Rural-urban differences in end-of-life nursing home care: facility and environmental factors.
OBJECTIVE
This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents.


METHODS
We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location.


RESULTS
We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas.


CONCLUSIONS
This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.
Department of Community and Preventive Medicine, School of Medicine and Dentistry. University of Rochester, NY 14642, USA. helena_temkin-greener@urmc.rochester.edu
Helena
H
Temkin-Greener
Nan Tracy
NT
Zheng
Dana B
DB
Mukamel
D000368:Aged; D005260:Female; D054625:Healthcare Disparities; D006707:Homes for the Aged / Q000592:standards*; D017051:Hospice Care / Q000592:standards; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare; D009735:Nursing Homes / Q000592:standards*; D019984:Quality Indicators, Health Care; D012111:Residence Characteristics; D019035:Rural Health Services / Q000458:organization & administration; D012424:Rural Population; D013727:Terminal Care / Q000592:standards*; D014481:United States; D019037:Urban Health Services / Q000458:organization & administration; D014505:Urban Population