Rural‐Urban Differences in Survival and Health care Utilization Among Medicare Beneficiaries Diagnosed with Alzheimer’s Disease and Related Dementias

Abstract

Research ObjectiveThere is poor understanding as to how survival and health care utilization vary among older adults living with Alzheimer’s disease and related dementias (ADRD) in rural versus urban areas of the United States. The objective of this study was to describe survival and trajectories of hospital, nursing home, and home health care use in the six years following a new diagnosis of ADRD among rural and urban Medicare beneficiaries.Study DesignProspective cohort study using 2008‐2015 Medicare claims linked with nursing home and home health assessment data.Population Studied1 203 897 Medicare fee‐for‐service beneficiaries who were newly diagnosed with ADRD in 2008 or 2009. 77% (n = 921 853) resided in metropolitan counties, 14% (n = 162 857) in micropolitan counties, and 10% (n = 119 187) in rural counties.Principal FindingsThe average age at ADRD diagnosis was about six months younger for beneficiaries residing in rural counties compared to metropolitan counties. Beneficiaries residing in metropolitan counties survived a mean of 1211 days (median 1188 days) after diagnosis. Adjusting for individual demographic and clinical characteristics, beneficiaries in rural and micropolitan counties survived 29.2 fewer days (95% CI −34.0, −24.4) and 31.9 fewer days (95% CI −36.1, −27.7) than metropolitan residents, respectively. Compared with metropolitan residents, rural residents spent an adjusted 82.9 fewer days (95% CI −87.6, −78.2) in the community without home health care services, received 3.0 fewer days of home health care services (95% CI −3.5, −2.5), and spent 59.8 more days (95% CI 56.7, 63.0) in nursing homes. We found similar patterns in health care utilization for micropolitan vs. metropolitan residents, though the magnitude of the differences was smaller. Differences between groups became more pronounced the greater the time from diagnosis.ConclusionsUrban‐dwelling older adults with ADRD are significantly more likely to remain in the community and less likely to use nursing homes than individuals in rural and micropolitan counties, particularly in later disease stages.Implications for Policy or PracticeDifferences in health care utilization and survival between rural and urban Medicare beneficiaries with ADRD likely reflect geographic differences in health care access for timely diagnosis, proximity to informal caregivers, and availability of formal support services offered by home health agencies and other community‐based long‐term care providers.Primary Funding SourceNational Institutes of Health.