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Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge

Toth, Matthew, PhD, MSW*; Holmes, Mark, PhD*; Van Houtven, Courtney, PhD†,‡; Toles, Mark, PhD, RN§; Weinberger, Morris, RN, PhD*; Silberman, Pam, JD, Dr PH*

Erratum

In the article that appeared on pages 800-808 in the September issue of Medical Care , there is an error in the last paragraph of the first page. Currently, the text reads “ED use can increase hospital spending per beneficiary and may have negative consequences for rural providers, particularly as it relates to the Hospital Value Based Purchasing program (HVBP)”. This sentence should read as follows:

“ED use can increase hospital spending per beneficiary and may have negative consequences for rural providers”.

On page two, in the last sentence of the first paragraph, the last part of the sentence reads “…may increase the risk of an ED visit, and place rural hospitals at greater risk of reduced payments under HVBP”. The sentence should read as follows:

“Poorer access to key post-discharge services, such as follow-up care, may increase the risk of an ED visit”.

The author apologizes for these errors.

Medical Care. 53(10):908, October 2015.

doi: 10.1097/MLR.0000000000000401
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Background: Hospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but little is known about their postdischarge care and outcomes. We hypothesize that rural Medicare beneficiaries compared with urban beneficiaries, will have fewer follow-up visits, and a greater likelihood of readmission and ED use.

Methods: We conducted a retrospective analysis of elderly Medicare beneficiaries discharged home using the Medicare Current Beneficiary Survey, Cost and Use files, 2000–2010. Multivariate Cox proportional hazard models were used to assess the risk of rural residency on readmission, ED use, and follow-up care up to 30 days’ postdischarge. Covariates include demographic, health, and hospital-level characteristics.

Results: Compared with urban beneficiaries, Medicare beneficiaries living in isolated rural settings had a lower rate of follow-up care [hazard ratio (HR)=0.81, P<0.001]. Beneficiaries in large and small rural settings had a greater risk of an ED visit compared with urban beneficiaries (HR=1.44, P<0.001; HR=1.52, P<0.01). Rural beneficiaries did not have a greater risk of readmission, though risk of readmission was higher for beneficiaries discharged from hospitals in large and small rural settings (HR=1.33, P<0.05; HR=1.42, P<0.05).

Conclusions: This study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.

*Department of Health Policy and Management, Sheps Center for Health Services Research, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill

US Department of Veterans Affairs, Durham VA Medical Center, Center for Health Services Research in Primary Care

Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham

§School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website, www.lww-medicalcare.com.

Supported by a T-32 National Research Service Award, Sheps Center for Health Services Research, Grant #: 2T32HS000032-25. Support was also provided by the North Carolina Rural Health Research Program. UL1-TR000083, F30-HL110483, T32-GM008719, and UNC Institute on Aging pilot grant supported the purchase of the Medicare Current Beneficiary Survey.

The authors declare no conflict of interest.

Reprints: Matthew Toth, PhD, MSW, Department of Health Policy and Management, Sheps Center for Health Services Research, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, 1101 McGavran-Greeberg Hall, CB #7411, Chapel Hill, NC 27599. E-mail: tbmatthe@live.unc.edu.

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