (>4,500 residents per PCP) were more likely to bypass local care (odds ratio, 1.58; 95% confidence interval, 1.02-2.46). Lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed local hospitals.
  
  
  CONCLUSIONS
  The sizable variation in bypass rates among this sample of Critical Access Hospital service areas suggests that strategies to reduce bypass behavior should be directed at the local community or facility level. Changing rural residents' perception of their local care, helping them gain a better understanding of the function of primary care, and increasing the number of PCPs might help hospitals retain patients and rural communities stay healthy.
authors.affiliation: Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA. jiliu@som.umaryland.edu
authors.forename: Jiexin Jason
authors.initials: JJ
authors.lastname: Liu
authors.forename: Gail
authors.initials: G
authors.lastname: Bellamy
authors.forename: Beth
authors.initials: B
authors.lastname: Barnet
authors.forename: Shuhe
authors.initials: S
authors.lastname: Weng
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001294:Attitude to Health; D002391:Catchment Area, Health; D005260:Female; D006297:Health Services Accessibility; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D010821:Physicians, Family / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D019035:Rural Health Services / Q000706:statistics & numerical data*; D014481:United States