Abstract
There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. Rurality of beneficiary's county of residence. Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.
Highlights
Alzheimer disease and related dementia (ADRD) affects roughly 9% of adults older than age 65 years, causing declines in cognition and the ability to perform daily activities.[1]
The adjusted share of survived days spent in nursing homes was 5.7 percentage points higher for rural vs metropolitan residents
The adjusted share of days in hospitals was 0.7 percentage points lower, and the share of days in community without home health care was 4.6 percentage points lower for rural vs metropolitan county residents
Summary
Alzheimer disease and related dementia (ADRD) affects roughly 9% of adults older than age 65 years, causing declines in cognition and the ability to perform daily activities.[1] The number of Americans living with Alzheimer disease, the most common cause of dementia, is projected to increase in the coming years from 5.8 million in 2019 to almost 14 million by 2050.2 Rural populations are, on average, older than urban populations and have higher rates of chronic conditions, such as hypertension, diabetes, obesity, hyperlipidemia, traumatic brain injury, and depression. Rural populations have higher rates of alcoholism and tobacco use and lower levels of formal educational attainment than urban populations.[3,4,5] Combined, these risk factors suggest that rural communities may be disproportionately affected by ADRD. Rural residents with ADRD may have more limited access to health care and community-based long-term care services than their urban counterparts. Nursing homes have historically been the dominant site of care for people with severe dementia[10,11]; these individuals are increasingly remaining in the community with the support of home health aides, adult day programs, and other communitybased long-term care services.[12,13] There is large regional variation in the availability of nursing homes and community-based services.[14,15] Rural county residents are more likely to receive postacute care in nursing homes and less likely to receive home health care than urban county residents.[16]
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