Rural Health
Research Gateway

Alana Knudson, PhD, EdM

Director, Rural Health Equity Research Center

Phone: 301.908.0835
Email: Knudson@etsu.edu

East Tennessee State University
College of Public Health
PO Box 70623
Johnson City, TN 37614

Current Projects - (6)

  • Building the Rural Evidence Base: Examining the Feasibility of Implementing Pilot Programs and Demonstrations in Rural Communities
    Evidence-based interventions are commonly developed in populated, urban centers and then adapted for rural communities. This project will investigate the benefits of piloting and evaluating interventions in rural areas to build the rural evidence base as a step in addressing health disparities and improving health conditions in rural communities.
    Research center: Rural Health Equity Research Center
    Topics: Health disparities and health equity, Health promotion and disease prevention, Health services
  • Examining Differences in Rural and Urban Medicare FFS Beneficiaries' Emergency Department Use Pre-COVID-19 and During COVID-19
    This study describes and compares the differences in the utilization of emergency department (ED) services among rural and urban Medicare Fee-For-Service enrollees during 2018-2021. We will identify factors associated with differences in ED use, including shifts in volume, primary diagnoses, and admission source, before and since the COVID-19 public health emergency in rural and urban areas.
    Research center: Rural Health Equity Research Center
    Topics: Coronavirus Disease 2019 (COVID-19), Critical Access Hospitals (CAHs), Emergency medical services (EMS) and trauma, Health disparities and health equity, Healthcare access, Hospitals and clinics, Medicare, Social determinants of health
  • Examining Post-Acute Care Utilization and Outcomes for Rural Medicare FFS and Medicare Advantage Beneficiaries
    This study will describe differences in post-acute care utilization and post-discharge outcomes between rural Medicare Fee-for-Service beneficiaries and rural Medicare Advantage beneficiaries overall and by region of the country, levels of rurality, and race and ethnicity.
    Research center: Rural Health Equity Research Center
    Topics: Care management, Critical Access Hospitals (CAHs), Healthcare access, Home health, Medicare, Medicare Advantage (MA), Post-acute care
  • Hierarchical Condition Category (HCC) Risk Scores: Designed to Predict Future Cost and Health Care Resource Use – Do They Also Accurately Reflect Differences in Health Status between Rural and Urban Beneficiaries?
    This CMS Hierarchical Condition Category (CMS-HCC) risk score study will investigate differences in underlying health between rural and urban populations using recent data and analyze which factors drive observed differences.
    Research center: Rural Health Equity Research Center
    Topics: Health disparities and health equity, Health services, Healthcare access, Hospitals and clinics, Medicaid and CHIP, Medicare, Medicare Advantage (MA)
  • Rural and Urban Sepsis Outcomes as a Measure of Health Care Quality: A Nationwide Comparative Analysis Using HCUP Data
    This study examines differences in sepsis prevalence, outcomes, costs, and treatment between rural and urban hospitals using the HCUP Nationwide Readmissions Database. It aims to inform policies related to access to timely, high-quality sepsis care and identify strategies to enhance healthcare outcomes across diverse hospital settings.
    Research center: Rural Health Equity Research Center
    Topics: Care management, Critical Access Hospitals (CAHs), Emergency medical services (EMS) and trauma, Health disparities and health equity, Healthcare access, Hospitals and clinics, Medicaid and CHIP, Medicare, Medicare Advantage (MA), Private health insurance, Quality, Social determinants of health
  • Rural/Urban Differences in Forgoing Health Care during the COVID-19 Pandemic
    Several surveys conducted during the COVID-19 pandemic showed that adults delayed or skipped healthcare services during the initial months of the COVID-19 pandemic. This study examines changes in healthcare utilization for primary and preventative care among rural and urban Medicare fee-for-service enrollees since the COVID-19 pandemic.
    Research center: Rural Health Equity Research Center
    Topics: Aging, Care management, Chronic diseases and conditions, Coronavirus Disease 2019 (COVID-19), Diabetes, Health disparities and health equity, Health promotion and disease prevention, Health services, Medicare, Mental and behavioral health, Minority health, Telehealth

Completed Projects - (7)

  • Examination of Rural and Frontier Home Health Services
    This mixed-method study is an in-depth examination of access to and utilization of home health services provided in rural and frontier areas. The study begins to explore how influential patient-centered decision-making is in determining the type of post-acute care services used by rural and frontier Medicare beneficiaries.
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Frontier health, Home health, Post-acute care
  • Exploring Global Budgets as a New Reimbursement Model for Low-Volume Critical Access Hospitals
    Given the complexity of the Global Budget reimbursement model, we were interested to learn if there are aspects of the model that could be applied to consolidate reimbursement across rural and frontier health care settings, particularly for CAHs with low-volume (e.g., < 5 acute patients as a daily census).
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Critical Access Hospitals (CAHs), Healthcare financing, Hospitals and clinics
  • Exploring Rural and Urban Mortality Differences
    This project examines the impact of rurality on mortality and explores the regional differences in the primary and underlying causes of death. It also explores the role of the rural public health systems in addressing social determinants of health.
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Public health, Social determinants of health
  • Hospitalizations of Rural Children for Ambulatory Care Sensitive Conditions
    This project uses state inpatient discharge data from six states, data from the Area Resource File and the AHRQ Pediatric Quality Indicators to examine Ambulatory Care Sensitive Condition admission rates for rural children.
    Research center: Upper Midwest Rural Health Research Center
    Topics: Children and adolescents, Chronic diseases and conditions
  • Impact of Health Insurance Coverage on Native Elder Health: Implications for Addressing the Health Care Needs of Rural American Indian Elders
    This project examined the types of health insurance coverage of rural Native American elders ages 55 and older, and examine how different types of health insurance coverage and lack of health insurance coverage impact access to health care services among Native American elders by geographic location (rural frontier, rural non-frontier and urban).
    Research center: Upper Midwest Rural Health Research Center
    Topics: Aging, American Indians and Alaska Natives, Frontier health, Healthcare access, Minority health, Private health insurance, Rural statistics and demographics, Uninsured and underinsured
  • Perspectives of Rural Hospice Directors
    Rural hospice care, as it is currently configured, is under pressure by a variety of factors (e.g., policy and regulation, economic and financial, and organizational and structural) which are reviewed in this document. However, a central core element of rural hospice remains the strong sense of community that is embodied in the system (i.e., typically a small non-profit arrangement) and design (i.e., a delivery system reliant on community connections and personal relationships) of care. This policy brief is the result of a national phone survey of rural hospice directors or key staff in 47 states. Fifty-three directors or key staff members were interviewed during a three-month period in 2013.
    Research center: North Dakota and NORC Rural Health Reform Policy Research Center
    Topics: Aging, Health services, Quality, Telehealth
  • Rural-Urban Analysis of Persistent Health Professional Shortage Areas
    The study described rural-urban differences in persistent Health Professional Shortage Area designations for primary care, mental health, and dental care between 2010 and 2020, including those located in persistent poverty and majority minority counties.
    Research center: Rural Health Equity Research Center
    Topics: Healthcare access, Mental and behavioral health, Oral health, Workforce

Publications - (19)

2023

2022

  • Meeting the Behavioral Health Needs of Farm Families in Times of Economic Distress
    Policy Brief
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 02/2022
    Economic fluctuations and periods of distress in farming cannot be eliminated, however, their impact on communities and individuals can be mitigated. Strategies for meeting the behavioral health needs of farm families by supporting community-based services, and expanding behavioral health services in rural contexts are highlighted in this work.
  • High-Performing Rural Health System
    Policy Brief
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2022
    This document updates the RUPRI Health Panel's framework, for a high-performing rural health system, originally published in 2011. It offers a revised vision statement and updates the high-performing rural health system pillars (access, affordability, community health, and quality) and describes an underlying base of equity considerations.

2021

  • Advancing Population Health in Rural Places: Key Lessons and Policy Opportunities
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2021
    This paper advances policy discussion of population health in rural places, focusing on the role of rural healthcare organizations. Lessons from ongoing programs provide policy considerations. Medicare and Medicaid programs should prioritize staff and infrastructure development, flexibility in covered benefits, and further expansion of telehealth.
  • Characteristics and Challenges of Rural Ambulance Agencies – A Brief Review and Policy Considerations
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 01/2021
    There are 23,272 ambulance agencies in the U.S., and 73% of those agencies report serving rural areas. This paper examines current rural ambulance agency characteristics and challenges and identifies public policy considerations designed to stabilize rural ambulance agencies.

2020

  • Considerations for Defining Rural Places in Health Policies and Programs
    Report
    RUPRI Health Panel: Rural Policy Analysis and Applications
    Date: 05/2020
    Rural definitions in statute and policy are used to direct resources to underserved people. But changes in population behavior and census processes have led to concern about historic methods of defining rural. This paper identifies key questions, reviews rural definitions, and discusses options for reconsidering rural definitions.

2017

2016

  • Exploring Rural and Urban Mortality Differences
    North Dakota and NORC Rural Health Reform Policy Research Center
    Date: 03/2016
    Contains visual aids which display indicators of mortality rates by cause of death, age group, rural-urban status, region, and sex for populations 15 years of age and older cross-referenced to tables and statistical results.

2015

  • Perspectives of Rural Hospice Directors
    Policy Brief
    North Dakota and NORC Rural Health Reform Policy Research Center
    Date: 03/2015
    Rural hospice care is under pressure by a variety of factors that are reviewed in this document. However, a central core element of rural hospice remains the strong sense of community that is embodied in the system and design of care. This policy brief is the result of a national phone survey of rural hospice directors or key staff in 47 states.

2014

  • The 2014 Update of the Rural-Urban Chartbook
    Chartbook
    North Dakota and NORC Rural Health Reform Policy Research Center
    Date: 10/2014
    This chartbook includes trends and disparities in urban/rural health. Reports on population characteristics include age, race and ethnicity, and poverty; risk factors such as smoking, alcohol use, and obesity; mortality data; health status measures such as adolescent births and total tooth loss; healthcare access/use; and mental health measures.
  • Rural-Urban Disparities in Heart Disease
    Policy Brief
    North Dakota and NORC Rural Health Reform Policy Research Center
    Date: 10/2014
    The Department of Health and Human Services' report Health, United States, 2001: With Urban and Rural Health Chartbook illustrated trends and highlighted priorities in urban/rural health. The Rural Health Reform Policy Research Center replicated the analyses using the most recent data available. This brief highlights key heart disease findings.

2010

2008

2007

2005