Use of post-acute care after hospital discharge in urban and rural hospitals.

Objectives: Geographic variation in the use of post-acute care (PAC - skilled nursing facility and home health care) after hospital discharge is substantial, but reasons for this remain largely unexplored. PAC use in urban hospitals compared to rural hospitals may be one key contributor. We aimed to describe PAC use, explore substitution of one type of PAC for another, and identify how PAC use varies by diagnosis in urban and rural settings.

Study design: Secondary analysis of the 2012 National Inpatient Sample including adult discharges to PAC after a hospitalization.

Methods: We adjusted for differences in patient demographics, comorbidities, hospital care provided, and hospital information, comparing use of PAC in urban and rural settings in multivariable logistic regression.

Results: Rural patients discharged from rural hospitals constituted 188,137 (12.1%) of the 1.56 million discharges in the sample. Rural discharges received less home health care (0.85; 0.80-0.90) than urban discharges, resulting in less rural PAC use overall (0.95; 0.91-0.99). Rural discharges received more overall PAC for stroke (OR 1.11; 95% CI 1.03-1.19) and less PAC for sepsis (0.92; 0.86-0.98), hip fracture (0.82; 0.70-0.96), and elective joint arthroplasty, where rural discharges had 41% lower odds of receiving PAC (0.59; 0.49-0.71).

Conclusions: The striking differences in receipt of post-acute care in urban and rural patients may constitute a disparity. Evaluation of costs and outcomes of PAC use in these settings is urgently needed as Medicare expands bundled payments for this care.