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.     

Rural-Urban Comparisons of Nursing Home Residents With Multiple Sclerosis

CONTEXT: Multiple sclerosis (MS) is the most common neurologic disease that disables younger adults, affecting as many as 350,000 Americans. PURPOSE: The objectives of this study are to develop profiles of nursing home residents with MS from rural areas and compare them to residents with MS who lived in urban areas, suburban areas, and large towns. METHODS: We analyzed all admission assessments for residents with MS (13,357 assessments) in the Minimum Data Set between June 23, 1998, and December 31, 2000, that also had the resident's ZIP code of primary residence before admission. FINDINGS: Urban and rural comparisons of residents with MS demonstrate a range of significant demographic differences. Significantly greater proportions of MS residents from rural areas exhibited a sense of initiative or involvement in activities of the nursing facility compared with residents with MS from urban and suburban areas. The differences in the utilization of physical and occupational therapies were striking, with MS residents from rural areas averaging significantly fewer minutes of these therapies. We also found that MS residents from rural areas averaged fewer minutes of psychological therapy in the nursing facility and also were less likely to have seen a licensed mental health specialist than MS residents from urban areas. CONCLUSIONS: Nursing home residents with MS from rural areas receive fewer therapies and less mental health care than residents with MS from other areas.     

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.     

Advance directives in nursing home residents aged > or =65 years: United States 2004

In 1996, 53% of US nursing home residents had advance directives. This report defines documentation of advance directives in a nationally representative survey of US nursing home residents aged !65 years in 2004, as well as advance directive use in relation to demographic factors and receipt of specialty services including hospice/palliative care. In 2004, advance directives were documented in 69.9% of US nursing home residents aged !65 years and in 93.6% of residents receiving hospice/palliative care. Documentation of advance directives increased substantially between 1996 and 2004 and is nearly universal among residents receiving hospice/palliative care services. However in 2004, 3 of every 10 US nursing home residents did not have documentation of advance care plans. Continued efforts are needed to promote the importance of advance care planning among US nursing home residents.     

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.     

Rurality and nursing home quality: results from a national sample of nursing home admissions

OBJECTIVES: We examined differences in quality of care among nursing homes in locales of varying degrees of rurality. METHODS: We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators. RESULTS: For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas. CONCLUSIONS: We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.     

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.     

Chiropractic Use by Urban and Rural Residents With Insurance Coverage

ABSTRACT:  Purpose: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use between urban and rural residents as well as whether differences in provider availability or patient cost-sharing explain the difference in utilization. Methods: Claims data from 237,500 claimants in 2 large insurance companies in Washington state for calendar year 2002 were analyzed, using adjusted clinical group risk adjustment for differences in disease burden and rural urban commuting area codes for rurality definition. Findings: The proportion of claimants using chiropractors was higher in rural than urban residents (44% vs 32%, P < .001). Lack of conventional providers in rural areas did not completely explain this difference, nor did differences in patient cost-sharing or demographics. Among those who used chiropractors, those in urban areas had more chiropractic visits than users of chiropractic in rural areas. Conclusions: Among insured adults, use of chiropractic care was higher in rural than in urban areas. Reasons suggested for this difference in previous reports were not borne out in this data set.     

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.     

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.     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

Medicare hospital charges in the last year of life: distribution by quarter for rural and urban nursing home decedents with cognitive impairment.

BACKGROUND: Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence. METHODS: We analyzed Medicare hospital charges in the last year of life for nursing home residents with severe cognitive impairment, focusing on rural-urban differences. The study population consisted of 3,703 nursing home residents (1,882 rural, 1,821 urban) in Minnesota and Texas who died in 2000-2001. Data on Medicare hospital charges were obtained from 1998-2001 Centers for Medicare and Medicaid Services MedPAR files. RESULTS: During the last year of life, unadjusted charges averaged $12,448 for rural subjects; $31,780 for urban. The charges were distributed across the last 4 quarters similarly for the 2 populations, with 15%-20% of charges incurred in each of the first 3 quarters, and 47% (rural) and 52% (urban) in the last quarter. At the individual level, a higher percentage of hospital charges were incurred in the last 90 days by urban than by rural residents (P < .001). A larger proportion of urban (43%) than rural (37%) residents were hospitalized in the final quarter. The charges for hospitalized residents (N = 1,994) were distributed similarly to those of the entire study population. DISCUSSION: Medicare hospital charges during the last year of life were lower for rural nursing home residents with cognitive impairment than for their urban counterparts. Charges tend to be more concentrated in the last 90 days of life for urban residents.     

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.     

Treatment of Depression in Rural Arkansas: Policy Implications for Improving Care

Policy-makers have long suspected that greater barriers to care result in depressed rural residents being less likely to receive high-quality treatment. This study recruited 470 depressed community residents in a 1992 telephone survey, followed 95 percent of them through one year, and abstracted additional data on their health care utilization from insurance claims, medical and pharmacy records. Bivariate and multivariate models demonstrated that during the year following the baseline, there were no significant rural-urban differences in the rate (probability of any outpatient depression treatment), type (probability of receiving general medical depression care only), or quality (completion of guideline-concordant acute-stage care) of outpatient depression treatment. Annual expenditures for outpatient depression treatment were lower for rural subjects compared with their urban counterparts. Rural subjects had 3.05 times the odds of being admitted to a hospital for physical problems and 3.06 times the odds of being admitted to a hospital for mental health problems during the year following baseline compared with urban subjects. Cost-offset analyses demonstrate that every dollar invested in depression treatment was associated with a $2.61 decrease in the cost of treating physical problems in depressed rural residents. Limited insurance coverage and limited availability of services were the most significant barriers to specialty and general medical outpatient treatment for depression in both rural and urban residents. More than 80 percent of depressed residents in both rural and urban areas visited a primary care provider during the year following baseline. The potential cost offset of depression treatment in rural populations plus the improvement in productivity observed in both rural and urban populations indicate that it may be economically possible to improve quality of care for depression without bankrupting an already strained health care budget.     

2000-2018年我国城乡居民医疗保健支出公平性变化研究

目的:了解我国城乡及地区间医疗保健支出现状及差异性,分析我国城乡居民医疗保健支出的公平性,为我国医药卫生体制改革提供科学参考。方法:收集2000—2018年城乡医疗保健支出、人均可支配收入及人均纯收入等相关数据,采用集中指数和集中曲线对我国城乡医疗保健支出进行公平性分析。结果:2010—2018年城镇居民人均医疗保健支出(实际值)年平均增长速度为3.55%,农村居民人均医疗保健支出(实际值)年平均增长速度为10.00%。2000—2017年我国城镇居民人均医疗保健支出集中指数呈下降趋势,其中2006年出现最大值为0.1332,除2015—2017年外,其余年份差异均具有统计学意义(P<0.05);2000—2017年我国农村居民人均医疗保健支出集中指数呈下降趋势,2004年出现最大值为0.2522,差异均具有统计学意义(P<0.05)。结论:我国城乡人均医疗保健支出逐年增加,全国和各地区城乡人均医疗保健支出差距较大。我国城乡人均医疗保健支出存在不公平性,城镇人均医疗保健支出优于农村人均医疗保健支出,公平性逐渐趋好。     

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 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.     

End-of-Life decision making for nursing home residents with dementia: a survey of nursing home social services staff

The purpose of this survey was to describe nursing home social services staff roles and perceptions related to end-of-life medical decision making for nursing home residents in endstage dementia. Using a self-designed questionnaire, 138 nursing home social services staff from across New York State answered questions about advance directives, medical interventions, and comfort levels with withholding and withdrawing of treatment. Results showed a high degree of involvement in advance directive discussions, problems in the implementation of advance directives, and wide variation in comfort levels with treatment issues. Results of this study indicate areas of need for further research and training of nursing home social services staff.     

Advance care planning among residents in long-term care

This study was conducted to determine whether two types of advance directives exist for individuals residing in long-term care facilities. Findings were based on data from the Medical Expenditure Panel Study-Nursing Home Component (MEPS-NHC), a survey using a two-stage stratified probability sample of nursing homes and residents to produce valid national estimates of the nursing home population in the United States. The two types of advance directives included basic, i.e., living will or do-not-resuscitate (DNR) order, and progressive (do-not-hospitalize order or orders restricting feeding, medication, or other treatment). Approximately 59 percent of long-term care residents had a basic advance directive, 9 percent have a progressive directive, and 60 percent have some type of directive. Logistic regression results indicate that the factors associated with the likelihood of each type of directive differ considerably, and only two variables (African American ethnicity and less time in the facility) were associated with a reduced likelihood of having either type of directive. Our results indicate that the two proposed types of advance directives are distinct with regard to the variables predicting each.