Rural Residence Associated with Receipt of Recommended Post-Discharge COPD Care among a Cohort of U.S. Veterans.

Rationale: Individuals with chronic obstructive pulmonary disease (COPD) in rural areas experience inequitable access to care.

Objective: To assess whether rural residence is associated with receipt of recommended post-discharge COPD care.

Methods: We conducted a cohort study of all U.S. Veterans discharged from a VA Medical Center following COPD hospitalization from 2010 to 2019. Rural residence was defined by Rural Urban Commuting Area classification. Our primary outcome was the proportion of recommended care received within 90 days of hospital discharge, including: smoking cessation therapy; appropriate management of supplemental oxygen; appropriate prescription of inhaled therapy; and pulmonary rehabilitation. We conducted multi-variable linear regression between rural residence and the proportion of recommended care received, adjusting for age, sex, race, ethnicity, comorbidities, and primary care facility type. We tested multi-variable linear probability models for each of the recommended therapies.

Results: Of 67,649 patients, 7,370 (10.8%) resided in rural areas, and 2,000 (3.0%) in highly rural areas. Overall, the proportion of recommended COPD treatments received was low (mean 15.0%, standard deviation 21.0%). Compared with urban residence, patients with rural and highly rural residence received fewer recommended COPD care treatments (rural estimate [adjusted % difference (95% CI)]: -1.1 (-1.6, -0.6); highly rural estimate: -1.2 (-2.1, -0.3)). Rural and highly rural residence were associated with lower likelihood of receiving appropriate inhaled therapy escalation (rural estimate: -4.0 (-5.1, -3.0); highly rural estimate: -3.0 (-5.0, -1.1)) and pulmonary rehabilitation referral (rural estimate: -1.2 (-1.6, -0.9); highly rural estimate: -2.1 (-2.7, -1.4)), but a higher likelihood of receiving smoking cessation therapy (rural estimate: 5.4 (3.3, 7.5); highly rural estimate: 7.2 (3.3, 11.2)). There was no significant difference in appropriate oxygen management (rural estimate: -1.0 (-2.8, 0.9); highly rural estimate: 3.1 (-0.7, 6.9)).

Conclusions: Patients across the rural-urban spectrum received few recommended post-discharge COPD treatments. Health systems approaches are needed to address widespread underutilization of evidence-based COPD care.