Rural Elderly Discharged to Post-Acute Care Have Higher Mortality Than Urban Peers

By Linda Carroll

January 10, 2020

(Reuters Health) - Rural seniors hospitalized for certain life-threatening conditions are more likely than city-dwelling peers to die within a month of being discharged and sent to an aftercare facility, a new study suggests.

In an analysis of data from more than 2 million U.S. elderly adults hospitalized for stroke, hip fracture, COPD, congestive heart failure or pneumonia, researchers determined that where you live may make the difference between life or death, according to the report published in JAMA Network Open.

"Among patients sent for post-acute care, the mortality rate among urban patients was 4.6% and among rural patients it was 6.6%," said Cyrus Kosar, a doctoral candidate in the School of Public Health at Brown University in Providence, Rhode Island. "That's a very, very large difference. It implies there is some sort of problem with post-acute care in rural settings."

Kosar and his colleagues combed through Medicare data on 2,044,231 patients aged 66 and older who were hospitalized between January 1, 2011 and September 30, 2015.

Where a patient lived did not make a difference in whether he or she was sent home without a stint in a post-acute care facility. But among those sent to post-acute care facilities, patients from rural areas were more likely than city-dwellers to be sent to a skilled nursing facility rather than an inpatient rehabilitation facility.

Patients from rural areas were also less likely than urban counterparts to be discharged to home care.

Rural patients sent home following their hospital stay were somewhat more likely to die within 30 days of discharge compared to city-dwellers: 1.8% versus 1.4%.

The much larger rural-urban difference in 30-day mortality among patients sent for post-acute care is why improving post-acute care in rural areas could be a way to improve outcomes, Kosar said.

The new study focuses on a "huge problem," said Dr. June McKoy, a health services researcher and an associate professor of medicine, preventive medicine and medical education at Northwestern University's Feinberg School of Medicine in Chicago.

Part of the problem may be that it's very hard to find home healthcare in rural areas for patients finished with post-acute care, McKoy said. "Often the distances are far and therapists do not want to come out to Timbuktu," she explained.

In an urban setting, patients receive skilled nursing care in a post-acute care facility and once they have achieved goals set by the staff, they transition in most cases to home with home health care, McKoy said. Because home healthcare often isn't available in rural settings, "rural patients remain in post-acute care facilities," she added. "Being in a long-term care facility carries risks. Additionally, older individuals recuperate better at home post short-stay rehab and have decreased rates of depression and anxiety."

Dr. Daniel Brotman agreed that some of the difference might come down to the difficulty in finding home healthcare in rural areas.

Patients tend to do better both psychologically and physically if they can be cared for at home and can be with loved ones, said Brotman, director of the hospitalist program at The Johns Hopkins Hospital and a professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland.

SOURCE: JAMA Network Open, online January 8, 2020.