A comparison of older veterans' mortality rates across the rural-urban residence spectrum

Objectives: More than one in five veterans lives in a rural setting. Several studies suggest that rural-dwelling VA users have greater healthcare needs than their urban counterparts, as measured by health-related quality-of-life scores, even after adjusting for socio-demographic and clinical factors, but face limited access to care because of distance. However, rural veterans' risk of death relative to their urban counterparts is unknown.

Methods: Among male veterans aged 65 and older, we examined the association between residing in a rural setting and survival by linking demographic survey data collected in 1999 to a 2006 vital status registry. We used ZIP-Code derived RUCA designations to categorize veterans into rural, large town, suburban, and urban residence. We used time-to-event regression models (including Cox's model for left-truncated data, and kernel smoothed hazards) to compare rural to urban survival rates after controlling for patient race, education, ZIP-Code median income, and marital and smoking status.

Results: Of the 372,463 male veterans of age 65 or older, approximately 80,000 lived in rural settings. Age adjusted mortality was 6% higher (95% Confidence Interval: 5.1% to 7.6%) among rural residents compared to urban residents. However, after adjusting for age, education and ZIP -Code median income, rural residents had 3% lower mortality (95% Confidence Interval: 2.2% to 4.5%). Compared to urban and suburban veterans, rural veterans' mortality at age 65 was 12% lower, but this advantage gradually diminished and was completely extinguished by age 75.

Conclusion: Several factors may explain why rural veterans have lower mortality than their urban counterparts of the same age and socio-economic status until age 75 years. Higher mortality for non-rural populations may be attributable to urban risk factors such as air pollution, poor water quality, motor vehicle accidents, pedestrian accidents, and a relative lack of social capital which is known to enhance psychological well-being, perhaps mitigating other disadvantages. Alternatively, older veterans who are able to live independently in rural settings where health care may be restricted may have a greater likelihood of surviving than those who move to the city specifically to access care. Conversely, rural veterans' survival rates up to age 75 may be greater because they are less likely to access or receive unnecessary and redundant healthcare services. If so, perhaps the VA and other healthcare providers should focus on “right-sizing” healthcare services to optimize health, quality-of-life, and mortality.