title: Rural populations and early periodic screening, diagnosis, and treatment services: challenges and opportunities for local public health departments.
abstract: OBJECTIVE
  We examined geographic differences in Early Periodic Screening, Diagnosis, and Treatment (EPSDT) visits as the South Carolina Department of Health and Environmental Control (SCDHEC) transitioned from direct service provision (DSP) to assuring delivery within the larger health care system.
  
  
  METHODS
  We examined infant cohorts with continuous Medicaid coverage and normal birth weights from 1995 to 2010. Outcome variables included any EPSDT visit and the ratio of observed to expected visits. Change in SCDHEC market share over time by residence was the primary variable of interest. We used growth curve models to examine changes in EPSDT visits by rural areas and levels of DSP over time.
  
  
  RESULTS
  A small proportion of the study population (10%) resided in rural counties that were more dependent on SCDHEC for DSP. The trajectory of not having visits among counties with high DSPs was steeper in rural areas (0.208; P = .001) compared with urban areas (0.145; P = .002). In counties with high DSPs, the slope of the predicted ratio in rural areas (-0.033; P < .001) was steeper than that of urban areas (-0.013; P < .001).
  
  
  CONCLUSIONS
  Health departments operations continue to transition from DSP, which might decrease access to well-child care in rural communities. Health care reform provides opportunities for health departments to work with community partners to facilitate DSP from public to private sectors.
authors.affiliation: Nathan L. Hale and Amy Brock-Martin are with the Department of Health Services Policy & Management, University of South Carolina, Arnold School of Public Health, Columbia. Michael Smith is with the South Carolina Department of Health and Environmental Control, Columbia. James Hardin is with the Department of Epidemiology and Biostatistics, University of South Carolina, Arnold School of Public Health, Columbia.
authors.forename: Nathan L
authors.initials: NL
authors.lastname: Hale
authors.forename: Michael
authors.initials: M
authors.lastname: Smith
authors.forename: James
authors.initials: J
authors.lastname: Hardin
authors.forename: Amy
authors.initials: A
authors.lastname: Brock-Martin
mesh_terms: D002662:Child Health Services / Q000458:organization & administration* / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008403:Mass Screening; D008484:Medicaid; D011635:Public Health Administration / Q000706:statistics & numerical data*; D015980:Public Health Practice / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D012424:Rural Population / Q000706:statistics & numerical data*; D013022:South Carolina; D014481:United States