Rural Medicare beneficiaries with Alzheimer’s disease, dementia have worse outcomes

Rural Medicare beneficiaries with Alzheimer’s disease and related dementia had worse outcomes than their urban counterparts, according to results of a retrospective cohort study published in JAMA Network Open.

“Much of what we know about rural-urban disparities in dementia care has come from small descriptive studies of specific rural communities with small sample sizes,” Momotazur Rahman, PhD, of the department of health services, policy and practice at Brown University School of Public Health, and colleagues wrote. “Lacking are detailed longitudinal studies that explore variation in health care use and outcomes between rural and urban communities across the entire country. The absence of such information hinders efficient and informed care planning and attenuates policy efforts to ameliorate rural-urban disparities in health outcomes.”

To address this research gap, the investigators sought to outline trajectories and survival of hospital, nursing home, hospice and home health care use among 555,333 Medicare beneficiaries with Alzheimer’s disease and related dementia in the 6 years following diagnosis. They linked Medicare claims data from January 2009 to December 2016 with nursing home and home health assessment data from all counties in the United States. Of the total beneficiaries, 76.5% lived in metropolitan counties, 13.5% in micropolitan counties and 10% in rural counties. Main outcomes and measures included number of days survived after initial diagnosis, as well as percent of survived days each month spent in the hospital, hospice nursing home, community with home health care services and community without home health care services.

Results showed rural beneficiaries were younger, less likely to be women, more likely to be white and eligible for Medicaid and had fewer pre-existing chronic conditions vs. metropolitan county residents. Those who resided in metropolitan counties had a mean survival of 1,183.5 days following diagnosis, whereas those who resided in rural and micropolitan counties survived approximately 1.5 months less than metropolitan residents after adjusting for individual demographic and clinical characteristics. Rural residents had an adjusted share of survived days spent in nursing homes that was 5.7 (95% CI, 4-7.5) percentage points higher vs. metropolitan residents. Rural residents also had an adjusted share of days in hospitals that was 0.7 (95% CI, –0.9 to –0.4) percentage points lower vs. metropolitan country residents. However, the researchers observed no statistically significant differences in home health or hospice use. They found similar patterns for micropolitan vs. metropolitan residents as for metropolitan vs. rural residents; however, the magnitude of the differences was smaller. With further time from diagnosis, the differences in time spent in community and nursing homes became more pronounced between rural vs. metropolitan beneficiaries.

“Our findings suggest that rural Medicare beneficiaries with [Alzheimer’s disease and related dementia] spend less time in the community than their urban counterparts,” Rahman and colleagues wrote. “Rural Medicare beneficiaries with [Alzheimer’s disease and related dementia] also appear to spend more time in nursing homes and experience shorter risk-adjusted survival and fewer hospitalizations than urban beneficiaries.”