Disparities in rural health care have been well established with respect to socioeconomic status, race, and geography. COVID-19 brought these disparities to the surface within most rural communities in the United States, highlighting the limited access to health care specialists and subspecialists.
As an otolaryngologist, I have had the privilege and unique opportunity of serving two different communities: Chicago’s city dwellers and residents of rural central Illinois. This past year, I have seen that the COVID-19 pandemic has further increased the already existing disparities between these two places, as it has across the nation.
Over the past five years, I have taken care of patients at the rural Gibson Area Hospital in central Illinois. My clinical experience at Gibson includes 2,500 patient visits and 450 surgical cases, performing surgeries including ear tubes, microlaryngoscopy, septoplasty, sinus surgery, and excision of head and neck tumors. Given the lack of otolaryngology services in the area, most patients seek guidance and proper management of their care.
The urban-rural health care disparities extend well beyond Illinois and across most rural communities in the United States. To bridge these disparities in otolaryngology and other medical fields, states should develop Rural Outreach Initiative Programs to link city hospitals to underserved populations. Such outreach programs would bring subspecialty care to rural communities, thereby improving patient quality of life and health outcomes. To achieve the above objective, any rural outreach initiative should include identifying specific services that are lacking. For example, in otolaryngology, ENT surgeons would serve the basic needs and provide complex care, including implantable hearing devices, screening for head and neck cancers, and using newer techniques to treat sleep apnea.
Frequently, I have seen rural patients with sudden hearing loss who may have been seen at either a local urgent care clinic or their primary care and were treated with antibiotics or decongestants. The standardized treatment of sudden hearing loss includes early diagnosis and treatment with oral steroids and intratympanic steroid injection. Often, when patients are referred to the ENT physician, enough time has elapsed where the recovery of hearing loss with treatment becomes difficult. Similarly, I have seen patients with neck masses who have been treated with antibiotics for several weeks. When they finally visit an otolaryngologist, their work-up indicates head and neck cancer. By the time they visit their local ENT, their otherwise initial stage of cancer has become advanced.
Based on the Department of Health and Human Services, less than 11 percent of physicians in the U.S. practice in rural areas, yet about 20 percent of the population resides in rural areas. According to the National Rural Health Association, there are only 30 specialists per 100,000 people in rural communities, compared to 263 specialists per 100,000 urban residents. And the National Center Health has found that 62.5 percent of rural communities in Illinois (accounting for 38 counties and 623,831 residents) had zero otolaryngologists per 100,000.
These enormous disparities in urban and rural otolaryngology care is evident in our daily clinical practice.
For example, I recently saw a patient who is an attorney and a local Chicago resident with a history of chronic sinusitis and prior sinus surgery. Living in Chicago, this patient can seek multiple opinions and care from several otolaryngologists within the same ENT department, giving him the best possible care and results in his treatment.
In contrast, many rural hospitals are not able to provide direct otolaryngology care to their communities. By providing otolaryngology service at the Rural Gibson Hospital, I have been able to identify patients with various complex disorders and treat them in a timely and effective fashion.
For instance, seeing the patients that I do in central Illinois has allowed me to identify many patients with sudden hearing loss in a timely fashion and provide treatment with intratympanic dexamethasone injections, allowing many of them to recover their hearing.
But there are still so many patients who never get seen or treated. To bridge the disparities between urban and rural health, there need to be significant medical education and health policy changes.
First, medical schools must develop programs that provide medical students and residents exposure to rural health and help develop a better understanding of rural communities’ health care needs.
Secondly, we need health policies that promote telemedicine programs and develop partnerships between urban and rural health programs to better allow specialists to perform needed surgeries within rural hospital settings. There is good incentive to doing so. For example, otolaryngologists seeing patients in rural hospitals can identify patients who may have a complex disease, such as an advanced or uncommon type of cancer, and offer guidance that would impact patient quality of life and survival. Developing partnerships between urban and rural hospitals would also help develop uniform policies and guidance in managing patients during the COVID-19 crisis.
Lastly, providing specialty care to rural communities would reinforce trust in local health systems for providing appropriate and up-to-date care, thereby enabling rural hospitals to continue to remain vital to their community. Implementation of the above policies to address rural health disparities will result in better patient outcomes, survival, and improved quality of life in Illinois and rural communities across the United States. That might be the most important outcome of all.
Ashok A. Jagasia is an otolaryngologist.
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