Rural vs. Urban Ambulatory Health Care: A Systematic Review
Rural vs. Urban Ambulatory Health Care: A Systematic Review
Overview
Approximately 3 million veterans, slightly more than one-third of all veterans enrolled in the Department of Veterans Affairs (VA) health care system, live in rural areas. This pattern is likely to continue, as a comparable proportion of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans are from rural areas. The Rural Veterans Care Act of 2006 was signed into law to improve care for rural veterans. Ensuring that the health care needs of rural veterans are met has become a top priority for VA, resulting in a considerable expansion of community based outpatient clinics (CBOCs), inclusion of rural health/access as a research priority, and creation of the VA Office of Rural Health (ORH) in 2006. Although there have been reports comparing health quality of life (both physical and mental) for rural and urban veterans, it remains unclear whether the observed lower health quality of life in rural veterans is due to disparities in health care, differences in disease prevalence, or other population differences. This systematic review examines the evidence regarding potential disparities between rural and urban areas in health care provision and delivery, and how differences in health care may contribute to disparities in health outcomes. Differences in rural-urban prevalence rates of diseases and other health conditions are beyond the scope of this review. Because veterans who use VA health care have been found to use more non-VA health care overall, we expanded the focus of this review to include comparisons of rural vs. urban health care in non-VA health systems. Our first goal was to determine if a health care disparity exists across the urban-rural spectrum. For a disparity to exist, it would have to be demonstrated that health care outcomes of patients in rural areas differ from those of patients treated in urban areas for similar conditions. Because differences in health care process or delivery do not necessarily lead to disparities, we looked for evidence associating differences with poorer health outcomes. For the purposes of this review we conceptualized rural-urban disparities as differences in health care quality or availability. A second goal of the review was to identify areas for intervention should any disparities be found. In order to develop a meaningful intervention, specific information regarding differences in the structure of health care and the way it is administered (i.e., the process) would be critical. Since differences in health outcomes can occur for reasons other than differences in the health care systems themselves (e.g., accessibility), our third goal was to examine what, if any, nonhealth care factors (e.g., travel distance to a clinic) affected health outcomes. Because veterans who use VA health care actually use more non-VA health care overall,9 we expanded the focus of this review to include comparisons of rural vs. urban health care in non-VA health systems The key questions were: Key Question #1. Do adults with health care needs who live in rural areas have different intermediate (e.g., hemoglobin A1c [HbA1c], Blood pressure, etc.) or final health outcomes (i.e., mortality, morbidity, quality of life [QOL]) than those living in urban areas? Key Question #2. Is the structure (e.g., types of available providers) or the process (e.g., likelihood of referral) of health care different for adults with health care needs who live in urban vs. rural environments? Key Question #3. If there are differences in the structure or the process of health care in rural vs. urban environments, do those differences contribute to variation in overall or intermediate health outcomes for adults with health care needs? Key Question #4. If there are differences in intermediate or final health outcomes for adult patients with health care needs, what other systems factors moderate those differences (e.g., availability of specialists, type of treatment needed, travel distance)?Description
Condition Guidelines
Books - New and Used
The following guidelines apply to books:
- New: A brand-new copy with cover and original protective wrapping intact. Books with markings of any kind on the cover or pages, books marked as "Bargain" or "Remainder," or with any other labels attached, may not be listed as New condition.
- Used - Good: All pages and cover are intact (including the dust cover, if applicable). Spine may show signs of wear. Pages may include limited notes and highlighting. May include "From the library of" labels. Shrink wrap, dust covers, or boxed set case may be missing. Item may be missing bundled media.
- Used - Acceptable: All pages and the cover are intact, but shrink wrap, dust covers, or boxed set case may be missing. Pages may include limited notes, highlighting, or minor water damage but the text is readable. Item may but the dust cover may be missing. Pages may include limited notes and highlighting, but the text cannot be obscured or unreadable.
Note: Some electronic material access codes are valid only for one user. For this reason, used books, including books listed in the Used – Like New condition, may not come with functional electronic material access codes.
Shipping & Delivery
Shipping Fees
- Stevens Books offers FREE SHIPPING everywhere in the United States for ALL non-book orders, and $3.99 for each book.
- Packages are shipped from Monday to Friday.
- No additional fees and charges.
Delivery Times
The usual time for processing an order is 24 hours (1 business day), but may vary depending on the availability of products ordered. This period excludes delivery times, which depend on your geographic location.
Estimated delivery times:
- Standard Shipping: 5-8 business days
- Expedited Shipping: 3-5 business days
Shipping method varies depending on what is being shipped.
Tracking
All orders are shipped with a tracking number. Once your order has left our warehouse, a confirmation e-mail with a tracking number will be sent to you. You will be able to track your package at all times.
Damaged Parcel
If your package has been delivered in a PO Box, please note that we are not responsible for any damage that may result (consequences of extreme temperatures, theft, etc.).
If you have any questions regarding shipping or want to know about the status of an order, please contact us or email to support@stevensbooks.com.
Returns & Refunds
You may return most items within 30 days of delivery for a full refund.
To be eligible for a return, your item must be unused and in the same condition that you received it. It must also be in the original packaging.
Several types of goods are exempt from being returned. Perishable goods such as food, flowers, newspapers or magazines cannot be returned. We also do not accept products that are intimate or sanitary goods, hazardous materials, or flammable liquids or gases.
Additional non-returnable items:
- Gift cards
- Downloadable software products
- Some health and personal care items
To complete your return, we require a tracking number, which shows the items which you already returned to us.
There are certain situations where only partial refunds are granted (if applicable)
- Book with obvious signs of use
- CD, DVD, VHS tape, software, video game, cassette tape, or vinyl record that has been opened
- Any item not in its original condition, is damaged or missing parts for reasons not due to our error
- Any item that is returned more than 30 days after delivery
Items returned to us as a result of our error will receive a full refund,some returns may be subject to a restocking fee of 7% of the total item price, please contact a customer care team member to see if your return is subject. Returns that arrived on time and were as described are subject to a restocking fee.
Items returned to us that were not the result of our error, including items returned to us due to an invalid or incomplete address, will be refunded the original item price less our standard restocking fees.
If the item is returned to us for any of the following reasons, a 15% restocking fee will be applied to your refund total and you will be asked to pay for return shipping:
- Item(s) no longer needed or wanted.
- Item(s) returned to us due to an invalid or incomplete address.
- Item(s) returned to us that were not a result of our error.
You should expect to receive your refund within four weeks of giving your package to the return shipper, however, in many cases you will receive a refund more quickly. This time period includes the transit time for us to receive your return from the shipper (5 to 10 business days), the time it takes us to process your return once we receive it (3 to 5 business days), and the time it takes your bank to process our refund request (5 to 10 business days).
If you need to return an item, please Contact Us with your order number and details about the product you would like to return. We will respond quickly with instructions for how to return items from your order.
Shipping Cost
We'll pay the return shipping costs if the return is a result of our error (you received an incorrect or defective item, etc.). In other cases, you will be responsible for paying for your own shipping costs for returning your item. Shipping costs are non-refundable. If you receive a refund, the cost of return shipping will be deducted from your refund.
Depending on where you live, the time it may take for your exchanged product to reach you, may vary.
If you are shipping an item over $75, you should consider using a trackable shipping service or purchasing shipping insurance. We don’t guarantee that we will receive your returned item.
Overview
Approximately 3 million veterans, slightly more than one-third of all veterans enrolled in the Department of Veterans Affairs (VA) health care system, live in rural areas. This pattern is likely to continue, as a comparable proportion of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans are from rural areas. The Rural Veterans Care Act of 2006 was signed into law to improve care for rural veterans. Ensuring that the health care needs of rural veterans are met has become a top priority for VA, resulting in a considerable expansion of community based outpatient clinics (CBOCs), inclusion of rural health/access as a research priority, and creation of the VA Office of Rural Health (ORH) in 2006. Although there have been reports comparing health quality of life (both physical and mental) for rural and urban veterans, it remains unclear whether the observed lower health quality of life in rural veterans is due to disparities in health care, differences in disease prevalence, or other population differences. This systematic review examines the evidence regarding potential disparities between rural and urban areas in health care provision and delivery, and how differences in health care may contribute to disparities in health outcomes. Differences in rural-urban prevalence rates of diseases and other health conditions are beyond the scope of this review. Because veterans who use VA health care have been found to use more non-VA health care overall, we expanded the focus of this review to include comparisons of rural vs. urban health care in non-VA health systems. Our first goal was to determine if a health care disparity exists across the urban-rural spectrum. For a disparity to exist, it would have to be demonstrated that health care outcomes of patients in rural areas differ from those of patients treated in urban areas for similar conditions. Because differences in health care process or delivery do not necessarily lead to disparities, we looked for evidence associating differences with poorer health outcomes. For the purposes of this review we conceptualized rural-urban disparities as differences in health care quality or availability. A second goal of the review was to identify areas for intervention should any disparities be found. In order to develop a meaningful intervention, specific information regarding differences in the structure of health care and the way it is administered (i.e., the process) would be critical. Since differences in health outcomes can occur for reasons other than differences in the health care systems themselves (e.g., accessibility), our third goal was to examine what, if any, nonhealth care factors (e.g., travel distance to a clinic) affected health outcomes. Because veterans who use VA health care actually use more non-VA health care overall,9 we expanded the focus of this review to include comparisons of rural vs. urban health care in non-VA health systems The key questions were: Key Question #1. Do adults with health care needs who live in rural areas have different intermediate (e.g., hemoglobin A1c [HbA1c], Blood pressure, etc.) or final health outcomes (i.e., mortality, morbidity, quality of life [QOL]) than those living in urban areas? Key Question #2. Is the structure (e.g., types of available providers) or the process (e.g., likelihood of referral) of health care different for adults with health care needs who live in urban vs. rural environments? Key Question #3. If there are differences in the structure or the process of health care in rural vs. urban environments, do those differences contribute to variation in overall or intermediate health outcomes for adults with health care needs? Key Question #4. If there are differences in intermediate or final health outcomes for adult patients with health care needs, what other systems factors moderate those differences (e.g., availability of specialists, type of treatment needed, travel distance)?Description
Condition Guidelines
Books - New and Used
The following guidelines apply to books:
- New: A brand-new copy with cover and original protective wrapping intact. Books with markings of any kind on the cover or pages, books marked as "Bargain" or "Remainder," or with any other labels attached, may not be listed as New condition.
- Used - Good: All pages and cover are intact (including the dust cover, if applicable). Spine may show signs of wear. Pages may include limited notes and highlighting. May include "From the library of" labels. Shrink wrap, dust covers, or boxed set case may be missing. Item may be missing bundled media.
- Used - Acceptable: All pages and the cover are intact, but shrink wrap, dust covers, or boxed set case may be missing. Pages may include limited notes, highlighting, or minor water damage but the text is readable. Item may but the dust cover may be missing. Pages may include limited notes and highlighting, but the text cannot be obscured or unreadable.
Note: Some electronic material access codes are valid only for one user. For this reason, used books, including books listed in the Used – Like New condition, may not come with functional electronic material access codes.
Shipping & Delivery
Shipping Fees
- Stevens Books offers FREE SHIPPING everywhere in the United States for ALL non-book orders, and $3.99 for each book.
- Packages are shipped from Monday to Friday.
- No additional fees and charges.
Delivery Times
The usual time for processing an order is 24 hours (1 business day), but may vary depending on the availability of products ordered. This period excludes delivery times, which depend on your geographic location.
Estimated delivery times:
- Standard Shipping: 5-8 business days
- Expedited Shipping: 3-5 business days
Shipping method varies depending on what is being shipped.
Tracking
All orders are shipped with a tracking number. Once your order has left our warehouse, a confirmation e-mail with a tracking number will be sent to you. You will be able to track your package at all times.
Damaged Parcel
If your package has been delivered in a PO Box, please note that we are not responsible for any damage that may result (consequences of extreme temperatures, theft, etc.).
If you have any questions regarding shipping or want to know about the status of an order, please contact us or email to support@stevensbooks.com.
Returns & Refunds
You may return most items within 30 days of delivery for a full refund.
To be eligible for a return, your item must be unused and in the same condition that you received it. It must also be in the original packaging.
Several types of goods are exempt from being returned. Perishable goods such as food, flowers, newspapers or magazines cannot be returned. We also do not accept products that are intimate or sanitary goods, hazardous materials, or flammable liquids or gases.
Additional non-returnable items:
- Gift cards
- Downloadable software products
- Some health and personal care items
To complete your return, we require a tracking number, which shows the items which you already returned to us.
There are certain situations where only partial refunds are granted (if applicable)
- Book with obvious signs of use
- CD, DVD, VHS tape, software, video game, cassette tape, or vinyl record that has been opened
- Any item not in its original condition, is damaged or missing parts for reasons not due to our error
- Any item that is returned more than 30 days after delivery
Items returned to us as a result of our error will receive a full refund,some returns may be subject to a restocking fee of 7% of the total item price, please contact a customer care team member to see if your return is subject. Returns that arrived on time and were as described are subject to a restocking fee.
Items returned to us that were not the result of our error, including items returned to us due to an invalid or incomplete address, will be refunded the original item price less our standard restocking fees.
If the item is returned to us for any of the following reasons, a 15% restocking fee will be applied to your refund total and you will be asked to pay for return shipping:
- Item(s) no longer needed or wanted.
- Item(s) returned to us due to an invalid or incomplete address.
- Item(s) returned to us that were not a result of our error.
You should expect to receive your refund within four weeks of giving your package to the return shipper, however, in many cases you will receive a refund more quickly. This time period includes the transit time for us to receive your return from the shipper (5 to 10 business days), the time it takes us to process your return once we receive it (3 to 5 business days), and the time it takes your bank to process our refund request (5 to 10 business days).
If you need to return an item, please Contact Us with your order number and details about the product you would like to return. We will respond quickly with instructions for how to return items from your order.
Shipping Cost
We'll pay the return shipping costs if the return is a result of our error (you received an incorrect or defective item, etc.). In other cases, you will be responsible for paying for your own shipping costs for returning your item. Shipping costs are non-refundable. If you receive a refund, the cost of return shipping will be deducted from your refund.
Depending on where you live, the time it may take for your exchanged product to reach you, may vary.
If you are shipping an item over $75, you should consider using a trackable shipping service or purchasing shipping insurance. We don’t guarantee that we will receive your returned item.
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