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Short Communication

The interaction between rural/urban status and dual use status among veterans with heart failure

AUTHORS

Kelly J Hunt1 PhD, Research Health Scientist

Mulugeta Gebregziahber2 PhD, Research Health Scientist

Charles J Everett3 PhD, Statistician

Paul A Heidenreich4 MD, Physician

R Neale Axon5 MD, Physician *

AFFILIATIONS

1, 2 Charleston Health Equity and Rural Outreach Innovation Center (HEROIC) and Department of Public Health Sciences, The Medical University of South Carolina, Ralph H. Johnson VA Medical Center, 109 Bee Street, MSC 151, Charleston, SC 29401, USA

3 Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), 109 Bee Street, MSC 151, Charleston, SC 29401, USA

4 Division of Cardiology, VA Palo Alto Healthcare System, Stanford University Medical Center, 3801 Miranda Avenue, Palo Alto, CA 94304-1290, USA

5 Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), 109 Bee Street, MSC 111, Charleston, SC 29401, USA

ACCEPTED: 21 November 2017


early abstract:

Introduction: Dual healthcare system use is associated with higher rates of healthcare utilization, but the influence of rurality on this phenomenon is unclear. This study aimed to determine the extent to which rurality modifies the likelihood for acute healthcare use among veterans with heart failure (HF).

Methods: Using merged VA/Medicare, and state-level data, a retrospective cohort study of 4985 veterans with HF was performed. Negative Binomial regression with interaction term for dual use and geographic location was used to estimate and compare the associations between dual use (as compared to VA-only use) and ED visits, hospitalizations, and 30-day hospital readmissions in rural/highly rural veterans versus urban veterans.

Results: The association between dual use compared to VA-only use and ED visits was stronger in rural/highly rural veterans [RR=1.28 (95% CI: 1.21, 1.35)] than in urban veterans [RR=1.17 (95% CI: 1.11, 1.22)] (interaction p-value=0.0109), while the association between dual use and all-cause hospitalizations was similar in rural/highly rural veterans [RR=2.00 (95% CI: 1.87, 2.14)] and in urban veterans [RR=1.87 (95% CI: 1.77, 1.98)]. The association between dual use and all-cause 30-day hospital readmission was also similar in rural/highly rural versus urban veterans.

Conclusion: Rurality significantly modifies the likelihood of ED visits for HF, though this effect was not observed for hospitalizations or hospital readmissions. While other patient- or system-level factors may more heavily influence hospitalization and readmission in this population, dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural veterans.