Urban/Rural differences in home health care quality

Background: The use of Home Health Care has been seen to reduce overall healthcare spending and provide for patient wishes of receiving care in the home. Home Health Care accomplishes these spending reductions by allowing hospitals to discharge sooner and reducing hospital re-admission rates. The objective of this study is to determine differences, if any, in reported quality indicators between rural and urban Home Health agencies, while controlling for other health-related socio-economic factors.

Methods: This cross-sectional study analyzed Medicare's Home Health Compare files, which included a provider file, services file, zip file, and quality measures file. These files were then merged by zip code to the 2010 Research Triangle Institute's Spatial Impact Factor Database. Lastly, rurality was measured by Rural-Urban Commuting Area Codes (RUCA), from the Department of Agriculture's Economic Research Service. The Home Health Compare Medicare files consisted of 9,996 Home Health Providers. These providers practice in a total of 36,213 zip codes. The Home Health Compare Quality Measures file included the following indicators: improvements in ambulation, bathing, transferring, oral medication management, pain management, acute care hospitalization, emergent care, discharge, shortness of breath, incontinence, surgical wound care, and emergent care for wound deterioration. Other zip code – level socio-economic factors were collected from the Research Triangle Institute's Spatial Impact Factor Database.

Results: Rural zip codes have lower measured quality across 10 out of the 12 indicators. In the multivariate model, controlling for percent White population, median income, percent of disabled males, percent disabled females, and the number of high school graduates, the level of rurality remained a significant predictor of poorer health outcomes in 9 of the 12 quality indicators.

Conclusions: When predicting differences in Home Health care quality, level of rurality is a very predictive variable. Even after controlling for a host of socio-economic factors, a rural zip code is generally at a disadvantage when predicting quality of Home Health services, as compared to an urban zip code. The disparity of Home Health care quality between urban and rural zip codes, as seen in this study, adds to the literature more evidence of a need for health care system re-design. By incentivizing nurses, particularly in the geriatric specialization, to practice home health care in rural areas, quality in rural areas will begin to improve. By infusing rural areas with more Home Health nurses, the urban and rural quality gap with begin to narrow.