The Effect of Rural Versus Urban Residence on Risk of Unplanned Readmission and Death in Older Veterans Discharged...

Evidence suggests that rural-residing adults-compared with urban-may be at greater risk of readmission and mortality. Operational leaders within the Department of Veterans Affairs (VA) Geriatric Learning Health System (GLHS) sought to understand the effects of rural residence on readmission and mortality risk for older Veterans discharged from hospital to home.

This observational cohort study included Veterans aged ≥ 65 years discharged from VA hospitals (fiscal year 2023) to home. A semi-competing risk model was fit to jointly model unplanned readmission, mortality, and mortality after readmission, with rural residence as the exposure of interest. Data were censored at 30-days, 90-days, or 1-year post discharge to examine short- and longer-term effects. Additional variables considered for the model were identified through prior literature, clinical significance and those selected by the Centers for Medicare & Medicaid Services for unplanned readmission.

Among 99,557 patients (120 hospitals), 28.4% were rural residents. Only 18% of rural residents lived within 30 min of a VA facility versus 80.3% of urban residents. At 30 days, compared to urban, rural-residing patients had a 5% lower risk of readmission (hazard ratio [HR] = 0.95, 95% confidence interval [CI] = [0.91-1.00]), 20% higher risk of mortality (HR = 1.20, 95% CI = [1.03-1.40]), and a similarly higher risk of mortality after readmission (HR = 1.19, 95% CI = [1.03-1.39]).

Rural-residing older Veterans had lower risk of readmission but higher risk of mortality. These findings will guide future VA GLHSs: seeking modifiable factors (e.g., social drivers of health, timely services) associated with mortality risk among rural Veterans that can inform practice, policy, and quality improvement, thereby reducing disparities in outcomes.