Assessment of Rural-Urban Differences in Postacute Care Utilization and Outcomes Among Older US Adults

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