• Matthew Toth, Mark Holmes, Courtney Van Houtven, Mark Toles, Morris Weinberger, and Pam Silberman.
• *Department of Health Policy and Management, Sheps Center for Health Services Research, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill †US Department of Veterans Affairs, Durham VA Medical Center, Center for Health Services Research in Primary Care ‡Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham §School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
• Med Care. 2015 Sep 1; 53 (9): 800-8.

BackgroundHospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but little is known about their postdischarge care and outcomes. We hypothesize that rural Medicare beneficiaries compared with urban beneficiaries, will have fewer follow-up visits, and a greater likelihood of readmission and ED use.MethodsWe conducted a retrospective analysis of elderly Medicare beneficiaries discharged home using the Medicare Current Beneficiary Survey, Cost and Use files, 2000-2010. Multivariate Cox proportional hazard models were used to assess the risk of rural residency on readmission, ED use, and follow-up care up to 30 days' postdischarge. Covariates include demographic, health, and hospital-level characteristics.ResultsCompared with urban beneficiaries, Medicare beneficiaries living in isolated rural settings had a lower rate of follow-up care [hazard ratio (HR)=0.81, P<0.001]. Beneficiaries in large and small rural settings had a greater risk of an ED visit compared with urban beneficiaries (HR=1.44, P<0.001; HR=1.52, P<0.01). Rural beneficiaries did not have a greater risk of readmission, though risk of readmission was higher for beneficiaries discharged from hospitals in large and small rural settings (HR=1.33, P<0.05; HR=1.42, P<0.05).ConclusionsThis study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.

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