Previous Projects

Rural Variation in Access to Naloxone for Opioid Overdose Prevention

• ICPE 2020

Naloxone is a life-saving drug designed to rapidly reverse opioid overdose by quickly restoring normal breathing to a person whose respiration has slowed or stopped due to an overdose. Prior research on naloxone dispensing by emergency medical services found higher odds of naloxone use in rural areas but lower-than-expected use based on a much higher rate of overdose mortality compared to urban areas. To our knowledge, there are no studies examining the outpatient pharmacy-based naloxone distribution in rural areas.

A number of state regulatory changes impact naloxone access and dispensing, including innovative pharmacy access laws (prescriptive authority, protocols or standing orders, collaborative practice agreements) that allow pharmacists to directly dispense naloxone without first having received a prescription from another health care provider, and immunity changes provided to pharmacists. Widely varying rates of naloxone dispensing between states has been reported, and states that expanded Medicaid access have distributed more naloxone than those which did not expand Medicaid.

Understanding the variability in naloxone access at the state level is an important first step, but examining naloxone distribution using rural constructs can help tailor local overdose prevention efforts. Therefore, we aim to: 1) Describe naloxone dispensing across the US and compare the access by rurality; 2) Examine variability in naloxone distribution and the effects of Medicaid expansion and pharmacy policy in rural areas; and 3) Create at least two types of interactive mapping visualizations: naloxone distribution counts/rates in rural areas and a Kentucky street map of pharmacies distributing naloxone via protocol in the state.

Principal Investigator

Chris Delcher, PhD, Assistant Professor, Pharmacy Practice and Science

Risky Substance Use among Adolescents and Adults in Non-Metropolitan and Metropolitan Counties

A dearth of contemporary information exists about risky substance use among children and adults residing in non-metropolitan and metropolitan counties nationally. Even less information is available about Native American and other racial or ethnic minorities residing in non-metropolitan counties. This project will fill important gaps in knowledge that health policy makers may use to develop and implement more effective substance use prevention interventions for non-metropolitan adolescents and adults.

Specifically, we aim to: 1) estimate and compare alcohol use and binge drinking between non-metropolitan and metropolitan adolescents and adults; 2) estimate and compare drug use (marijuana, other illicit drugs, and non-medical use of other drugs) between non-metropolitan and metropolitan adolescents and adults; and 3) estimate and compare alcohol, tobacco, and drug use between Native American and other racial or ethnic groups residing in non-metropolitan counties.

This project will provide evidence about the prevalence of these risky behaviors among non-metropolitan residents that will inform the allocation and implementation of prevention programs aimed at reducing risky alcohol and drug use among rural Americans.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Rural and Urban Differences in Access to Psychiatric Partial Hospitalization Programs

• NRHA Annual Conference

Psychiatric partial hospitalization programs (PHPs) allow patients to reside at home while receiving intensive and structured services, routine psychiatric evaluation, medication management, and individual and group counseling, in outpatient settings during the day. Although some evidence indicates that PHP service utilization has grown overall over the past two decades, very little information exists about the availability of psychiatric PHPs in non-metropolitan (rural) as compared to metropolitan (urban) areas. Similarly, very little information exists about the provision of psychiatric PHPs by Medicare-designated critical access hospitals (CAHs), rural referral hospitals, and sole community hospitals serving rural clientele. Analyzing the American Hospital Association Annual Survey of hospitals, the purpose of this project is to describe the availability of psychiatric PHPs amongst hospitals in metropolitan, micropolitan, and other non-metropolitan areas nationally. Because psychiatric PHP services are financed by Medicare and Medicaid, the project findings will have federal policy relevance for improving the accessibility of outpatient mental health services.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Rural and Urban Variation in Family Physicians' Demographics and Practices

A growing body of evidence suggests that racial and ethnic similarities between physicians and their patients improves patient outcomes by increasing access to care for underserved populations. However, there is relatively little research on the racial and ethnic makeup of family physicians by urbanicity. This project will explore the racial and ethnic distribution of family physicians in rural and urban areas nationwide, along with the personal demographics of their patients. This project will use 2013-2020 American Board of Family Medicine data collected from family physicians.

Principal Investigator

Lars E. Peterson, MD, PhD, Vice President at American Board of Family Medicine

Rural/Urban Variations in Cancer Screening During the COVID-19 Pandemic

• 2023 HINTS Data Users Conference

Using the National Cancer Institute Health Information National Trends Survey, we will examine how the COVID-19 pandemic has disrupted the receipt of recommended screenings for common cancers. Findings will inform policy makers about potential widening of rural/urban disparities in the receipt of cancer preventive services and the potential need to target these services toward rural residents.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Serious Mental Illness and Access to Care among Rural and Urban Adults

The federal government defines serious mental illness (SMI) as satisfying criteria for at least one Diagnostic and Statistical Manual (DSM) disorder, excluding substance use disorders, that leads to substantial functional life impairment. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates the prevalence of SMI from the National Survey on Drug Use and Health (NSDUH). The etiology and treatment of SMI has been recognized as a Department of Health and Human Services priority, but little research has investigated this issue among rural residents in recent years. Consequences of untreated SMI include drug and alcohol abuse, suicide, and overall premature mortality from so-called deaths of despair, all of which have risen to the national forefront of public health concerns in rural areas.

This project will provide up-to-date estimates of the prevalence and correlates of past-year SMI and, among persons with SMI, treatment utilization, unmet treatment needs, and treatment barriers among metropolitan and non-metropolitan adults nationally. From a policy perspective, the project is timely because Federal agencies and policymakers need information about the prevalence and correlates to SMI and treatment access to more effectively target services across geographic areas.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Unintentional Injury in Metropolitan and Nonmetropolitan Settings by Race or Ethnicity

• 2022 NRHA Annual Conference

This study will describe the rates of fatal and nonfatal unintentional injury comparing metropolitan and nonmetropolitan areas, stratified by race or ethnicity. For this study, we will use Centers for Disease Control (CDC) WONDER data (2014-2018) and the 2018 National Hospital Ambulatory Medical Care Survey (NHAMCS).

Principal Investigator

Jeffery Talbert, PhD, Professor in the Department of Pharmacy Practice and Science, and Director of the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Project Data Scientist-Statistician

Lindsey Hammerslag, PhD

Medicare Beneficiaries’ Access to Preventive Services: Diabetes Self-Management Training (DSMT), Medical Nutrition Therapy (MNT), and Health and Behavior Assessment and Intervention (HBAI)

• DSMT

Diabetes self-management education and training (DSMT) is an important part of clinical management of diabetes that is associated with increased use of primary and preventive services and lower use of acute, inpatient hospital services. Furthermore, nutrition-based interventions have proven to be both effective at producing physical indicators of increased metabolic health and cost-effective in terms of savings generated by their usage. However, previous studies have shown that utilization of DSMT services is altered by geographic region and availability of such services (Strawbridge, Lloyd, Meadow, Riley, & Howell, 2015; Remler et al., 2007), despite coverage by Medicare Part B.

Using the publicly available Medicare Provider Utilization and Payment Data supplemented by unique clinic site and physician-level information for 30,000 family physicians nationally that is only available through the American Board of Family Medicine, we propose to investigate geographic disparities (i.e., rural versus urban) in the provision of DSMT, Medical Nutrition Therapy (MNT), and Health and Behavior Assessment and Intervention (HBAI) and identify whether challenges or barriers exist for rural providers in billing for these services, as well as propose solutions to addressing challenges faced by providers in billing for these services in disparate populations. Using national county-level aggregate totals of DSMT, MNT, and HBAI services among Medicare fee-for-service beneficiaries from 2012 to 2015, we will compare rural and urban providers to determine characteristics of the practice sites on a national level.

Principal Investigator

Jeffery Talbert, PhD, Professor in the Department of Pharmacy Practice and Science, and Director of the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Rural and Urban Cancer Survivors’ Follow-Up Care Experiences

• 2023 NRHA Annual Conference
• 2022 ATRN Health Summit

After completing treatment, cancer survivors require follow-up services for surveillance of cancer recurrence, detection of new cancers, continued care management, and the monitoring of late or long-term treatment side effects. This project will examine rural vs. urban differences in cancer survivors’ follow-up care experiences by conducting analyses of the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivors module. Specific aims of this study are:
1. To provide nationally representative estimates and compare/contrast the prevalence of rural and urban cancer survivors’ follow-up care experiences.
2. To understand how having a regular PCP is associated with cancer survivors’ follow- up care experiences and if this association is stronger among rural than urban cancer survivors.
3. To determine if racial/ethnic differences in cancer survivors’ follow-up care experiences vary by rural/urban residence.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Rural Family Physicians’ Ability to Address Patients’ Social Determinants of Health Needs

• 2021 NAPCRG Annual Meeting

Rural populations fare worse than their metropolitan counterparts in social determinants of health including access to services, economic opportunity, intimate partner violence, life expectancy and poverty. Very little research exists to describe the ability of rural primary care physicians to address patients’ non-medical social determinants of health needs. This project will make use of a unique dataset collected among family physicians nationally in 2017 through 2019.

Principal Investigator

Lars E. Peterson, MD, PhD, Vice President at American Board of Family Medicine

The Association of Occupation with Mental Illnesses and Death by Suicide

• NRHA Annual Conference
• GSA 2020 Annual Meeting

Globally, suicide accounts for 1.4% of all deaths, making it the 18th leading cause of mortality worldwide. However, in the United States, suicide accounts for 1.8% of all deaths and is the 10th largest cause of mortality. Previous research has linked depression, psychological distress, and lower levels of well-being with substantially higher risk of suicide. However, recent data suggest more than half of suicide victims did not have any prior mental health diagnosis, indicating that factors other than mental illness should be explored. Higher risks for suicide have been associated with select occupations. This project will evaluate the association of occupational risk factors with mental illnesses, all-cause mortality, and suicide using the National Health Interview Survey (NHIS) and the Panel Study of Income Dynamics (PSID) datasets.

Principal Investigator

Ahmed A. Arif, PhD, CPH, FACE, Associate Professor of Public Health Sciences at UNCC

Longitudinal Trends in Community Mental Health Center and Federally Qualified Health Center Supply in Non-Metropolitan and Metropolitan Counties

Community mental health centers (CMHCs) provide ambulatory mental health services and engage in other activities to foster community mental health. Federally qualified health centers (FQHCs) also frequently provide mental health services. However, no prior research has examined how the supply of CMHCs and FQHCs has changed over time in non-metropolitan and metropolitan areas nationally.

This study will thus fill an important void in our contemporary knowledge of CMHCs and FQHCs in rural (and urban) America. The topic is also a priority given Medicare’s proposed reductions in partial psychiatric hospitalization program payments to CMHCs and the broader question about how CMHCs are filling a need in providing critical mental health services in non-metropolitan areas nationally.

Specific aims of the project are to: 1) Describe and compare longitudinal changes in the availability of CMHCs and FQHCS among non-metropolitan and metropolitan counties; and 2) Describe and examine how county-level population demographics (e.g., age, gender, and race/ethnicity), economics (e.g., per capita income and health insurance coverage), and health care factors (e.g., psychiatrists and psychologists per 10,000 population) are associated with the presence/absence of a CMHC and FQHC within non-metropolitan areas.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Rural and Urban Primary Care Physicians' Colorectal Screening Performance

Additional research is warranted to further understand the roles of primary care physicians in assuring that their patients receive recommended colorectal cancer screenings, especially considering that primary care physicians (particularly family physicians) are the predominant clinicians in rural America. Family physicians can provide endoscopy services themselves as opposed to referring patients to other specialists, such as gastroenterologists, but these numbers are low (<5% overall). Our prior research found that the percentage of rural family physicians doing colonoscopy (6% to 4%) and endoscopy (6% to 3%) both declined from 2014 to 2016, further threatening rural access to screening.
The objectives of this project are to profile, compare, and further understand rural vs. urban differences in colorectal screening performance among primary care physicians nationally. To address these issues, we will analyze data from the American Board of Family Medicine’s PRIME Registry, which captures electronic health record data from more than 2500 clinicians in approximately 800 practices located in 47 states caring for 5.4 million patients. PRIME practices are disproportionately rural, small, and independent compared to all US primary care practices.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Substance Use, Depression, and Suicide: What are the Individual and Policy-Modifiable Correlates amongst Metropolitan and Non-Metropolitan Adults?

• Reforming States Group Meeting
• RUHRC Fall 2018 Symposium
• NRHA Annual Conference

Very little research has investigated the associations between substance use, depression, and suicidal ideation amongst adults residing in rural and urban areas nationally. Using nationally representative data from the National Survey on Drug Use and Health (NSDUH), this study will a) estimate the prevalence of major depression and suicidal ideation and attempts in metropolitan, micropolitan, and other non-metropolitan areas nationally and b) investigate the individual-level (e.g., demographic, socioeconomic, region of residence, and health status) and policy-modifiable health care (e.g., insurance, access to a regular health care provider, and access to mental health and substance use treatment) correlates of depression and suicide indicators among metropolitan, micropolitan, and other non-metropolitan residents.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Mental Health Treatment Access: How do Mental Health Treatment Use and Unmet Treatment Need Vary among Rural and Urban Adults Nationally?

• NHRA Annual Conference

Recent research indicates that residents of rural areas have similar rates and residents of semi-rural areas have higher rates of mental health illnesses than residents of large metro areas. Although rural residents on average need mental health services just as much as their urban counterparts, a dearth of research has investigated unmet mental health treatment need and treatment utilization amongst rural and urban residents with mental health problems. Using nationally representative data from the National Survey on Drug Use and Health, this study will a) estimate rates of unmet treatment need and treatment utilization and b) investigate the individual-level (e.g., demographic, socioeconomic, region of residence, and health status) and policy-relevant health care (e.g., insurance and access to a regular health care provider) correlates of unmet need and treatment utilization among metropolitan, micropolitan, and other non-metropolitan residents. In addition, we will repeat our analyses of rates and correlates of unmet need and treatment use amongst Native Americans/American Indians.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Rural/Urban and Racial/Ethnic Inequities in Patient-Reported Health Care Access and Quality among Medicare Beneficiaries with Lung or Colorectal Cancer

Incidence and mortality for colorectal and lung cancer are higher in rural versus urban residents, but many rural cancer patients lack accessible, high-quality care. This study will 1) Identify rural/urban inequities in Medicare cancer patient-reported health care access and quality and 2) Determine if rural racial/ethnic minority patients have worse health care access and quality than rural White patients.

Principal Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Diabetes Management in Urban and Rural Areas of the U.S.

• 2022 NRHA Annual Conference

This project will use the IBM MarketScan database to examine differences in type 2 diabetes prevalence and monitoring for a commercially insured sample. It will also employ definitions from the Health Effectiveness Data and Information Set (HEDIS) guidelines for comprehensive diabetes care to determine if rural residents are more or less likely to meet recommended standards for type 2 diabetes monitoring and control.

Principal Investigator

Jeffery Talbert, PhD, Professor in the Department of Pharmacy Practice and Science, and Director of the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Lung Diseases among Coal Miners

• Coal-Figure-1
• Coal-Figure-2
• Coal-Figure-3
• Coal-Figure-4

• APHA Annual Meeting
• ATS Annual Conference
• UK-CARES Seminar Series
• RUHRC Fall 2018 Symposium

Coal mining is considered one of the most dangerous and hazardous occupations worldwide. In the U.S., rates of fatal and non-fatal injuries are substantially higher among coal miners as compared to those working in private jobs. Coal miners are at increased risk of both restrictive and obstructive lung diseases such as coal worker’s pneumoconiosis (CWP), progressive massive fibrosis (PMF), rapidly progressive pneumoconiosis (RPP), and COPD. Using the Medicare administrative claims data, Kentucky (KY) Medicaid claims data, and the National Health Interview Survey (NHIS), we propose to determine factors related to respiratory health effects among miners and non-miners, assess and compare health care utilization among patients with and without CWP across regions, and map health care utilization of CWP and other lung diseases relative to HRSA-funded Black Lung Clinics.

Principal Investigator

Ahmed A. Arif, PhD, CPH, FACE, Associate Professor of Public Health Sciences at UNCC

Principal Investigator

Jeffery Talbert, PhD, Professor in the Department of Pharmacy Practice and Science, and Director of the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Predictors of Buprenorphine Prescribing by Family Physicians in Rural Areas Nationally

• NRHA Annual Conference

Family physicians are the most prevalent physician specialty in rural America and can treat opioid use disorder (OUD) with buprenorphine if they complete training to obtain a special Drug Enforcement Agency license. However, the uptake of buprenorphine prescribing by family physicians has been low. This study will examine rural vs. urban and intra-rural variation in family physicians’ prescribing of buprenorphine nationally and will examine how physician and practice-level factors are associated with prescribing buprenorphine. To address these questions, we will conduct a multilevel logistic regression analysis of a nationally representative cohort of family physicians registering for the American Board of Family Medicine (ABFM) recertification examination.

Principal Investigator

Lars E. Peterson, MD, PhD, Vice President at American Board of Family Medicine

Barriers and Disparities Associated with Pneumococcal Immunization among Rural Elderly Adults

• Influenza
• Pneumococcus

• NRHA Annual Conference
• RUHRC Fall 2018 Symposium

Vaccines offer a cost-effective means of preventing illnesses at the population level. However, very little research has investigated rural/urban variations in vaccine utilization. Our Center will conduct analyses of national survey data and unique insurance claims data sets (UK has a collaborative agreement with Humana) to identify how rurality of residence and key demographic (including race and ethnicity), social, and economic characteristics serve as barriers or facilitators to vaccination against pneumococcal disease, which is relatively common among older Americans.

Principal Investigator

Jeffery Talbert, PhD, Professor in the Department of Pharmacy Practice and Science, and Director of the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Co-Investigator

Patricia (Trish) Rippetoe Freeman, PhD, Director of the Center for the Advancement of Pharmacy Practice, Clinical Associate Professor in the Pharmacy Practice and Science Department, and Faculty Associate in the Institute for Pharmaceutical Outcomes and Policy in the UK College of Pharmacy

Project Data Scientist-Statistician

Aric Schadler, MS, Data Scientist Manager/Statistician in the UK College of Pharmacy.

Variation in Scope of Practice and Medical Services Available at Family Physician Practices within Rural Areas

Family physicians are the foundation of medical care in many rural areas and, as such, are frequently required to have a broader scope of practice, defined as the ranges of services they provide, than their urban counterparts. A family physician offering the full scope of practice can provide ambulatory and urgent/emergent care, staff rural hospitals, and deliver all non-surgical care to a rural population. Despite the importance of family physicians to rural health care delivery systems, very little research has investigated their scope of practice in rural areas, particularly in socioeconomically disadvantaged areas. Using data collected during recertification examination registration of family physicians certified by the American Board of Family Medicine (ABFM), this project will examine variation in the scope of practice of family physicians and services available in the primary practice site by degree of rurality and within rural categories by community-level deprivation. Additionally, we will examine variation by Patient-Centered Medical Home (PCMH) status.

Principal Investigator

Lars E. Peterson, MD, PhD, Vice President at American Board of Family Medicine

The Impact of Medicaid Expansion on Rural/Urban Variations in Access to Substance Use Treatment

• NVAC Meeting
• NRHA Annual Conference

Abuse of illicit drugs, such as cocaine and methamphetamine, as well as licit drugs, such as prescription opioids, is a substantial public health problem in many rural areas of the U.S. One explanation for these high rates of drug misuse is that some persons residing in impoverished areas use drugs to cope with hopelessness associated with poor prospects of employment and other opportunities. Regardless of the underlying causes of drug use, research indicates that substance use treatment access is insufficient in rural areas. With implementation of the ACA, substance use treatment funding has been expanded, particularly through Medicaid expansion in many states. However, it is not clear if and how Medicaid expansion has impacted substance use treatment in rural localities. We will make use of our rare access to restricted use NSDUH data to offer new insights about the impact of Medicaid expansion on access to substance abuse treatment among individuals with substance abuse disorders. We will conduct analyses of 13 years (2004-2016).

Co-Investigator

Tyrone F. Borders, PhD, Professor, College of Nursing

Exploring the Impact of Rural Hospital Closures on Use of Emergency Medical Services

• KRHA 20th Annual Conference
• RUHRC Fall 2018 Symposium
• NHRA Annual Conference

Since 2010 over 70 hospitals have closed their emergency department doors or the entire hospital. These closures have primarily occurred in the southern United States, but the closures are expected to broaden around the country and more than 250 hospitals are vulnerable to closure. In the wake of such closures, access to a hospital for real emergencies—and the distance and time to the next nearest hospital—could mean the difference between life and death. We expect to see increased reliance on Emergency Medical Services (both air and ambulance) to transport patients further distances at high cost. Rural, lower-income households, and older individuals tend to use the emergency department more than others; thus the impact of rural hospital closures will likely disproportionately affect these same populations. Additional considerations include the non-uniform geographic distribution of rural hospitals and how emergency transportation service resources in a community are affected by a rural hospital closure. Using a unique national database, The Enterprise Data Trust, we will explore pre- and post-closure emergency department use with specific emphasis on those who used public emergency medical transportation, testing for significant changes. This study will be the first to look at the impacts of rural hospital closure at the patient level.

Principal Investigator

Alison F. Davis, PhD, Professor in the UK Department of Agriculture Economics and Executive Director of the Community & Economic Development Initiative of Kentucky.