VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans' health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.

Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.

Telemedicine as a technology has been available for nearly 50 years, but its diffusion has been slower than many had anticipated. Even efforts to reimburse providers for interactive video (IAV) telemedicine services have had a limited effect on rates of participation. The resulting low volume of services provided (and consequent paucity of research subjects) makes the phenomenon difficult to study. This paper, part of a larger study that also explores telemedicine utilization from the perspectives of referring primary care physicians and telemedicine system administrators, reports the results of a survey of specialist and subspecialist physicians who are users and nonusers of telemedicine. The survey examined self-assessed knowledge and beliefs about telemedicine among users and nonusers, examining also the demographic characteristics of both groups. Statistically significant differences were found in attitudes toward telemedicine between users and nonusers, but in many respects the views of the two groups were rather similar. Physicians who used telemedicine were aware of the limitations of the technology, but also recognized its potential as a means of providing consultation. Demographic differences did not explain the differences in the knowledge and beliefs of user and nonuser consultant physicians, although some of the differences may be explained by other aspects of the professional environment.

Although only used in 3.5% of ED encounters on average, our findings provide evidence that tele-emergency activation is well reasoned and related to those situations when extra expert assistance is particularly beneficial.

This paper provides a review of the scholarly and applied literature published between 1970 and 1993 on health and health care access problems among racial and ethnic minority group members living in rural U.S. areas. Results on the distribution of specific illnesses and diseases, and utilization of medical services are summarized for two major minority groups—African Americans and Hispanic Americans. Findings generally document the expected pattern of rural and minority disadvantage. A review of the conceptual and methodological limitations of existing research suggests that research does not yet permit any clear understanding of the underlying structures and processes that give rise to racial health disparities. Very little is known about the health of rural minorities living in some areas of the country, for example, the west north central United States (Kansas, Missouri, Nebraska, Iowa, North Dakota, South Dakota and Minnesota).

Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural-relevant ACO-performance measures and provide necessary technical assistance to rural providers and organizations.

Moose (Alces alces) found dead (FD) and hunter-killed (HK) in 1995 on the north slope of Alaska (USA) in the Colville River Drainage were evaluated for heavy metal and mineral status. Compared to previous reports for moose and domestic cattle, and data presented here from Alaska moose outside the Colville River area, levels of Cu were determined to be low in hoof, hair, liver, kidney, rumen contents, and muscle for these north slope moose. Iron (Fe) was low in muscle as well. These findings, in conjunction with evidence of poor calf survival and adult mortality prompted investigation of a mineral deficiency in moose (serum, blood, and hair) captured in the spring of 1996 and 1997. Captured males had higher Ca, Zn and Cu levels in hair than captured females. Female moose hair samples were determined to be low (deficient) in Cu, Ca, Fe, and Se with mean levels (ppm) of 2.77, 599.7, 37.4, and 0.30, respectively. Serum Cu level was low, and to a lesser degree Zn was deficient as well. Whole blood (1997 only) was marginally deficient in Se and all animals were deficient in Cu. Based on whole blood, sera and hair, Cu levels were considered low for moose captured in spring 1996 and 1997 in the Colville River area as compared to published data and other populations evaluated in this study. Low levels of ceruloplasmin activity support this Cu deficiency theory. Evidence indicates that these moose are deficient in Cu and other minerals; however, the remote location precluded sufficient examination of animals to associate this apparent deficiency with direct effects or lesions. Renal levels of Cd increased with age at expected levels.

Lack of access to quality health care for a large number of Americans, particularly those living in rural areas, is a major health care problem. Differences in access between rural and urban areas are caused by obstacles to providing adequate care, such as hospital closures and physician shortages, and low income and/or employment that does not provide health insurance as an employee benefit. This study, based on a random sample of 6,000 households in Nebraska, finds that access to health care is better for residents of rural than urban areas. The relationship holds with controls for health status and health insurance. The pattern in Nebraska reflects an absence of differences in income, health insurance, and health status that produce differences in access between rural and urban areas nationwide. The findings suggest that any serious proposal to reform health care delivery should involve the states and use established patterns of seeking care among state residents.