Rural–Urban Differences in Medical Care for Nursing Home Residents with Severe Dementia at the End of Life

Abstract

To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. Minnesota and Texas nursing homes. Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.