Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.     

Variations in Nursing Home Discharge Rates for Urban and Rural Nursing Facility Residents With Hip Fracture

CONTEXT: The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents. PURPOSE: This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility. METHODS: The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture. FINDINGS: The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status. CONCLUSIONS: The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.     

Diagnosed Mental and Physical Health Conditions in the united States Nursing Home Population: Differences Between Urban and Rural Facilities

CONTEXT: There has been limited examination of the differences in health characteristics of the rural long-term care population. Recognizing these differences will allow policymakers to improve access to long-term care services in rural communities. PURPOSE: To determine whether differences in likelihood of diagnosis exist between urban and rural nursing home residents for 8 common medical conditions: 4 mental health conditions (depression, anxiety, Alzheimer's, and non-Alzheimer's dementia) and 4 physical health conditions (cancer, emphysema/chronic obstructive pulmonary disease, heart disease, and stroke/transient ischemic attack). METHODS: We used multivariate logistic regression to examine data derived from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multistage stratified probability sample of 815 nursing homes and 5899 residents, representing 3.1 million individuals in the United States who spent 1 or more nights in nursing homes during 1996. FINDINGS: Residents in rural homes were less likely to be diagnosed with depression compared to those in homes in large metropolitan areas, and residents in homes in small metropolitan areas were less likely to have cancer than those in large metropolitan areas. Diagnostic status between urban and rural residents was comparable for the other 6 conditions. CONCLUSIONS: Further research is necessary to determine whether and why depression is inadequately diagnosed in rural nursing homes and to ascertain which types of cancer are responsible for the observed differential. Such research is particularly important for elderly nursing home residents who are more likely to suffer from chronic conditions that require significant medical supervision.     

Differences in health-related quality of life in rural and urban veterans

OBJECTIVES: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.     

Rural-Urban Comparisons of Age and Health at the Time of Nursing Home Admission

This study re-examines the contention that rural elders admitted to nursing homes are younger and healthier than their counterparts who enter urban facilities. The analysis uses interview data gathered in both urban and rural nursing homes. Residents were interviewed at or near the time of admission regarding their health and circumstances immediately prior to entering the nursing home. The findings indicate few and modest differences between urban and rural residents. In those instances where differences are observed, there is ambiguity--some measures indicate lower health status in the case of rural residents, while others suggest that urban residents are more likely to report health impairments. The divergence of these findings from earlier research may be due to differences in the study populations, measurement differences, or, more likely, that policies and processes have changed over time.     

The importance of place of residence: examining health in rural and nonrural areas

We examined differences in health measures among rural, suburban, and urban residents and factors that contribute to these differences. Whereas differences between rural and urban residents were observed for some health measures, a consistent rural-to-urban gradient was not always found. Often, the most rural and the most urban areas were found to be disadvantaged compared with suburban areas. If health disparities are to be successfully addressed, the relationship between place of residence and health must be understood.     

Determinants of the use of specialist mental health services by nursing home residents.

OBJECTIVE. This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals. DATA SOURCES/STUDY SETTING. The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987. STUDY DESIGN. Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification. DATA COLLECTION/EXTRACTION METHODS. Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions. PRINCIPAL FINDINGS. Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment. CONCLUSIONS. Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.     

Functional Disability at Nursing Home Admission: A Comparison of Urban and Rural Admission Cohorts

This study's objective was to examine the relationships between rural residence and availability of nursing home and home health care to functional disability at the time of nursing home admission. Secondary data were obtained from the Minimum Data Set (MDS) 2.0 for Nebraska for 3,443 rural and 1,296 urban older people admitted to nursing facilities. Data from the MDS were merged with county-level data on home health agencies and nursing homes in Nebraska. The relationship of rurality of nursing home residents' prior residence and availability of nursing home and home health care to functional status at admission, controlling for demographic and health characteristics of older people, was estimated using multiple linear regression with robust variance estimates. After taking account of demographic and health status characteristics, rural residence and availability of home health and nursing home care had nonsignificant effects on functional status at admission. The findings indicate that functional disability at admission is associated with specific diseases and medical conditions, cognitive status, gender, living arrangements and marital arrangements. Rural older people are not at higher risk of admission at lower levels of functional disability compared to their urban counterparts.     

Urban-rural patterns of increasing antidepressant use among nursing facility residents

OBJECTIVE: To characterize changing patterns of antidepressant use in nursing facilities across the urban-rural continuum during the mid-1990s. DESIGN: Retrospective analysis of antidepressant drug codes and demographic/clinical data from the Minimum Data Set (MDS) 1994 to 1997. SETTING: Kansas nursing facilities. PARTICIPANTS: Facility residents aged 65 and older. MEASUREMENTS: We examined (1) admission use and (2) after-admission use for newer and older antidepressants for each year separately, using a 4-stratum system to classify nursing facility location by county, from urban to most rural. Incidence rate ratios were determined for antidepressant use in each stratum using the urban strata as the reference. RESULTS: Remarkable increases in use of newer antidepressants were seen over time in all strata, but use was highest in the urban area. Modest urban-rural gradient effects attenuated over time and were not consistently seen across analyses and years. Tricyclic antidepressant (TCA) use remained largely unchanged over time and at much lower rates than newer agents. However, TCA use was also modestly higher in urban areas. Differences were clearer for use after admission, in contrast with admission use patterns. CONCLUSIONS: Newer antidepressants were rapidly adopted across the urban-rural continuum from 1994 to 1997. Marked increases in both admission and after-admission use of newer antidepressants were seen. Both newer and older antidepressants were used at modestly higher rates in urban areas. Further work is needed to elucidate the patient, prescriber, and facility factors that explain these prescribing patterns.     

Analyses of nursing home residents with diabetes at admission

OBJECTIVE: The objective of this study was to profile nursing home residents with diabetes at admission to the nursing facility. METHODS: We used all admission assessments in the Minimum Data Set recorded throughout the United States during 2002 to identify 144,969 residents with diabetes, or 26.4% of all admissions. RESULTS: Only approximately one fourth of residents with diabetes were projected to have stays in the facility of 90 days or less when admitted. Heart and circulatory comorbidities were common among residents with diabetes at admission, as was depression. More than half of residents with diabetes were in pain at admission. A majority of residents with diabetes were either totally dependent or required extensive assistance in the self-performance of many activities of daily living and more than one third were at least moderately impaired in cognitive performance. CONCLUSIONS: Residents with diabetes could be one of the most "heavy care" groups in nursing facilities, as demonstrated by their levels of functional disability and prevalence of serious comorbid conditions. The care provided to residents with diabetes should address depression, pain, and low rates of advance care planning.     

Adequate Access to Posthospital Home Health Services: Differences Between Urban and Rural Areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.     

Urban-rural differences in amitriptyline use among nursing facility residents

OBJECTIVE: To characterize patterns of amitriptyline use across the urban-rural continuum. DESIGN: Retrospective analysis of antidepressant drug codes and demographic and clinical data from the Minimum Data Set (MDS), 1994 to 1997. SETTING: Kansas nursing facilities. PARTICIPANTS: Facility residents aged 65 and older. MEASURES: A four-strata system was used to classify nursing facility location by county, from urban to frontier. We examined admission use and after-admission use of amitriptyline across strata for each year separately. Unadjusted and adjusted odds ratios were determined for each stratum, using the urban stratum as the point of reference. RESULTS: Admission use of amitriptyline occurred in 2.3 to 4% of all admissions, and although such use was highest in the most rural stratum, no clear urban-rural gradient was found. In contrast, amitriptyline use 30 days or more after admission demonstrated modest urban-rural gradients in unadjusted and adjusted analyses. In 1997, when adjusted for demographic factors, odds ratios for amitriptyline use were 2.10 (1.54-2.87), 1.68 (1.33-2.13), and 1.49 (1.17-1.90) for the Frontier, Rural, and Densely Settled Rural categories as compared with the Urban reference group. CONCLUSIONS: After admission to Kansas nursing facilities, rural practice patterns for amitriptyline use are less favorable than those in urban areas, and an urban-rural gradient is identified. Further work is needed to identify explanatory patient, facility, and prescriber factors.     

Alcohol consumption among urban, suburban, and rural Veterans Affairs outpatients

Purpose: United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care‐based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol consumption among urban, suburban, and rural Veterans Affairs (VA) outpatients. Methods: Outpatients from 7 VA facilities responded to mailed surveys that included the validated Alcohol Use Disorders Identification Test Consumption (AUDIT‐C) screening questionnaire. The ZIP code approximation of the US Department of Agriculture's rural‐urban commuting area (RUCA) codes classified participants into urban, suburban, and rural areas. For each area, adjusted logistic regression models estimated the prevalence of past‐year abstinence among all participants and unhealthy alcohol use (AUDIT‐C ≥ 3 for women and ≥ 4 for men) among drinkers. Findings: Among 33,883 outpatients, 14,967 (44%) reported abstinence. Among 18,916 drinkers, 8,524 (45%) screened positive for unhealthy alcohol use. The adjusted prevalence of abstinence was lowest in urban residents (43%, 95% CI 42%‐43%) with significantly higher rates in both suburban and rural residents [45% (44%‐46%) and 46% (45%‐47%), respectively]. No significant differences were observed in the adjusted prevalence of unhealthy alcohol use among drinkers. Conclusions: Abstinence is slightly more common among rural and suburban than urban VA outpatients, but unhealthy alcohol use does not vary by rurality. As the VA and other health systems implement evidence‐based care for unhealthy alcohol use, more research is needed to identify whether preventive strategies targeted to high‐risk areas are needed.     

Social capital and health in rural and urban communities in South Australia

Objective : This paper seeks to compare the relationships between social capital and health for rural and urban residents of South Australia.
Methods : Using data from a South Australian telephone survey of 2,013 respondents (1,402 urban and 611 rural), separate path analyses for the rural and urban samples were used to compare the relationships between six social capital measures, six demographic variables, and mental and physical health (measured by the SF-12).
Results : Higher levels of networks, civic participation and cohesion were reported in rural areas. Education and income were consistently linked with social capital variables for both rural and urban participants, with those on higher incomes and with higher educational achievement having higher levels of social capital. However, there were also differences between the rural and urban groups in some of the other predictors of social capital variables. Mental health was better among rural participants, but there was no significant difference for physical health. Social capital was associated with good mental health for both urban and rural participants, but with physical health only for urban participants. Higher levels of social capital were significantly associated with better mental health for both urban and rural participants, but with better physical health only for urban participants.
Conclusions and implications : The study found that social capital and its relationship to health differed for participants in rural and urban areas, and that there were also differences between the areas in associations with socioeconomic variables. Policies aiming to strengthen social capital in order to promote health need to be designed for specific settings and particular communities within these.     

Rural, Suburban, and Urban Variations in Alcohol Consumption in the United States: Findings From the National Epidemiologic Survey on Alcohol and Related Conditions

CONTEXT: Alcohol consumption is a major public health problem nationally, but little research has investigated drinking patterns by rurality of residence. PURPOSE: To describe the prevalence of abstinence, alcohol use disorders, and risky drinking in rural, suburban, and urban areas of the United States. METHODS: Analyses of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were conducted to estimate prevalence rates for abstinence, a current alcohol use disorder, and exceeding recommended daily and weekly drinking limits. Logistic regression analyses were conducted to test for rural and urban versus suburban differences after adjusting for potential confounders. Additional analyses were stratified by Census Region. FINDINGS: Nationally, the odds of abstinence and, among drinkers, the odds of a current alcohol disorder and exceeding daily limits were higher in rural than suburban areas. Stratified analyses revealed differences in the associations between rurality of residence and drinking across Census Regions. Rural residents of the Northeast, Midwest, and South and urban residents of the Northeast had higher odds of abstinence than their suburban peers. Among drinkers, rural and urban residents of the Midwest had higher odds of a current alcohol disorder and exceeding daily limits; urban residents of the Midwest had higher odds of exceeding weekly limits. CONCLUSIONS: Abstinence is particularly common in the rural South, whereas alcohol disorders and excessive drinking are more problematic in the urban and rural Midwest. Health policies and interventions should be further targeted toward those places with higher risks of problem drinking.     

Eye care in the skilled nursing facility: a pilot study of prevalence and treatment patterns of glaucoma

OBJECTIVE: The objective of this study was to determine the rates of ophthalmic examinations for glaucoma, prevalence rates of glaucoma, ongoing evaluation (follow-up) rates and rates of treatment for a population of residents in a skilled nursing facility. DESIGN: We conducted a retrospective evaluation and chart review of glaucoma-related ophthalmology services. SETTING: This study was conducted in a skilled nursing facility located in a large metropolitan area located in the Midwest. Participants: We studied all nursing home residents of the facility on October 1, 2002 (n = 160). Methods: We conducted a retrospective evaluation and chart review of glaucoma-related ophthalmology services for 160 patients. The medical records used for review included admission records, physician history and physical records, hospital notes, nursing assessments, consultation notes, and medication reviews (including medications administered during hospital stays). Minimum data set (MDS) data and individual patient interviews were used to supplement and verify chart abstraction findings. RESULTS: Eighty-three residents (52%) had evidence of assessment for glaucoma. Thirty-three of these residents (40%) had documentation of a diagnosis of glaucoma; 25 (76%) had current treatment orders for a topical ophthalmic agent. Nine patients were using combination therapy; four used topical and oral beta-adrenergic-blocking agents. CONCLUSIONS: Visual impairment remains a serious problem for nursing facility residents. Assessment of visual abilities is infrequent or nonexistent. Education for nursing home personnel, discussion and activation among nursing home thought leaders, and guidelines for the evaluation and management of glaucoma in this care environment are needed.     

Urban and rural differences in end-of-life pain and treatment status on admission to a nursing facility

Individuals receiving end-of-life (EOL) care may have needs that are unrecognized or treated inappropriately. Yet, very little is known about differences in pain and special-care needs of EOL patients admitted to rural nursing facilities compared with urban nursing facilities, and whether the differing payer mix in urban and rural facilities affects the treatment ordered on admission. We examine a nationally representative sample of 6084 EOL patients upon admission to nursing homes to examine differences in diseases, pain assessments, and treatment orders. We found that rural EOL residents have higher rates of congestive heart failure, cancer, renal failure, and emphysema than urban EOL residents and are significantly more likely to report frequent pain, however, they are less likely to receive treatments such as IV medications, dialysis, and wound care.     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.     

Rural, Urban and Suburban Comparisons of Preventive Services in Family Practice Clinics

Numerous studies have compared health services provided in rural and urban areas, and overall they have found that utilization is lower in rural areas. A significant factor in lower utilization is that rural residents have less access to health services. Much less is known about rural and urban utilization differences once a patient has access to a service provider. This paper focuses on preventive services received when a patient is already in a clinic. Using data from an in-depth qualitative study of 16 family practice clinics in Nebraska, comparisons of physician-specific preventive service rates are made across three geographic categories: rural, urban and suburban. Results from a one-way multivariate analysis of variance show that preventive services rates for nine services examined were as high or higher in rural areas, suggesting that rural health services do not lag for patients with access.