‘There aren’t many of us’: The challenges of delivering rural ID care
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Despite the importance of the specialty of infectious diseases in modern medicine — made all the more evident by the COVID-19 pandemic — many rural areas of the United States do not have access to specialized ID care.
“The biggest challenge in delivering rural ID care is that ID physicians are not there in general — there aren't many of us,” Caitlyn Hollingshead, MD, assistant professor of medicine and director of telemedicine for the division of infectious diseases at the University of Toledo College of Medicine and Life Sciences in Ohio, told Healio | Infectious Disease News.
Findings from a review of Medicare data published in the Annals of Internal Medicine in 2020 showed that nearly 80% of U.S. counties did not have a single ID physician, and that 208 million people were living in a county with low or no ID physician coverage.
“We're all kind of clustered in more suburban or urban areas,” Hollingshead said. “The singular challenge is to get a physician to rural areas, and there are many, many places that don't have any access to [ID care] whatsoever and are kind of just left to their own devices.”
For this month’s cover story, we checked in with Hollingshead and others about how ID care is delivered in rural America and how facilities are working to close the gap in coverage using technology and lessons learned from the COVID-19 pandemic.
Physician shortage
Nearly half of ID fellowship programs and a quarter of ID fellowship positions in the U.S. went unfilled on Match Day last year, according to data announced by the Infectious Diseases Society of America. The number of ID applicants also decreased to 330 from 364 the year before.
“This has an effect [on rural ID services] because there are fewer ID physicians available to practice in rural settings,” said Nupur Gupta, DO, MPH, a clinical assistant professor of infectious diseases at the University of Pittsburgh.
Fewer ID physicians means less access to specialty care, an increase in unnecessary antibiotic prescribing, more patient transfers and readmissions, more deaths and a lack of access to diagnostics, among other issues, Gupta said.
“ID is difficult to support,” Hollingshead said, describing areas in the U.S. with fewer people and smaller hospitals that are separated by long distances. “My fear is that as our numbers dwindle, we're going to be put in the position of having to choose who to see. We only have a certain amount of bandwidth, and at a certain point. that's exhausted. If we don’t increase our numbers, that will of course have deleterious effects on rural ID care.”
Hollingshead and colleagues studied patient transfers from eight community hospitals without access to ID consultation to tertiary care centers for specialized ID care over an 8-month period in 2019 and found that, among more than 3,700 patients with an indication for an ID consultation, only 0.01% were transferred, a result she called “terrifying.”
"Possible explanations for the low utilization of transfer may include the reticence of patients to transfer to tertiary care facilities due to inconvenience and cost, lack of awareness of physicians practicing in community hospitals of the value that ID physicians provide, and an informal reliance on ‘curbside’ phone calls from ID physicians as a substitute for transfer,” Hollingshead and colleagues wrote.
A multitude of studies over the years have shown the positive impact that ID consultation has on the risk for serious outcomes from infection. In their study, Hollingshead and colleagues determined that an ID physician would have made modifications in treatment for 68.5% of patients.
“Increasing awareness in community hospitals regarding the role of ID consultants should be prioritized so that resources such as patient transfer for ID consultation or ID telemedicine services will be utilized,” they wrote.
‘A work in progress’
Rural hospitals faced numerous struggles during the COVID-19 pandemic, including staffing and bed shortages, lack of available testing and financial constraints, according to Gupta.
“The COVID-19 pandemic showed that when there is a rise in new and emerging infections, rural hospitals will undoubtedly need help managing such cases,” Gupta said.
Experts warned early on that rural communities — where many people cannot work from home or telecommute — could be disproportionately affected by the pandemic.
One study assessing the association between hospital admissions, mortality and rurality among COVID-19 patients in South Carolina between January 2021 and January 2022 showed that rural residents accounted for 31% of all encounters for COVID-19, according to results published last year in the Journal of Community Health.
In the study, rural patients faced higher odds of overall hospital mortality (adjusted OR =1.19; 95% CI, 1.04-1.37) as both inpatients (aOR=1.18; 95% CI,1.05-1.34) and outpatients (aOR=1.63; 95% CI,1.03-2.59).
Months after COVID-19 vaccines became widely available, data published in MMWR showed that vaccination coverage was nearly seven percentage points lower in rural U.S. counties (38.9%) compared with urban counties (45.7%), with the disparity persisting across age groups. More recent data published in MMWR in March 2022 showed that the disparity continued, with coverage of one dose of vaccine estimated to be 58.5% in rural areas and 75.4% in urban counties.
Part of the experience of delivering care during the pandemic involved making specific adaptions in ID management, according to Healio | Infectious Disease News Editorial Board Member Raghavendra Tirupathi, MD, FACP, FIDSA, FRCP, an infectious disease physician for Keystone Health in Pennsylvania.
“Local health care practices have evolved to prioritize infectious disease preparedness, including the establishment of community-level response teams, enhanced surveillance, and targeted education campaigns to empower residents with accurate information,” he said. “It is a work in progress and a lot needs to be done.”
Although Hollingshead said rural hospitals have increased their pandemic preparedness “by leaps and strides,” that does not mean they are prepared for the next pandemic.
“Is anyone prepared?” she asked. “There are many conversations to be had about increasing our preparedness, and a lot of that is difficult for the rural physician and the rural hospital to tackle alone. In the end, I think we need national oversight and guidance.”
Telehealth ‘transformative’ for rural medicine
Among its many impacts on medicine, the COVID-19 pandemic helped move telemedicine into the mainstream, studies have shown.
According to Medicare and commercial health insurance data reported in Health Affairs, approximately 30% of all outpatient visits in the early months of the pandemic were conducted using telehealth.
“Telehealth services are continuing to expand as a potential solution to health care shortages, especially in rural areas,” Gupta said. “The demand from patients remains high because it is an easy way to connect with specialty providers. Expansion of telehealth is also reflected in the fact that many of the pandemic-era rules regarding telehealth” — including HHS waiving Medicare restrictions on remote care — “have been extended.”
Using telehealth during the pandemic, ID clinicians could remotely assess and manage cases of COVID-19, offer follow-up care, and educate patients and providers, Tirupathi said.
“Telehealth services have been transformative in rural practice,” he said. “The convenience and accessibility have fundamentally shifted how specialists engage with rural communities, providing ongoing support beyond the immediate challenges posed by the pandemic.”
A survey performed during the pandemic demonstrated that both patients and providers support telehealth. More than 73% of rural patients had favorable perceptions of telehealth visits, although satisfaction was generally higher among younger patients. Difficulty scheduling follow-up appointments, lack of personal contact and technology challenges were all listed as common barriers.
More than 80% of the providers responding to the survey reported that telehealth added value to their practice, with 36.6% agreeing that telehealth visits are more efficient than in-person visits.
“With the ongoing health care shortages, including in ID fellowships, access to ID care in rural hospitals will remain a challenge unless we can change the care delivery model,” Gupta said. “Patients are having more complex medical problems and for that specialty care is often needed. Telehealth can provide direct consultations and continuity of care. This can reduce health care costs and the strains on rural hospitals.”
Physicians who evaluated an ID telemedicine consult service employed by rural hospitals in the Mayo Clinic Health System found that it was associated with a decrease in 30-day mortality and hospital readmissions, according to results published in Open Forum Infectious Diseases.
“Telehealth services, particularly in rural America, are poised to endure as a significant and lasting change,” Tirupathi said. “The newfound reliance on remote consultations has addressed challenges related to distance and limited local expertise.”
Hollingshead said electronic consults between ID physicians and providers at rural hospitals during the pandemic consisted mostly of COVID-19 cases, but have shifted to more “bread and butter” ID cases.
“At the University of Toledo, we have a pretty robust telemedicine program that services six community hospitals around our area that wouldn't have access to an ID physician otherwise,” she said.
Complicated bloodstream infections are a common clinical issue for which rural hospitals seek an ID consult, Gupta said. According to Hollingshead, Staphylococcus aureus bacteremia is a common reason for consultation.
“Every patient with S. aureusreally benefits from an ID consult. That’s been shown in many studies,” she said.
One study published last year showed that consulting with an ID physician within 3 1/2 days of diagnosing a patient with S. aureus bacteremia increased adherence to five quality care indicators for treatment and shortened patients’ median hospital stays by more than 3 days.
Telehealth is also a practical way to reduce the stigma associated with providing care for sexually transmitted infections in rural areas, according to experts from the CDC’s Division of STD prevention.
“Telehealth is not only socially protective but is also simply practical,” they wrote in the journal AIDS and Behavior. “Calls for telehealth services have become more common for STI prevention, screening and care, particularly as self-collection testing kits and diagnostics availability has increased. Continued investment in the necessary infrastructure to coordinate care is needed.”
In their study about patient transfers from community hospitals without access to ID consultation, Hollingshead and colleagues said having the option to consult with an ID clinician can also help rural facilities optimize the selection of antibiotics.
Under a CMS rule announced in 2019 and enacted in 2020, all acute-care hospitals that participate in Medicare or Medicaid are required to have an antimicrobial stewardship program.
“But many hospitals don’t have access to an ID physician,” Hollingshead said. “Without those resources, they do the best they can.”
Many of these stewardship programs are overseen and managed remotely by an ID clinician, Gupta noted.
“That’s kind of where we are,” Hollingshead said. “A lot of the brunt of stewardship is done by our ID stewardship pharmacists or physicians.”
Addressing inequities
According to the CDC, Americans living in rural areas are more likely to die prematurely from five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke.
“The pandemic has illuminated existing health care inequities in rural America,” Tirupathi said. “Disparities in access to health care resources, including testing and vaccination sites, have become evident.”
In an October 2023 letter to the House Ways and Means Committee, which requested information on improving access to health care in rural communities, the IDSA noted that many medical procedures — including cancer chemotherapy — carry a risk for infection. Additionally, the organization said, many chronic conditions like diabetes and heart disease raise the risk for more severe infections, necessitating the need for better access to ID care in rural communities.
The IDSA made four recommendations to improve access to health care in rural communities, including a 10% payment increase for ID physician services that would be similar to previous incentive programs used in primary care and general surgery.
“Urgent action is needed to improve ID reimbursement in order to strengthen ID physician recruitment and expand Medicare beneficiary access to ID physician care in rural and underserved areas,” Healio | Infectious Disease News Editorial Board Member and then-IDSA president Carlos del Rio, MD, FIDSA, wrote.
“Access to ID care is critical to protecting the health of people who live in rural and underserved areas.”
References:
- American Society for Microbiology. CMS final rule on antibiotic stewardship programs. https://asm.org/articles/policy/2019/cms-final-rule-on-antibiotic-stewardship-programs. Published Oct. 18, 2019. Accessed Jan. 26, 2024.
- CDC. Telehealth in rural communities. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/telehealth-in-rural-communities.htm. Last reviewed Sept 8, 2022. Accessed January 26, 2024.
- Cole JC, et al. Clin Infect Dis. 2023;doi:10.1093/cid/ciad110.
- Del Rio C. Letter to the House Ways and Means Committee. Oct. 5, 2023. https://www.idsociety.org/globalassets/idsa/policy--advocacy/current_topics_and_issues/antimicrobial_resistance/strengthening_us_efforts/letters-manually-added/w-m-rfi-rural-areas.pdf.
- Giannouchos TV, et al. J Comm Health. 2023;doi:10.1007/s10900-023-01216-6.
- Hollingshead CM, et al. Infect Dis Ther. 2023;doi:10.1007/s40121-023-00810-4.
- IDSA. ID fellowship match results. https://www.idsociety.org/professional-development/student--resident-opportunities/id-match/match-resources/. Published Nov. 29, 2023. Accessed Jan. 18, 2024.
- Klee D, et al. BMC Health Serv Res. 2023;doi:10.1186/s12913-023-09994-4
- Murthy BP, et al. MMWR Morb Mortal Wkly Rep. 2021;doi:10.15585/mmwr.mmmm7020e3.
- National Resident Matching Program. 2022 appointment year. https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf. Accessed Jan. 18, 2024.
- Patel SY, et al. Health Affairs. 2021;doi:10.1377/hlthaff.2020.01786.
- Saelee R, et al. MMWR Morb Mortal Wkly Report. 2022;doi:10.15585/mmwr.mm7109a2.
- Tande AJ, et al. Open Forum Infect Dis. 2020;doi:10.1093/ofid/ofaa003.
- Valentine JA, et al. AIDS Behav. 2022;doi:10.1007/s10461-021-03416-4.
- Walensky RP, et al. Ann Intern Med. 2020;doi:10.7326/M20-2684.
For more information:
Nupur Gupta, DO, MPH, can be reached at guptan8@upmc.edu.
Caitlyn Hollingshead, MD, can be reached at caitlyn.hollingshead@UToledo.edu.
Raghavendra Tirupathi, MD, FACP, FIDSA, FRCP, can be reached at drraghutg@gmail.com.
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