Abstract
Although people living in rural areas of the United States are disproportionately older and more likely to die of conditions that require postacute care than those living in urban areas, rural-urban differences in postacute care utilization and outcomes have been understudied. To describe rural-urban differences in postacute care utilization and postdischarge outcomes. This retrospective cohort study used data from Medicare beneficiaries 66 years and older admitted to 4738 US acute care hospitals for stroke, hip fracture, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia between January 1, 2011, and September 30, 2015. Participants were tracked for 180 days after discharge. Data analyses were conducted between October 1, 2018, and May 30, 2019. County of residence was classified as urban or rural using the US Department of Agriculture Rural-Urban Continuum Codes. Rural counties were divided into those adjacent and not adjacent to urban counties. Primary outcomes were discharge to community vs a formal postacute care setting (ie, skilled nursing facility, home health care, or inpatient rehabilitation facility) and readmission and mortality within 30, 90, and 180 days of hospital discharge. Among 2 044 231 hospitalizations from 2011 to 2015, 1 538 888 (75.2%; mean [SD] age, 80.4 [8.3] years; 866 540 [56.3%] women) were among patients from urban counties, 322 360 (15.8%; mean [SD] age, 79.6 [8.1] years; 175 806 [54.5%] women) were among patients from urban-adjacent rural counties, and 182 983 (9.0%; mean [SD] age, 79.8 [8.1] years; 98 775 [54.0%] women) were among patients from urban-nonadjacent rural counties. The probability of discharge to community without postacute care did not differ by rurality. However, compared with patients from urban counties, patients from the most rural counties were more frequently discharged to a skilled nursing facility (adjusted difference, 3.5 [95% CI, 2.8-4.3] percentage points), while discharge to an inpatient rehabilitation facility was less common among patients from rural counties than among those from urban counties (urban vs urban-adjacent rural: adjusted difference, -1.9 [95% CI, -2.4 to -1.4] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -1.8 [95% CI, -2.4 to -1.2] percentage points) as was discharge to home health care (urban vs urban-adjacent rural: adjusted difference, -1.7 [95% CI, -2.3 to -1.2] percentage points; urban vs urban-nonadjacent rural: adjusted difference, -2.4 [95% CI, -3.0 to -1.8]). For patients from the most rural counties, adjusted 30-day readmission rates were 0.4 (95% CI, 0.2-0.6) percentage points higher than those of patients from urban counties among those who were discharged to the community but 0.3 (95% CI, -0.6 to -0.1) percentage points lower among patients receiving postacute care. Adjusted 30-day mortality rates were 0.4 (95% CI, 0.3-0.5) percentage points higher for patients from the most rural counties discharged to the community and 2.0 (95% CI, -1.7 to 2.3) percentage points higher among those receiving postacute care. Rural-urban differences in 90-day and 180-day outcomes were similar. These findings suggest that rates of discharge to the community and postacute care settings were similar among patients from rural and urban counties. Rural-urban differences in mortality following discharge were much larger for patients receiving postacute care compared with patients discharged to the community setting. Improving postacute care in rural areas may reduce rural-urban disparities in patient outcomes.
Highlights
60 million people in the United States reside in rural areas, accounting for 19% of the US population overall and approximately one-quarter of all Medicare beneficiaries.[1,2] Several studies have found that compared with urban and suburban areas, rural communities have less access to health care services, such as primary and secondary ambulatory care and hospital care.[3,4,5] Less is known about the use of postacute care in rural America
Compared with patients from urban counties, patients from the most rural counties were more frequently discharged to a skilled nursing facility, while discharge to an inpatient rehabilitation facility was less common among patients from rural counties than among those from urban counties as was discharge to home health care
Rural-urban differences in 90-day and 180-day outcomes were similar. These findings suggest that rates of discharge to the community and postacute care settings were similar among patients from rural and urban counties
Summary
60 million people in the United States reside in rural areas, accounting for 19% of the US population overall and approximately one-quarter of all Medicare beneficiaries.[1,2] Several studies have found that compared with urban and suburban areas, rural communities have less access to health care services, such as primary and secondary ambulatory care and hospital care.[3,4,5] Less is known about the use of postacute care in rural America. Rural communities are composed of residents who are disproportionately older and affected by chronic illnesses compared with residents of nonrural communities.[3] Second, the quality of postacute care and type of posthospital setting are associated with clinical and health service utilization outcomes.[6,7] Third, the primary conditions associated with the increasing rural-urban disparity in life expectancy commonly require hospitalization and subsequent postacute care.[8,9]
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