NIH GUIDE, Volume 21, Number 16, May 1, 1992

PA NUMBER:  PA-92-71

P.T. 34


  Health Services Delivery 

  Community/Outreach Programs 

  Disease Prevention+ 

  Health Promotion 

Agency for Health Care Policy and Research


The purpose of this program announcement (PA) is to stimulate the

development of new research in the areas of delivery, organization, and

financing of rural health services.  The Agency for Health Care Policy

and Research (AHCPR) invites research applications that address

important research questions in rural health.


The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a statement of national health goals in 21 priority areas, to be met by

the year 2000.  Many of the issues addressed within the broad range of

topics covered by this PA, Health Services Research on Rural Health,

are related to these priority areas.  Potential applicants may obtain

a copy of "Healthy People 2000" (Full Report:  Stock No.

017-001-00474-0) or "Healthy People 2000" (Summary Report:  Stock No.

017-001- 00473-1) through the Superintendent of Documents, Government

Printing Office, Washington, DC 20402-9325 (telephone 202-783-3238).


Applications may be submitted by domestic and foreign non-profit

organizations, public and private, including universities, clinics,

units of State and local governments, non-profit firms, and non-profit

foundations.  Applications from minority and women investigators are



This PA is intended for the traditional research grant program (R01).

Responsibility for the planning, direction, and execution of the

proposed project will be solely that of the applicant.  It is

anticipated that projects will vary from one to three years in length.

Project lengths may be up to five years in rare cases due to the

complexity or breadth of the subject area.



AHCPR conducts and supports research, demonstrations, and evaluations

of the quality, appropriateness, and effectiveness of health care

services and systems for the delivery of such services.  This

announcement focuses on these issues in respect to rural areas and

underserved populations residing in rural areas.

New rural health problems have developed in recent years and some rural

health problems have worsened.  Newly emerging rural health issues such

as AIDS, State and Federal policy changes, and increased emphasis on

managed care have been woven into the research agenda with longstanding

issues, such as health professionals, emergency services, and care of

indigent persons.  In addition, there is increasing interest in

learning whether or not differences in care delivered to rural

residents, compared to urban counterparts, are associated with

different health outcomes.


The following topic areas and questions are illustrative of relevant

research needed to improve the scientific base for informed rural

health policy recommendations.  The issues raised in the different

sections are often interdependent; those raised in a particular section

may be applicable to topics in other sections as well.


A key issue facing policy makers is ensuring access to care in rural

areas where small hospitals have closed, other health facilities are

having financial difficulty, availability of primary health care

practitioners is declining, and mid-level practitioners are leaving

practice or leaving the rural area.

o  What are the dimensions and characteristics of access problems in

rural areas?  What services and what resources are necessary to meet a

minimal level of need?  What discrete services are unavailable and how

should they be provided?

o  What impact has the medical liability situation had on the practice

patterns of providers in rural areas and, in particular, on

availability of care for pregnant women?

Health Professionals

There are many factors that affect the supply of physicians, nurses,

and other health professionals in rural communities, such as:  the

demand for services, the availability of continuing education,

professional concerns with quality assurance, lifestyle preferences,

and availability of support services.  Unanswered questions include:

o  What factors of geography, community, health facilities, and

practice affect the mix and availability of medical personnel in rural


o  What techniques of recruitment and retention of health care

professionals have been used successfully?

Emergency Care Delivery Systems

One quarter of Americans live in rural areas, which occupy four-fifths

of the nation's land areas.  Residents of these areas face special

problems in receiving emergency care.  Research questions regarding

rural emergency care are:

o  How can emergency transportation and communication problems be

improved in rural areas, especially those with poor roads or without

911 services or similar emergency numbers?

o  What are the appropriate criteria and standards that govern

effective stabilization, triage, and referral to regional trauma and

medical centers; what are the barriers to regionalization, and what can

be done to further promote adoption of coordinated emergency care


Rural Hospital and Hospital-based Delivery Systems

Rural hospitals form a vital connection in a community's health care

system and economy.  Growing financial stress and decline and closure

of rural hospitals raise concerns about access to health care.  During

the 1980s, Congress enacted a number of programs aimed at strengthening

rural hospitals and health care services to improve access. Suggested

research questions are:

o  What are the effects of Federal initiatives on maintaining access to

rural health services, hospital survival, and community social and

economic well-being?

o  Are there differences in quality of care, case mix, and

uncompensated care between rural hospitals that are members of hospital

chains and those that are not?

Alternative Delivery Systems and Managed Care

The term "managed care" includes a variety of administrative structures

that integrate the financing and delivery of health care in an effort

to improve the cost-effectiveness of health care.  Managed care

organizations have emerged in response to increasing pressures to

contain costs without sacrificing quality, and may enhance the

coordination and quality of care.  Little is known about the

effectiveness of managed care organizations in rural areas.  Suggested

research questions include:

o  What has been the experience of managed care organizations in rural

areas with respect to market penetration and effects on access to care?

o  How do managed care organizations in rural areas compare to those in

urban and suburban settings with respect to costs, quality of care, and

patterns of utilization?

Provision of Primary Health Care

Limited research exists on primary care practice and its quality and

variation in rural areas.  Insufficient attention has been paid to

assuring the continued viability of primary care and to documenting the

effects of changes in funding and support of primary care services in

rural areas. Research questions on primary care include:

o  What is the extent of medical practice variation within and between

rural areas and between urban and rural areas? Are there differences in

the use of specific services and in health outcomes for particular

medical problems treated?

o  What are the most effective alternative models for providing primary

care that are responsive to the specific health needs of local rural


Health Promotion and Disease Prevention

Prevention objectives identified in "Healthy People 2000" can be

achieved by removing barriers that impede access to and use of clinical

preventive services.  Research issues for health promotion and disease

prevention in rural populations are:

o  What factors unique to rural areas do health promotion/disease

prevention programs and strategies need to consider in order to be

successful in changing provider and/or consumer behavior with respect

to health promotion/disease prevention recommendations?

o  How can rural health care providers, community leaders, and

voluntary agencies develop and implement cost-effective health

promotion and disease prevention programs?


Significant barriers to technology diffusion to rural areas exist.  The

cost of financing a new technology when high volume use is not

anticipated is often a limiting factor. Limitations in access to

technology often raise questions about quality of care.  Some questions


o  How can technology be used to improve care in isolated rural areas?

In what areas of care is technology most likely to make a difference in

access, cost, or quality of care rendered?

o  What technology could enhance communication and knowledge transfer

between specialists in urban health care facilities and rural

practitioners, and facilitate provision of state-of-the-art care by

rural practitioners?


Research is encouraged on the delivery of services to people with AIDS,

the homeless, the elderly, rural poor, mothers, children, and

adolescents, and rural/ethnic minority populations.  Examples of

research needed are:

o  Studies of health care utilization, health status and access to

coordinated community services for special populations in rural areas,

and basic demographic studies of their social characteristics.

o  Studies of variations in informal caregiving among the rural elderly

by racial and ethnic characteristics.



The AHCPR requires all applicants for research grants to include

minorities and women in study populations so that research findings can

be of benefit to all persons at risk of the disease, disorder, or

condition under study.  Special emphasis must be placed on the need to

include minorities and women in studies of diseases, disorders and

conditions which disproportionately affect them.  This policy is

intended to apply to males and females of all ages.  If women or

minorities are excluded or inadequately represented in research, a

clear and compelling rationale should be provided.  AHCPR will not

award grants for applications which do not comply.  If the required

information is not contained in the application, the application will

be returned without review.

The composition of the proposed study population must be described in

terms of gender and racial/ethnic group.  In addition, gender and

racial/ethnic issues should be addressed in developing a research

design and sample size appropriate for the scientific objectives of the

study.  This information should be included in the form PHS 398 in

Sections 1-4 of the Research Plan AND summarized in Section 5, Human


Applicants are urged to assess carefully the feasibility of including

the broadest possible representation of minority groups.  However,

AHCPR recognizes that it may not be feasible or appropriate in all

research projects to include representation of the full array of United

States racial/ethnic minority populations (i.e., Native Americans,

Asian/Pacific Islanders, Blacks, Hispanics).  Where appropriate, the

applicant must provide the rationale for studies on single minority

population groups.

This policy applies to all biomedical and behavioral studies of

etiology, epidemiology, prevention (and preventive strategies),

diagnosis, or treatment of diseases, disorders or conditions, including

but not limited to clinical trials.

For foreign awards, the policy on inclusion of women applies fully;

since the definition of minority differs in other countries, the

applicant must discuss the relevance of research involving foreign

population groups to the United States' populations, including


If the required information is not contained within the application,

the application will be returned.

Peer reviewers will address specifically whether the research plan in

the application conforms to these policies.  If the representation of

women or minorities in a study design is inadequate to answer the

scientific question(s) addressed AND the justification for the selected

study population is inadequate, it will be considered a scientific

weakness or deficiency in the study design and will be reflected in

assigning the priority score to the application.

All applications for research submitted to AHCPR are required to

address these policies.  AHCPR will not award grants or cooperative

agreements that do not comply with these policies.


Applications are to be submitted on the grant application form PHS 398

(rev. 9/91), and will be accepted at the standard application deadlines

as indicated in the application kit.  State and local governments may

use Form PHS 5161 and submit an original and two copies of the


Application kits are available at most institutional business offices

and may be obtained from the Office of Grants Inquiries, Division of

Research Grants, Westwood Building, Room 449, National Institutes of

Health, Bethesda, MD 20892, telephone 301/496-7441.  They may also be

obtained from the Office of Scientific Review, Agency for Health Care

Policy and Research, Suite 602, 2101 East Jefferson Street, Rockville,

MD 20852, telephone 301-227-8449.  The title and number of the

announcement must be typed in Section 2a on the face page of the


The completed original application and five legible copies (two copies

when using the PHS 5161) must be sent or delivered to:

Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD  20892**

The Division of Research Grants (DRG) will not accept any application

in response to this announcement that is essentially the same as one

currently pending initial review, unless the applicant withdraws the

pending application.  The DRG will not accept any application that is

essentially the same as one already reviewed.  This does not preclude

the submission of substantial revisions of applications already

reviewed, but such applications must include an introduction addressing

the previous critique.

The first due date is October 1, 1992.  Thereafter, the due dates for

applications are February 1, June 1, and October 1.  However, an

application received after the deadline may be acceptable if it carries

a legible proof-of-mailing date assigned by the carrier and the

proof-of-mailing date is not later than one week prior to the deadline

data.  If the receipt date falls on a weekend, it will be extended to

Monday; if the date falls on a holiday, it will be extended to the

following work day.  The receipt date will be waived only in

extenuating circumstances.  To request such a waiver, an explanatory

letter must be included with the application.  No waiver will be

granted prior to receipt of the application.


The review criteria for these applications are:  significance and

originality from a scientific and technical viewpoint; adequacy of the

method to carry out the project; availability of data or the proposed

plan to collect data required for the project; qualifications and

experience of the Principal Investigator and proposed staff; adequacy

of the plan for organizing and carrying out the project; reasonableness

of the proposed budget; and adequacy of the facilities and resources

available to the applicant.

The Division of Research Grants, NIH, serves as a central point for

receipt of applications for most discretionary PHS grant programs.

Applications received under this announcement will be assigned to an

Initial Review Group (IRG) in accordance with established PHS Referral

Guidelines.  The IRGs, consisting primarily of non-Federal scientific

and technical experts, will review the applications for scientific and

technical merit.  Notification of the review recommendations will be

sent to the applicant after the initial review.  Applications will

receive a second-level review by an appropriate National Advisory

Council.  Only applications recommended by a council may be considered

for funding.


Applications will compete for available funds with all other

applications.  The following will be considered in making funding

decisions:  Quality of the proposed project as determined by peer

review, availability of funds, and program balance among research areas

of the announcement.


Those considering an application in response to this PA are strongly

encouraged to discuss the project with the AHCPR program administrators

before formal submission.  The AHCPR welcomes the opportunity to

clarify any issues or questions from potential applicants.  A Grant

Announcement discussing research issues in this PA will be available

from the AHCPR Publications Clearinghouse, PO Box 8547, Silver Spring,

MD 20907, (1-800-358-9295) by June 15, 1992.

Direct inquiries regarding programmatic issues to:

Paul Nutting, M.D., M.S.P.H.

Director, Division of Primary Care

Center for General Health Services Extramural Research

Agency for Health Care Policy and Research

Executive Office Center, Suite 502

2101 East Jefferson Street

Rockville, MD  20852-4908

Telephone:  (301) 227-8357

FAX:  (301) 227-8155

Direct inquiries regarding fiscal matters to:

Ralph Sloat

Grants Management Officer

Agency for Health Care Policy and Research

2101 East Jefferson Street, Suite 601

Rockville, MD  20852-4908

Telephone:  (301) 227-8447


This program is described in the Catalog of Federal Domestic Assistance

No. 93.180 and 93.226.  Awards are mad under authorization of the

Public Health Service Act, Title IX, as amended (Public Law 101-239)

and administered under PHS grants policies and Federal Regulations 42

CFR 67, Subpart A and 45 CFR Part 74, (45 CFR Part 92 for State and

local governments).  This program is not subject to the

intergovernmental review requirements of Executive Order 12372.


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