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Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults.
JAMA Netw Open. 2020 01 03; 3(1):e1918738.JN

Abstract

Importance

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.

Objective

To describe rural-urban differences in postacute care utilization and postdischarge outcomes.

Design, Setting, and Participants

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.

Exposures

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.

Main Outcomes and Measures

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.

Results

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.

Conclusions and Relevance

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.

Authors+Show Affiliations

Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island. Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island. Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles.Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island. Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island. Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island. Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.

Pub Type(s)

Comparative Study
Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

31913495

Citation

Kosar, Cyrus M., et al. "Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults." JAMA Network Open, vol. 3, no. 1, 2020, pp. e1918738.
Kosar CM, Loomer L, Ferdows NB, et al. Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults. JAMA Netw Open. 2020;3(1):e1918738.
Kosar, C. M., Loomer, L., Ferdows, N. B., Trivedi, A. N., Panagiotou, O. A., & Rahman, M. (2020). Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults. JAMA Network Open, 3(1), e1918738. https://doi.org/10.1001/jamanetworkopen.2019.18738
Kosar CM, et al. Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults. JAMA Netw Open. 2020 01 3;3(1):e1918738. PubMed PMID: 31913495.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults. AU - Kosar,Cyrus M, AU - Loomer,Lacey, AU - Ferdows,Nasim B, AU - Trivedi,Amal N, AU - Panagiotou,Orestis A, AU - Rahman,Momotazur, Y1 - 2020/01/03/ PY - 2020/1/9/entrez PY - 2020/1/9/pubmed PY - 2020/7/28/medline SP - e1918738 EP - e1918738 JF - JAMA network open JO - JAMA Netw Open VL - 3 IS - 1 N2 - Importance: 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. Objective: To describe rural-urban differences in postacute care utilization and postdischarge outcomes. Design, Setting, and Participants: 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. Exposures: 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. Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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. SN - 2574-3805 UR - https://www.unboundmedicine.com/medline/citation/31913495/Assessment_of_Rural_Urban_Differences_in_Postacute_Care_Utilization_and_Outcomes_Among_Older_US_Adults_ L2 - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2019.18738 DB - PRIME DP - Unbound Medicine ER -