Open Spaces Everywhere and Not a Rad in Sight

How Rural Populations are Being Shortchanged on Medical Imaging Services—And What Radiology Can Do About It

A woman living in the suburbs of a midsize U.S. city finds a lump in her breast. She calls her primary care provider, who sees her immediately and refers her to a breast-imaging center. There she undergoes diagnostic mammography the day after her concerning discovery. She and her doctor know the results in a matter of hours.  

Many miles away, somewhere in the vast farmlands of the Great Plains, another woman self-detects a breast lump. Deciding the lump doesn’t hurt and isn’t seriously troublesome, she puts off calling a doctor. It’s just too much bother, she figures, to miss work for a long ride to a medical appointment outside of an emergency. Besides, she believes she can’t afford any doctors’ bills right now anyway. 

Poles-apart scenes like these probably play out frequently if not daily all across America. For, when it comes to accessing important radiology services—not just for breast care but for all health issues—rural populations are getting short shrift. 

And while the cracks to fall through are not the fault of radiology per se, researchers and rural radiologists agree that much needs to be done if location-based disparities are to be cut down to size.  

“It’s a crisis—one that’s being fueled by multiple catalysts,” says Eric Friedberg, MD, who works for Emory University’s division of community radiology specialists and serves as vice chair of the ACR’s commission on general, small, emergency and/or rural practices. “We need to be addressing this situation from multiple angles.” 

That seems a sound recommendation, given U.S. Census Bureau data showing that roughly 60 million people—1 in 5 Americans—live in rural areas. 

Obstinate Obstacles

All too often, the tipping point for rural residents is their healthcare budget—or lack thereof—on top of their distance from healthcare providers. And that double-team block sometimes only tells the beginning of the story. 

Amy Patel, MD, Liberty Hospital Women’s Imaging/University of Missouri

“Affordability is definitely at the top of the list,” says Amy Patel, MD, medical director of Liberty Hospital Women’s Imaging in Liberty, Mo., and clinical assistant professor at the University of Missouri-Kansas City School of Medicine. “Many patients are either uninsured or underinsured, or they’re dependent on Medicaid/Medicare coverage. Many others don’t have access to transportation or cannot afford the gas to drive.  Childcare—or really, lack of childcare—also can be a problem.”

A limited understanding of how modern healthcare works is not infrequently a part of the mix. Overall,  rural populations tend to be less “in the know” than suburban and urban populations, notes Daniel Ortiz, MD, of Summit Radiology Services in Cartersville, Ga. 

A limited understanding of how modern healthcare works is not infrequently a part of the mix. Overall, rural populations tend to be less up to speed than suburban and urban populations, notes Daniel Ortiz, MD, of Summit Radiology Services in Cartersville, Ga. 

“Often a lack of education—and interestingly, a growing mistrust of science—causes people from rural areas to avoid care, including imaging services, and to discount its importance,” he says. 

This is particularly true of asymptomatic diseases, Ortiz notes. “When faced, for example, with the choice of whether to pay to sign up a child for soccer or go for a recommended imaging procedure,” he adds, “they’ll often pick soccer.”

Meanwhile elements inherent to the rural life sometimes short out the inclination to seek care, states radiologist David Lerner, MD, of the University of Washington. Lerner recalls an incident he witnessed while working in rural Kansas some years ago. The episode began when a 90-year-old farmer went to the emergency room after falling from a combine.

“He waited 12 hours before going to the hospital,” Lerner recalls for RBJ. “An imaging procedure quickly showed he had fractured his neck.” 

Why did the man wait so long to act on what must have been terrible pain? “Because he had to finish his work first and didn’t want to go to the emergency room until he ‘needed’ to,” Lerner says. “He said, ‘Son, the crops ain’t gonna pick themselves.’”

New Ways Needed 

With that, Lerner realized that dedication to work is likely a common complicator for rural residents who avoid “going to see a doctor” until an illness or injury gets bad enough to come between them and their job.  

Other underreported factors only exacerbate the problem. It must be noted, Friedberg says, that rural hospitals are closing at an alarming rate. More than 100 such facilities have shut their doors since 2010, he points out. And of those that remain open, a distressingly high percentage are either operating in the red or living on the brink of bankruptcy. 

“On top of that, when hospitals close, job loss follows,” Friedberg adds. “The end result is distress to the communities they serve, since these hospitals are commonly one of the largest employers—if not the very largest—in their communities. This in turn puts care for some rural residents even further out of reach.” 

Worse still, Patel points out, new and jobhunting radiologists tend to gravitate toward suburban and urban opportunities, not toward openings “out in the country.” As a result, she notes, subspecialized radiologists and interventionalists are a rarity in rural locations.

Some experts believe the answers will emanate from providers’ willingness to innovate and open themselves to new ways of doing business. For example, Patel would like to see radiology practices and departments find ways to solve patients’ transportation challenges. 

“Sometimes, for patients with a vehicle, the difference between getting care and not getting care is as simple as supplying a gas card,” she observes. “Other times, it’s affording another kind of transportation.” She has applied for and received grants to tackle this issue.

Lerner believes efforts to increase access among any underserved population should include considering patients’ financial concerns.  

“It would be great if imaging providers could work with patients on payment plans that would make getting care more manageable for them,” he says. “Some are ready to do it now, but more need to follow.”

Time, Effort—and Results 

Adapting services to better meet rural patients’ unique challenges can go far in encouraging them to keep up with their own care, leading to earlier detection of sickness, higher quality of life and lower total costs of care. 

For example, Lerner suggests, consider the patient who has driven far for imaging only to find the exam can’t be performed due to an error in the order. 

“There’s a good chance that patient won’t make a second trip for a rescheduled exam,” Lerner says. “An openness to picking up the phone and seeing about having the order changed or corrected, right then and there, would prevent many [rescheduled no-shows] from happening.”

Education—for referring physicians and imaging-service providers as well as for patients—is another area where radiology can, as one source puts it, “move the needle of care for rural populations in the right direction.” 

Thinking similarly along those lines, cardiothoracic radiologist Tina Tailor, MD, of Duke University and Duke Health believes radiology must undertake initiatives to ensure that primary care physicians are fully familiar with screening guidelines. 

The deeper the understanding of the guidelines, the stronger the doctor’s push for patients to regularly get screened, Tailor suggests.

Patel concurs. She frequently meets with hospital executives, administrators and referring physicians and addresses audiences at events like “lunch and learn” sessions to discuss, among other topics, the importance of breast cancer screening and share ways to engage patients in their own care.

Patel also ensures that radiology departments and technologists working in the rural and community hospitals in which she oversees breast imaging have the tools and equipment they need to provide the highest caliber of care to their patients. 

When local hospitals installed 3D imaging equipment, she provided support, educating breast-care colleagues on protocols and techniques.

“Yes, these activities take time and effort,” Patel says. “However, it’s radiology’s duty to invest that time and effort—especially if you’re the lead interpreting radiologist or oversee any type of imaging in a radiology department. Without [your] effort, we can never hope to break down the barriers to care faced by rural populations in this country.”

Talking Telehealth

Telehealth and teleradiology have been tagged as a potential panacea for what ails rural radiology. Sources believe the idea of using telehealth solutions likely holds appeal for some patients who would readily seek out imaging services—if not for a lack of transportation, an inability to find childcare, scheduling conflicts or similar challenges and obstacles.

“There are many patients who would, under different circumstances, go for screenings or pay attention to instructions to ensure they get follow-up care,” Tailor says. “They don’t only because they don’t own a car, or they can’t take a day off work to travel to a faraway imaging center or hospital, or something of that nature. For them, telehealth would be a solution. Maybe not a perfect solution, but a solution.”

When RBJ spoke with Tailor, Duke Health was preparing to implement a telehealth platform to provide remote counseling for patients undergoing lung cancer screening. “We think the platform and others like it will be very effective in giving patients, including those from rural areas, fewer reasons to not receive the care they require,” Tailor says.

Friedberg agrees, adding that out-of-the-box approaches to minimizing or reducing cost-based implementation obstacles could make teleradiology a more viable remedy for rural radiology ills.  

“Funding the capital costs for implementing new technology can be quite significant, though,” he says. “Rarely are these communities fortunate enough to have high net worth individuals whose leisure-time pursuits take them to remote locations, such as skiers to the Pacific Northwest, who may be willing to make generous donations to ensure access to quality care. Most commonly, the solution to these challenging funding issues has proven to be daunting. 

“The answer commonly depends on many variables,” Friedberg adds. “But on a go-forward basis, it will likely require some combination of local business and/or community investment. And if these facilities are going to survive while supporting financially distressed populations, [local investments] will need to be combined with improved and sensible federal reimbursement approaches.” 

All In on All Angles 

Patel recognizes the benefit of using teleradiology to provide increased, higher-caliber imaging services to rural populations—but also voices concerns about the downsides. “In situations where there are remote reads or a teleradiology service, there could be longer wait times due to factors such as different types of internet connections,” she says.

She further notes that, while telehealth solutions can bridge gaps in radiology services—and other types of healthcare—the technology may also remove some of the human element from the equation. 

“The absence of a face-to-face conversation can be an issue if additional testing is needed,” Patel says.

Tailor has similar reservations. But she frames them within the broader challenge at hand. 

“We need a defined process for situations where telehealth is used to ‘reach’ rural patients, because without one, it’s inevitable that many patients will still slip through the cracks,” Tailor says. “And above all, we need to remember that telehealth is just one way to address disparities in the delivery of imaging services to rural and non-rural populations. The more angles from which we address the problem, the better.”