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August 6, 2018

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Fax: 202-639-0559

Debra Houry, MD, MPH
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
4770 Buford Highway NE., Mailstop F-63
Atlanta, Georgia 30341

Re: Traumatic Brain Injury Disparities in Rural Areas (TBIDRA) - 83 Fed. Reg, 26464 (July 7, 2018)/Docket No. CDC-2018-0052

Dear Dr. Houry,

The National Rural Health Association (NRHA) is pleased to offer comments on the CDC Traumatic Brain Injury Disparities in Rural Areas (TBIDRA) project. We appreciate your continued commitment to the needs of the 62 million Americans residing in rural and underserved areas, and look forward to our continued collaboration to improve health care access and quality.

NRHA is a non-profit membership organization with more than 21,000 members nation-wide that provides leadership on rural health issues. Our membership includes nearly every component of rural America’s health care infrastructure, including rural community hospitals, critical access hospitals, doctors, nurses and patients. We work to improve rural America’s health needs through government advocacy, communications, education and research.

We appreciate the CDC’ continued emphasis on narrowing the gap between rural patients and the providers. This letter outlines suggestions for which the NRHA believes this project can be strengthened. We look forward to our continued collaboration in ensuring the twenty percent of Americans living in rural areas have the access to critical health care services in their local communities they need following traumatic brain injury.
www.RuralHealthWeb.org

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Sixty percent of trauma deaths occur in rural America, while only 20 percent of the population calls rural home. The literature on limitations regarding access to trauma care in rural America are well documented, as is the fact that rural residents are more likely to die from a similar traumatic event than their urban counterparts (an increase in mortality of 14 percent for rural residents according to one study). The concerns for traumatic brain injury care include limited access to emergency care as well as limited access to follow up care which impacts longevity as well as quality of life. NRHA is pleased CDC is undertaking a study of rural specific traumatic brain injury (TBI).

Access to quality, affordable health care is essential for the 62 million Americans living in rural and remote communities. Rural Americans are more likely to be older, sicker and poorer then their urban counterparts.  Access in rural America is impeded by not only geography, but also by decreasing reimbursements, physician shortages, and excessive regulatory burdens. This is exacerbated by the increasing crisis of rural hospital closures. Eighty-seven rural hospitals have closed since 2010. Even more concerning is that 673 rural hospitals are at risk of closure, meaning sustained Medicare cuts threaten the financial viability of 1 in 3 rural hospitals. 

Medical deserts are appearing across rural America, leaving many of our nation’s most vulnerable populations without timely access to care, especially in an emergency when every moment matters. Seventy-seven percent of rural counties in the U.S. are Primary Care Health Professional Shortage Areas while nine percent have no physicians at all. Rural seniors are forced to travel significant distances for care, especially specialty services. In an emergency, rural American travel twice as far as their urban counterparts to receive care. Furthermore, in an emergency rural EMS is increasingly overburdened with longer transport times as rural hospital closures extend the distance to a hospital in many rural communities.

NRHA urges the inclusion of a variety of different communities, including ones that have lost their hospital or are in danger of the local hospital closing. Each rural area is different and unique with a varied mix of likely sources of TBI and different types of providers of care. Including this variety will provide a better understanding of care for TBI in rural America, including the various types of challenges in accessing care.

We appreciate the include of a broad scope of rural providers include NP and PAs, these providers are an important component of the rural health care workforce. NRHA urges the inclusion of providers providing care through telehealth, this is an important source of local care in rural America and will provide a more wholistic view of care in rural America. We encourage CDC to examine other provider types that play a role in patient care post TBI including for example optometrists and physical or occupational therapists. These providers can serve both as an entry point for care or as an essential member of the care team once TBI is diagnosed. For example, for patients who may not realize they suffered a brain injury, a yearly comprehensive eye exam can detect visual signs that may indicate a TBI and lead to referrals to other members of the TBI care tam. This is an important entry point into TBI care, without which many patients may continue to needlessly suffer from untreated TBIs. These varied sources of care are  reflective of the limited number of providers in rural America and the fact that rural providers often provide broader scope of care and work to the top of their licensure to ensure patients receive the necessary care.

Thank you for the chance to offer comments on this proposed rule, and for your consideration on our comments. We very much look forward to continuing our work together to ensure our mutual goal of improving quality of and access to care. If you would like additional information, please contact Diane Calmus at dcalmus@nrharural.org, or 202-639-0550.

Sincerely,

Alan Morgan

Chief Executive Officer

National Rural Health Association

www.RuralHealthWeb.org