Self-identified rurality in a nationally representative population in the US

Area of Science:

• Health Services Research
• Rural Health
• Geographic Classification

Background:

• The Rural-Urban Commuting Area (RUCA) classification is standard for measuring rurality in US health services research.
• Existing RUCA codes often misrepresent rurality and do not account for individual healthcare experiences or inequities.
• A patient-centered approach is needed to accurately define rurality and its impact on health disparities.

Purpose of the Study:

• To develop a patient-centered definition of rurality using RUCA codes.
• To evaluate the concordance between self-identified rurality and existing RUCA classifications.
• To propose a revised RUCA-based classification that better reflects patient perceptions.

Main Methods:

• A cross-sectional online survey was conducted with US residents asking about their perceived rurality and rationale.
• Concordance between self-reported rurality and ZIP code-derived RUCA designations was assessed using Cohen's kappa and percent agreement.
• RUCA codes 2-3 were reclassified as rural based on participant responses and analyzed for improved agreement.

Main Results:

• Moderate agreement (kappa=0.48) was found between perceived rurality and conventional RUCA classifications.
• Low agreement (19.6%) was observed for individuals in RUCA 2-3 areas, driven by perceptions of population density and proximity.
• Reclassifying RUCA 2-3 as rural increased overall concordance (kappa=0.56), indicating improved patient-centricity.

Conclusions:

• A patient-centered RUCA-based classification is essential for accurately assessing rurality's impact on health disparities.
• Reclassifying RUCA 2-3 designations as rural offers a more accurate and patient-centric definition.
• This revised classification can be readily implemented in future health services research, especially when self-reported data is unavailable.