摘要：Objectives . We examined differences in quality of care among nursing homes in locales of varying degrees of rurality. Methods . We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators. Results . For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas. Conclusions . We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population. The demographic shift in the United States to a significantly older population has been well-documented. Estimates are that 1 in 5 persons in the country will be aged 65 years or older by 2030. 1 However, for the planning of service delivery systems and planning for change in these delivery systems, it is also critical to understand the geographic distribution of the elderly. Rurality is a significant factor in gauging the proportion of a locale’s population that is elderly and likely to need long-term care services. In urban areas in 2000, only 5.6% of the population were aged 75 years or older, whereas in isolated rural areas the percentage was roughly one third higher (7.4%). In nonurban areas, this aging population has resulted in relatively higher rates of nursing home use, with over 560000 nursing home residents receiving care in nursing homes operating outside metropolitan areas. 2 Researchers interested in nursing homes in rural areas have focused largely on an array of topics emphasizing access and utilization rather than quality of care. They have shown interest in the “premature” use of nursing homes in rural areas, 3 the characteristics of admissions to urban and rural nursing homes, 4, 5 and differences in other aspects of nursing home and long-term care use. 6– 10 Much less attention has been given to questions of quality differences in homes in locales differing in rurality. 11 Only recently has research on quality of care in rural nursing homes begun to appear. Recent literature now contains comparisons of feeding tube use in urban and rural homes in 1 state, 12 data on multiple hospitalizations from 6 states, 13 and a more general analysis of quality indicators in a single state. 14 The research presented in this article attempts to move beyond previous research on quality of care in rural nursing homes through (1) use of an admission cohort to alleviate problems in risk-adjustment; (2) use of a measure of rurality that includes commuting patterns as well as population; (3) the merging of individual and home characteristics; and (4) use of a nationally representative sample of individuals admitted to certified nursing homes. These differences allow the research team to make, for the first time, statements about quality differences in urban and rural nursing homes that are generalizable to the nation as a whole.
