Among patients from both rural and urban counties, rates of discharge to the community and postacute care settings were similar; however, rural-urban differences in mortality after discharge were much larger for patients receiving postacute care in rural areas compared with patients discharged to the community setting, according to a study published in JAMA Network Open.

The authors noted that there are several reasons why postacute care may be less available or lower quality in rural areas. Several studies have found that compared with urban and suburban areas, rural communities have less access to healthcare services such as primary and secondary ambulatory care and hospital care.

To examine the differences in postacute care use among rural and urban Medicare beneficiaries, researchers used the Medicare Beneficiary Summary File and the Medicare Provider Analysis and Review database to identify hospitalized patients between January 1, 2011, and September 30, 2015. Patients were hospitalized with a primary diagnosis of stroke, hip or femur fracture without joint replacement, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia. These conditions have been associated with increasing rural-urban differences in mortality rates and are commonly treated in postacute care, noted the authors.

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Individuals were classified as rural- or urban-dwelling based on the 2013 Rural-Urban Continuum Code assigned to their county of residence. Rural residents were further divided into those residing in counties adjacent to metropolitan areas and those residing in counties not adjacent to metropolitan areas.

The primary outcomes were posthospital discharge setting, hospital readmission, and postdischarge mortality. Additional outcomes included readmission and mortality at 90 days; mortality within 180 days of discharge was used as a long-term outcome measure.

Among 2,044,231 hospitalizations from 2011 to 2015, 1,538,888 (75.2%) were among patients from urban counties, 322,360 (15.8%) from urban-adjacent rural counties, and 182,983 (9.0%) from urban-nonadjacent rural counties. Patients from rural counties were more frequently hospitalized for pneumonia or hip or femur fracture, and less frequently hospitalized for stroke. These patients were also less likely to have been admitted to an intensive care unit.

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The probability of discharge to the community without postacute care did not differ by location. Compared with patients from urban counties, however, patients from the most rural counties were more frequently discharged to a skilled nursing facility. Discharge to an inpatient rehabilitation facility or home health care was less common among patients from rural counties than among those from urban counties.

In adjusted analyses, the 30-day readmission rate was 9.2% for residents of urban counties, 9.7% for residents of urban-adjacent rural counties (adjusted difference, 0.5 percentage points), and 9.7% for residents of urban-nonadjacent rural counties (adjusted difference, 0.4 percentage points), noted the authors.

For those discharged to a postacute setting, the 30-day readmission rate was 11.9% for residents of urban counties, 11.9% for residents of urban-adjacent rural counties (adjusted difference, −0.1 percentage points), and 11.6% for residents of urban-nonadjacent rural counties (adjusted difference, −0.3 percentage points).

Adjusted 30-day mortality rates were 0.4 percentage points higher for patients from the most rural counties discharged to the community and 2.0 percentage points higher among those receiving postacute care. Rural-urban differences in 90-day and 180-day outcomes were similar.

“We found that patients from rural and urban counties were equally likely to be discharged to a formal postacute care setting; however, the type and course of postacute care differed according to rurality,” the authors concluded. “After discharge to an institutional postacute care setting, patients from rural counties were less likely to receive follow-up home health care and were more likely to remain institutionalized.”


Kosar CM, Loomer L, Ferdows NB, Trivedi AN, Panagiotou OA, Rahman M. Assessment of rural-urban differences in postacute care utilization and outcomes among older US adults. JAMA Netw Open. 2020;3(1):e1918738.