Focus On...Rural Health

Addressing Rural Health from a Public Health Perspective

Peter D. Rumm, MD, MPH; Vinod Daniel, MBBS, MPH; Steve Marshall, MS; Thomas Anderson, RS; John Chapin

Wisconsin remains in many areas a rural state. On average, its population density is 98.8 persons per square mile. This population concentration makes it one of 22 states that fit the lowest topographic map density category in the United States (<103/sq. mile). Moreover, among Wisconsin’s 72 counties, 44 had populations under 50,000 in the 2000 Census. The population of these counties is about 1.7 million or about one third of the state population.

Author Affiliations: Authors are with the Division of Public Health, Department of Health and Family Services. Doctor Rumm is Chief Medical Officer and State Epidemiologist for Chronic Diseases, Bureau of Chronic Disease Prevention and Health Promotion; Daniel is Advanced Epi

Corresponding Author: Please address correspondence to the Wisconsin Medical Soceity at 608.442.3800

Pesticide Exposure, Host Susceptibility Factors and Risk of Parkinson’s Disease: An Introduction to a Work in Progress

Anne R. Greenlee, PhD; James K. Burmester, PhD; Bradley C. Hiner, MD

Background Parkinson’s disease (PD) is a common neurological disorder (second only to Alzheimer’s disease) and affects close to 1 million Americans. It occurs in all ethnic groups with an average prevalence of about 150/100,000 in North America and Western European countries. Both genetic and environmental factors are thought to influence the course of PD.1 Prevalence of PD in the United States is highest in five midwestern states—Iowa, Minnesota, Nebraska, North and South Dakota—where agrochemicals are used intensively, suggesting that pesticide exposure may contribute to disease etiology.2 Progressive disability results from tremor, muscular rigidity, slowing of movements (bradykinesia), and impairment of gait and balance.3 The clinical features of PD are the result of neuronal loss in the dopamine-producing region of the upper brainstem, the substantia nigra.4 The presentation of PD can be broadly classified as “early onset” with symptoms typically occurring before the age of 40, or “idiopathic,” also referred to as “sporadic,” with symptoms appearing typically after the age of 50.



Author Affiliations: Drs. Greenlee and Burmester are with Marshfield Medical Research Foun-dation, Marshfield, Wisconsin. Doctor Hiner is with the Department of Neurology, Marshfield Clinic, Marshfield, Wisconsin.

Corresponding Author: Correspondence to Anne R. Greenlee, PhD, Marshfield Medical Research Foundation, 1000 N Oak Ave, Marshfield, WI 54449; 715.389.4012; Fax 715.389.3808; e-mail: greenla@mfldclin.edu.

Recruiting Physicians to Rural Areas

Marc Kennedy

Attracting and retaining quality physicians, nurses and technical specialists are as much a facet of the rural medical milieu as church socials, red barns and small-town cafes are to the landscape of the state’s less populated environs. But with today’s nationwide shortage in the health care workforce, the task is not easy. And according to many prognosticators, it’s a problem that could last years into the future.


Author Affiliations: Special for WMJ

Corresponding Author: Please address correspondence to Wisconsin Medical Society at 608.442.3800

One Successful Approach

Marc Kennedy

So often it’s the case that if there is a problem statewide, it’s more apparent in rural areas,” says Tim Size, executive director of the Rural Wisconsin Health Cooperative. The problem to which Size refers is a shortage of health care professionals in many areas nationwide. “We already have higher shortage rates; the demographics for rural Wisconsin now look like what the rest of the country will look like in 10 to 20 years.”

Author Affiliations: Special for WMJ

Corresponding Author: Please address correpondence to the Wisconsin Medical Society at 608.442.3800

Editorials

The textured landscape that is rural health in Wisconsin

Thomas C. Meyer, MD, Medical Editor, WMJ

As summer wanes, this topic brings to mind headlines no doubt we’ve all read—those about children and adults injured on the farm during the harvest season. But this is just one part of the rural health landscape. And although we certainly have not exhausted the subject in this issue of the Journal, we hope we have conveyed some of its many facets.


Author Affiliations: Medical Editor, WMJ

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Commentary: Rural Health Can Help Lead The Way

Tim Size

Rural health, both clinically and administratively, has always been a great field in which to work. Addressing above average challenges with below average resources means that the work stays challenging. The smaller scale of most rural health organizations allows more opportunity to generalize, to appreciate the linkages among diverse practices and issues. And innovation has always been easier in smaller, less bureaucratic organizations. Rural people have traditionally appreciated the value of individual relationships and institutional collaboration within the community. Now, we are beginning to understand that rural health is also playing a key role in helping to transform the American health care “system.” Where but in rural health is more done with less? Rural health care presents an important opportunity to better understand how to deliver cost-effective care under challenging circumstances.



Author Affiliations: Mr. Size is the Executive Director of the Rural Wisconsin Health Cooperative, Sauk City, WI.


Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Antibiotic Resistance: Unnatural selection in the office and on the farm

William A. Agger, MD

Antimicrobial drugs are one of the greatest advances of medical science, and the practice of modern medicine is heavily dependent on their effectiveness. Unfortu-nately, after more than a half century of increasing antimicrobial use, related in part to a rising human population, now greater than 6 billion, bacterial resistance has become a worldwide problem both in humans and in animals.

Author Affiliations: Doctor Agger is Director of Microbiology and Chief of Infectious Disease at Gundersen Lutheran Medical Center in La Crosse, WI.


Corresponding Author: Please address correpondence to the Wisconsin Medical Society at 608.442.3800

Original Research

A Smoking Cessation Clinic with a 57% Success Rate: What Makes it Work?

Brenda Rooney, PhD; Kim Sakis, BS, CHES; Sarah Havens, BS; Christine Miller, MD

Objective: To describe an outpatient smoking cessation clinic, and what predicts participant success.

Methods: In 1999, a 12-week smoking cessation clinic was begun. In 2000, the duration was expanded to include an additional 12 weeks of relapse prevention. Participants completed surveys at the beginning and end of their clinic. All participants, even those who dropped out, were surveyed to determine current status. If they were not reached, they were assumed to be smoking.

Results: Eleven clinics have been completed thus far, with 117 people enrolling. Of all participants, 57% were not smoking at their last contact (average length of follow-up was 14 months). Age, baseline smoking rate, and presence of a non-smoking support person were the best predictors of abstinence.

Conclusions: A 57% abstinence rate was achieved in this outpatient clinic, serving a mix of rural and non-rural patients.



Author Affiliations: Authors are with Gundersen Lutheran Medical Center, 1836 South Avenue, La Crosse, WI 54601.


Corresponding Author: Please address correspondence to Gundersen Lutheran Medical Center

Colorectal Cancer Screening: Physician Attitudes and Practices

Mary Lou Taylor, PhD; Ruric (Andy) Anderson, MD

Purpose: The American Cancer Society (ACS) set a nationwide goal to increase to 75% by 2015 the proportion of people aged 50 and older who have colorectal cancer (CRC) screening consistent with ACS guidelines. Little is known about current physician screening practices and attitudes. The purpose of this study was to document current physician attitudes and practices regarding CRC screening, and to formulate appropriate interventions to meet the ACS screening goal. Methods: Questionnaires were sent to a random sample of 600 primary care physicians in Wisconsin. The survey measured 1) screening preferences; 2) estimates of patients screened by each method; 3) agreement to statements regarding screening guidelines and practices, patient compliance, effectiveness in reducing mortality, factors regarding colonoscopy as a screening tool; 4) use of reminder systems; 5) demographics. Results: Physicians prefer combining fecal occult blood testing (FOBT) with flexible sigmoidoscopy for CRC screening, while they believe patients prefer FOBT alone. Only 1.5% view colonoscopy as their preferred method of screening. There is discrepancy between physicians’ beliefs that patients should be screened and estimated numbers they screen. Only 38.2% of respondents would screen a moderate-risk patient at the ACS recommended age. Physicians perceive screening compliance to be low. Cost, availability, risks, and lack of proof of effectiveness influence physician decisions. Fewer than half have any reminder system for CRC screening. Conclusions: CRC screening rates are currently lower than the 2015 ACS goal. Influential factors include physician attitudes and beliefs about effectiveness, familiarity with guidelines, perception of patient preferences and compliance, and lack of adequate reminder systems. Targeting interventions to these factors may increase the rate of CRC screening. Despite increased consensus from professional societies on colonoscopy as the best choice for screening, few primary care physicians would choose this option.

Author Affiliations: Authors are with the Medical College of Wisconsin. Dr. Taylor is with the Pain Management Center; Dr. Anderson is with Dept. of General Internal Medicine. This study was supported by the American Cancer Society, Midwest Division, Wisconsin Council.

Corresponding Author: Reprint requests to: Mary Lou Taylor, PhD, Pain Management Center, Medical College of Wisconsin, FMLH East Clinics, 9200 West Wisconsin Ave, Milwaukee, WI 53226; 414.805.6150; Fax 414.805.6154; e-mail mltaylor@mcw.edu.

Polypoid Angiomyofibroblastoma: A Case Report and Review of the Literature

Michael McCormick, MD; Suzanne Riley, MD

A case of a polypoid angiomyofibroblastoma of the distal anterior vaginal vault in a 56-year-old woman is presented. Clinical, histological, and immunohistochemical features of this entity are discussed, along with the differential diagnosis and a review of the literature.



Author Affiliations: Authors are with Holy Family Medical Center, Department of Pathology, Manitowoc, Wis.


Corresponding Author: Please address correspondence to the Wisconsin Medical Society

Atypical Presentation of Subarachnoid Hemorrhage: Case Report and Review of the Literature

Mark N. Weissman, MD, FACS

Subarachnoid hemorrhage is a threatening condition often associated with significant morbidity and mortality. The risk of rebleeding and ischemic complications can be markedly reduced when the prompt diagnosis of cerebral aneurysmal rupture is made. The sudden onset of severe headache with or without neurologic deficit raises the clinical suspicion, however atypical symptoms exist making the diagnosis difficult. A 49-year-old male with a 3-day history of neck discomfort, without headache, was admitted following a generalized seizure. A serum sodium of 115mEq/L was noted. A computed tomographic scan of the brain revealed a subarachnoid hemorrhage. Two intracranial cerebral aneurysms were identified by cerebral angiography and subsequently treated. The diagnosis and treatment of subarachnoid hemorrhage is reviewed.



Author Affiliations: Doctor Weissman is Board Certified by the American Board of Neurological Surgery and has been in the private practice of General Neurosurgery since January, 1986. He currently is an Attending Neurosurgeon at the Wausau Hospital and is Chief of Surgery at

Corresponding Author: Please address correspondence to Wisconsin Medical Society at 608.442.3800

Your Practice

Strengthening a longstanding commitment to rural health

Philip M. Farrell, MD, PhD

In Wisconsin, where one third of all residents live a significant distance from a major urban center, it is difficult for medical educators to ignore the unique challenges of providing health care in rural areas. The challenges include problematic access to care, distance barriers to education and, above all, an inadequate workforce.



Author Affiliations: Doctor Farrell is Dean, University of Wisconsin Medical School, and Vice Chancellor for Medical Affairs at UW-Madison.


Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Changes ahead for Medicare appeals process

Daniel F. Miller, JD

The letter from the Medicare Carrier arrived unexpectedly, as the physician’s office staff had responded to the last request for information concerning the postpayment audit several months earlier. Nonetheless, the letter stated that the Carrier had completed its audit of the physician’s claims for 20 patients with a particular CPT code over a six-month period, and the Carrier had determined that the services provided to 12 of the patients were not medically necessary. Based upon this sampling, which the Carrier deemed a statistically valid random sample, it concluded that the 60% overpayment rate should be applied to all of the physician’s claims for the particular CPT code over a three-year period, and it demanded that the physician return more than $200,000 in Medicare reimbursement in recognition of this overpayment. Further, payment was expected in full within 30 days or interest at the rate of 13% per annum would be applied to any outstanding balance, which would be taken from future Medicare remittances until the outstanding balance and all accrued interest was repaid.



Author Affiliations: Miller is an attorney in the Milwaukee office of Whyte Hirschboeck Dudek. A member of the Health Care Law group, he focuses his practice in the area of health law litigation on behalf of hospitals, physicians and other health care providers. Miller’

Corresponding Author: He can be contacted via e-mail at dmiller@ whdlaw.com