PURPOSE:VHA's Rural Interprofessional Faculty Development Initiative (RIFDI) is a structured program designed to develop teaching and leadership skills among clinical educators in rural settings. While prior literature indicates engagement in professional development programs increases retention of staff in health systems, no prior work has quantitatively evaluated the relationship between level of engagement and the associated effect on retention. We evaluated the impact of RIFDI on employee turnover by level of program engagement among VHA clinicians nationwide. METHODS:We employed a quasi-experimental study design using RIFDI program records and VHA administrative data from 2019 to 2024. Turnover was defined as leaving employment within 1 year after completing RIFDI. We used latent class methods to identify sub-groups among 134 RIFDI participants based on completion rate of RIFDI curriculum activities, allowing us to classify participants by level of program engagement. Using a propensity weighting approach, we compared predicted probabilities of turnover between each engagement group and 150,045 comparable non-RIFDI clinicians. FINDINGS:We identified two sub-groups among RIFDI participants: lower engagement participants (31%); and higher engagement participants (69%). In adjusted models, turnover was 12.8% among lower engagers, <1.0% among higher engagers, and 11.3% among non-RIFDI participants. Turnover was approximately 11 times lower for higher engagers compared with non-RIFDI participants (p-value < 0.001). CONCLUSION:The impact of RIFDI on VHA clinician turnover varied by level of program engagement, with highly engaged participants experiencing significantly lower turnover rates. Health systems should consider programs like RIFDI as a potential strategy for improving rural clinician retention.
PURPOSE:The Veterans Health Administration (VHA) reports provider shortages in up to 86% of their hospitals, with rural VHA Medical Centers (VAMCs) disproportionately affected. To address this, the VHA's Office of Rural Health launched the Telehospital Medicine Program to provide hospitalist coverage in understaffed facilities. This evaluation describes adoption and expansion of this program across six rural VHA hospitals. METHODS:Using a mixed-methods approach guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance framework, we evaluated implementation across six VHA facilities. Reach was assessed by measuring the number of inpatient bed days of care at rural facilities served by the Telehospital Medicine Program. Costs were evaluated through a budget impact analysis, while adoption, implementation, and maintenance were examined using facility-, provider-, and individual-level metrics, and staff and Veteran interviews and surveys. FINDINGS:On average, the Telehospital Medicine Program covered an average of 87 beds per day, with a range of 50-395 beds per day across the six facilities analyzed. Estimated savings for the facilities served range from $72K to $1.05M per year, equivalent to a reduction on average of ∼1.5 full-time equivalents of on-site providers, with the largest hospitals perceiving the largest savings. Additionally, no increases in length of stay, hospital readmissions, or mortality rates were observed following implementation. Factors influencing adoption include "hesitancy among newer nurses," "training components for residents and advanced practice providers," and "technology logistics." Staff found the program easy to integrate and effective in filling care gaps. Maintenance remained robust 6 months after implementation. CONCLUSIONS:The VHA's rural Telehospital Medicine Program demonstrated scalability, adaptability, and sustainability across a variety of practice settings-highlighting the program's ability to meet varying staffing needs across rural VHA facilities.
BACKGROUND:Technical assistance (TA) programs can support rural hospitals in addressing ongoing operational and financial challenges. However, there is limited evidence regarding the organizational motivations, facilitators, and barriers influencing rural hospitals' decisions to participate in these programs. OBJECTIVE:This study explored the motivations, facilitators, and barriers affecting rural hospitals' participation in TA initiatives. METHODS:Secondary qualitative data were obtained from applications submitted by rural hospitals to the Targeted Technical Assistance for Rural Hospitals Program between November 2023 and September 2025. Applications included organizational profiles and open-ended responses describing motivations, anticipated barriers, and factors supporting successful participation. Data were analyzed thematically using a hybrid inductive-deductive approach guided by Braun and Clarke's framework. RESULTS:Hospitals were motivated to seek TA to improve organizational sustainability by addressing financial challenges, enhancing clinical and operational processes, and developing their workforce. Key enablers included stakeholder buy-in, access to resources, perceived benefits of TA, strong mission orientation and community commitment, and prior TA or operational improvement experience. Commonly reported barriers involved capacity and staffing, operations, community engagement and perception, and coordination and logistics. To overcome these challenges, hospitals suggested strategies such as intentional planning and program prioritization, streamlining operational workflows to accommodate program participation, leveraging leadership support, and maintaining transparent communication with stakeholders. CONCLUSION:Rural hospitals' engagement in TA programs reflects both their resilience and desire to address systemic vulnerabilities. Tailoring support to the realities of rural healthcare is essential for enhancing hospital sustainability and maintaining access to care in underserved communities.
PURPOSE:American Indian and Alaska Native (AI/AN) populations receive care through multiple healthcare systems, including the Indian Health Service (IHS), which provides care to nearly two million users. To better understand inpatient quality of care, we examined patient satisfaction at IHS hospitals and assessed whether operation of IHS hospitals under self-determination contracts or compacts was associated with higher satisfaction than federally operated IHS hospitals. METHODS:We conducted a cross-sectional analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from October 1, 2020 to September 30, 2023. We evaluated top-box responses for nurse communication, physician communication, and overall hospital rating from 9642 surveys across 22 IHS hospitals. 19 of the 22 hospitals (86%) were located in non-metropolitan counties defined by US census tracts classified as rural or isolated rural by Rural-Urban Commuting Area (RUCA) codes. Multilevel logistic regression clustered by hospital examined associations with tribal operation of IHS hospitals, region, county poverty rate, and Area Deprivation Index. FINDINGS:Hospital-level averages for all HCAHPS measures were lower for IHS hospitals than the national HCAHPS average. Tribal operation of IHS hospitals was associated with higher odds of top-box overall hospital rating (OR 1.41, 95% CI 1.04-1.94) but not with nurse or physician communication. Physician communication scores were inversely associated with area deprivation. Substantial variation existed across IHS regions. CONCLUSION:IHS hospitals demonstrated lower satisfaction scores than the national average, with wide variability across facilities. Tribal operation of IHS hospitals was associated with higher overall hospital ratings, suggesting potential benefits of local governance. Findings highlight opportunities to strengthen patient experience across the IHS and the value of examining high-performing hospitals to inform improvement efforts.
PURPOSE:Increasing population longevity has led to greater demand for home and community-based services (HCBS) to assist older adults as an alternative to institutional care. Despite the recognized benefits of HCBS, there are significant differences in their availability and utilization between rural and urban communities. This study aimed to (1) compare rural and urban caregivers of older veterans in terms of searching for and receiving services and (2) examine differences in expressed interest in various service types. METHODS:Five hundred and eleven older veterans' caregivers completed an online survey on various HCBS. Rural-Urban Commuting Area codes (RUCA) were utilized to determine rurality, and data were analyzed using chi-squares, t-tests, and logistic regressions. FINDINGS:There were no differences in service interest between urban and rural caregivers. However, there were differences between the services searched for and those received. Urban caregivers were less likely than rural caregivers to seek respite. Urban caregivers also reported receiving more services than rural caregivers. CONCLUSION:This study indicates that rural and urban caregivers' interest in services is similar; however, rural veterans receive fewer HCBS than their urban counterparts. This study highlights potential gaps in the service pathway for rural caregivers. It provides insights into which specific services might benefit from targeted interventions to improve access and utilization for veterans in rural areas. The findings directly inform evidence-based resource allocation, targeted program development, and policy interventions designed to mitigate rural-urban disparities in caregiver support.
PURPOSE:Given persistently low rates of lung cancer screening among eligible individuals, we examined racial and geographic differences in proximity to low-dose computed tomography (LDCT) screening facilities among American Indians and Alaska Natives (AIAN) and White adults in North Carolina. METHODS:We used cancer registry data linked with health insurance claims (2016-2020) to examine a cohort of 18,154 AIAN and NHW lung cancer patients. We calculated straight-line distances between patient's residential ZIP code and nearest LDCT facility available in the year prior to diagnosis, (within ZIP code, 1-10 miles, or ≥10 miles). Logistic regression models assessed associations between distance and stage at diagnosis (localized vs. non-localized and distant vs. non-distant), adjusting for race, age at diagnosis, and health insurance status. FINDINGS:AIAN were more likely than NHW patients to live ≥10 miles from an LDCT facility (36% vs. 17%) and less often diagnosed at a localized stage (19% vs. 26%). Patients living ≥ 10 miles away had lower odds of localized stage diagnosis (adjusted OR = 0.89; 95% CI: 0.82-0.98) compared to those with access within their residential ZIP code. CONCLUSIONS:Greater distance to LDCT facilities was associated with reduced odds of early-stage diagnosis. Strategies such as mobile screening units and culturally tailored outreach may improve access and outcomes in underserved AIAN communities.
PURPOSE:To describe and assess the initial feasibility of the National Tele-Rheumatology Program (NTRP), a centrally managed hub-and-spoke telehealth model designed to expand access to rheumatology care for Veterans served by facilities with high proportions of rural Veteran populations. METHODS:Using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework, we analyzed Veterans Affairs (VA) program records, administrative and electronic health record data, Veteran questionnaires, and staff interviews from July 2024 through June 2025. Feasibility indicators included enrollment of spoke sites, delivery of care to Veterans in rural or highly rural areas, growth in encounter volume, changes in non-VA care utilization, Veteran satisfaction, and identification of implementation barriers and adaptations. FINDINGS:Eleven spoke sites enrolled during NTRP's first year. NTRP reached 1227 Veterans (82% male, 81% White; mean age 62.8 years), including 47% from rural or highly rural areas, and delivered 2577 encounters, 45.3% to rural or highly rural Veterans. Among 149 Veterans with a non-VA rheumatology care claim in the prior year, 89.3% had no further claims after their first NTRP visit. Veteran satisfaction was moderate to high and did not differ by rurality. Staff interviews identified technology access, reluctance to virtual care, and workflow variation as recurring challenges and described adaptations, including technology support and alternative clinic-based video access. CONCLUSIONS:Early feasibility indicators are promising. The NTRP reached its intended population, was acceptable to Veterans across rural and urban settings, and produced a preliminary signal of reduced non-VA care utilization. Continued evaluation should assess sustainment, costs, and clinical outcomes, with particular attention to rural-specific outcomes as the program grows.
PURPOSE:Mailed fecal immunochemical test (FIT) and patient navigation for follow-up colonoscopy have been shown to increase colorectal cancer (CRC) screening rates, but implementation barriers exist in rural settings. Partnerships between clinics and Medicaid health plans may address these barriers. In a large pragmatic randomized trial, we conducted a qualitative analysis to identify ways in which practice facilitation supported the implementation of a partnered health plan-clinic intervention of mailed FIT and patient navigation to improve CRC screening among rural Medicaid enrollees. METHODS:In the SMARTER CRC pragmatic trial, study team practice facilitators supported rural clinics and Medicaid health plans in implementing mailed FIT and patient navigation for follow-up colonoscopy. Qualitative data collected during the first year of implementation included clinic and health plan interviews, clinic contact logs, and monthly periodic reflections with the facilitator team. FINDINGS:Practice facilitation was needed to support both clinics and health plans in the study. Facilitators supported continued engagement of clinics and health plans, used workflow mapping to align implementation between clinics and health plans, provided technical support for sharing of patient data, and facilitated communication between clinics and health plans. Prior study team experience implementing CRC screening interventions enabled successful facilitation. CONCLUSIONS:Practice facilitation can successfully support partnered health plan-clinic implementation of mailed FIT and patient navigation in rural clinics. Our findings highlight the importance of assessing support needs across all partnering organizations when implementing multilevel preventive care interventions and underscore the importance of subject matter expertise in practice facilitation. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04890054.
PURPOSE:Rural veterans experience challenges and strengths related to military service and rural residence. Defining rurality for healthcare facilities is vital for allocating resources, estimating impacts of rural health initiatives, and evaluating rural veteran access and outcomes. While geolocation is one way of conceptualizing rural healthcare facilities, rurality exists on a continuum and is influenced by many factors. The purpose of this work was to create an empirically informed taxonomy of VHA acute care hospitals that moves beyond a geography-based classification alone and to propose facility-level variables that can be used to measure rural veterans' access to hospital-based care. METHODS:We conducted a cluster analysis of 110 Veterans Health Administration (VHA) acute care hospitals using k-means clustering. Hospital-level variables included number of enrollees, number and percentage of rural and highly rural enrollees, VHA hospital complexity classification level (low, medium, high), and mean drive times for veterans to access VHA care (primary, secondary, tertiary). FINDINGS:Three clusters emerged. The Low Rural Serving (LRS) Cluster (N = 40) comprised 39 high complexity hospitals, with an average of 16.5% of veteran enrollees residing in rural areas. The Medium Rural Serving (MRS) Cluster (N = 26) contained all high complexity hospitals, with an average of 32.8% of veteran enrollees residing in rural areas. The High Rural Serving (HRS) Cluster (N = 44) comprised 10 low, 12 medium, and 22 high complexity hospitals, with an average of 61.9% of veteran enrollees residing in rural areas. The average percentage of highly rural veteran enrollees was 1.0% for LRS, 1.6% for MRS, and 9.7% for HRS. Average drive times to primary, secondary, and tertiary care increased incrementally across clusters. CONCLUSIONS:Using 9 hospital-level factors that may characterize degree of hospital rurality, we identified 3 clusters that differentiate VHA hospitals and the rural populations they serve.
PURPOSE:This study explored how rural public health leaders in Wisconsin experienced and sustained resilience during the COVID-19 pandemic, with particular attention to the role of relational connections across professional, personal, and community domains. METHODS:Using hermeneutic phenomenology, the study examined the lived experiences of rural county health officers and other supervisory leaders. Twenty semistructured interviews were conducted via Zoom between September and November 2023. Participants were purposively sampled from rural counties, as defined by the National Center for Health Statistics' Urban-Rural Classification Scheme. Interviews were recorded, transcribed, and thematically analyzed through iterative coding and synthesis. FINDINGS:Resilience was closely linked to the embeddedness of rural communities. Longstanding trust, shared history, and a sense of mutual responsibility strengthened leaders' resolve. At the same time, this closeness also increased feelings of scrutiny, blurred personal and professional boundaries, and exposed leaders and their families to hostility. Leaders relied on tightly knit staff teams, cross-jurisdictional peer networks, and supportive governing officials. CONCLUSIONS:In rural settings, resilience is co-constructed through community connections. Strengthening peer support and preparing governing bodies to lead with empathy are important for sustaining this workforce.
INTRODUCTION:Lung cancer screening enables earlier detection and improved outcomes, yet geographic inequities persist in access to low-dose computed tomography (LDCT). We quantified tract-level access to LDCT screening in Tennessee and examined disparities by rurality and Appalachian status. METHODS:We compiled an inventory of LDCT-capable sites and measured access using a 30-min enhanced two-step floating catchment area (E2SFCA) index with three banded decay weights. Access was compared across four strata (urban Appalachia, rural Appalachia, urban non-Appalachia, and rural non-Appalachia) using Kruskal-Wallis and pairwise Wilcoxon tests (Holm adjustment). Rank-based associations between E2SFCA and tract sociodemographics were evaluated using Spearman correlations. RESULTS:We identified 198 LDCT sites in Tennessee. Urban residents account for 74.10% of those living within ≤20 min, whereas rural residents constitute the majority (63.50%) of the 30-45-min band. Access differed across strata (Kruskal-Wallis χ2 = 277.46, p < 2.2 × 10-16): Medians (per 1000) were highest in urban non-Appalachia (0.464) and urban Appalachia (0.430), and lower in rural Appalachia (0.210) and rural non-Appalachia (0.197); all urban-rural contrasts were significant. Regional patterns diverged: West Tennessee showed the largest coverage gap (13.9% zero-access tracts), East Tennessee had the lowest capacity among served tracts (median = 0.339; overall median = 0.293), and Middle Tennessee showed the strongest overall access (overall median = 0.380; 73/647 zero-access; 11.3%). CONCLUSIONS:Rural communities face longer travel times to access LDCT screening sites with more zero-access tracts than urban communities. Our findings support interventions such as adding service points in West Tennessee and expanding capacity in East Tennessee. Strengthening navigation and referral pathways for rural and Appalachian residents is also necessary.
PURPOSE:To evaluate the impact of the Veterans Health Administration's (VA) virtual acute care programs-tele-emergency care (TEC) and virtual care visits (VCV)-on short-term utilization, mortality, and costs among rural veterans. METHODS:This retrospective study used national call center data (January 2022-September 2024) linked with VA administrative and community care records. Completed TEC or VCV encounters were grouped by triage acuity: acute (recommended follow-up within 8 h; n = 61,408) and non-acute (>8 h; n = 66,319), and compared with matched controls using propensity-score methods. Primary outcomes were emergency department (ED) visits, hospital admissions, and 30-day mortality. Secondary outcomes included total, inpatient, outpatient, pharmacy, and community care costs. FINDINGS:Among 631,437 nurse triage calls from rural veterans, virtual care was associated with significantly lower ED visits (acute: -11.87 percentage points (pp), 95% CI -12.47 to -11.26; non-acute: -3.62 pp, 95% CI -4.02 to -3.22) and hospitalizations (acute: -0.55 pp; non-acute: -0.15 pp). Thirty-day mortality did not differ significantly in either group. Total costs were modestly higher in both groups that received virtual care (acute: +$549; non-acute: +$386), driven by outpatient spending and partially offset by lower community care costs. CONCLUSIONS:Virtual acute care substantially reduced short-term emergency and hospital utilization among rural veterans across both acuity groups but was associated with higher total 30-day costs. These findings highlight the potential of embedded virtual programs to improve access for rural veterans, while underscoring the need to evaluate their long-term value and return on investment.
PURPOSE:Family Resource Centers (FRCs) are place-based programs with great potential to address rural access barriers and improve health outcomes, yet empirical evidence on these programs is lacking. Using multiple data sources from a longitudinal investigation in Wisconsin, this mixed-methods study analyzed whether and how FRCs address rural access barriers. METHODS:A convergent parallel mixed-methods design was used to gather, analyze, and interpret quantitative and qualitative data. Data from the Child Opportunity Index were used to compare opportunities in rural and nonrural areas statewide and among 646 rural and nonrural families who received support from one of 18 FRCs. Qualitative data gathered from interviews with nine FRC participants and 11 FRC staff were synthesized to describe rural access barriers and facilitators. To compare the types of support received by rural and nonrural families, baseline survey data collected from 646 FRC participants were analyzed using chi-square tests. To test whether FRC participation increased referral connections, follow-up survey data collected from 319 FRC recipients and a matched sample of 458 adults were analyzed via logistic regression. FINDINGS:Disparities between rural and nonrural ZIP codes were evident statewide and in FRC catchment areas. Qualitative analyses identified rural resource gaps, transportation barriers, and FRC facilitators of family engagement. Baseline survey responses indicated that rural families were more likely to receive resource referrals; nonrural families were more likely to participate in parenting programming and parent-child activities. Longitudinal analyses linked FRC participation to higher rates of resource connections. CONCLUSIONS:FRCs address social determinants that disproportionately affect rural communities. Implications for public health intervention and policy are discussed.
PURPOSE:This study examines differences between major city and regional and remote participants in engagement in a digital alcohol support intervention (Daybreak), risky drinking, and psychological distress and tests the mediating role of psychological distress. METHODS:This was a longitudinal, observational cohort study of Daybreak participants between January 2019 and December 2024 (N = 12,824). Outcomes were risky drinking and psychological distress. Ordered logistic regression examined associations between the outcomes and program engagement, and multilevel generalized structural equation modeling tested mediation by psychological distress. FINDINGS:At 6 months, risky drinking scores declined by 42% in major city participants and 57% in regional and remote participants. High engagement in reacting to posts reduced risky drinking in both metro (OR = 0.47, 95% CI 0.27-0.80) and regional and remote areas (OR = 0.42, 95% CI 0.18-0.99). High engagement in post sharing was associated with lower odds of high risky drinking only in major city participants (OR = 0.56, 95% CI 0.33-0.98). In regional areas, participants who aimed to quit drinking at registration had lower risky drinking (OR = 0.72, 95% CI 0.53-0.99), while longer program inactivity increased odds of psychological distress (OR = 1.95, 95% CI 1.13-3.38). Psychological distress mediated 56% of the association between post reactions and risky drinking in major city participants and 33% in regional and remote participants. CONCLUSIONS:Distinct engagement pathways across regional and remote and major city settings suggest the need for more flexible digital program designs. Psychological distress, as a partial mediator, should be both a treatment target and a mechanism of change.
PURPOSE:Describe the perceptions of patients receiving rural home hospital (RHH) care. METHODS:This is a qualitative evaluation of a randomized controlled trial comparing RHH (intervention) versus brick-and-mortar (BAM) care (control) in three rural sites in the United States and Canada between February 23, 2022, and January 17, 2024. Participants include acutely ill patients who received RHH. RHH programs provided patients with twice-daily nurse/paramedic visits, daily physician visits (remote), hospital-level diagnostics and treatments in the home, and other care tailored to the patient. Patient experience while receiving RHH care analyzed thematically to identify advantages and disadvantages of this model of care in the rural setting. FINDINGS:We interviewed 38 of 79 RHH patients recruited to our randomized controlled trial. Mean age was 67 (SD 17), 100% were White, 29% female, 82% Medicare recipients, and 62% retired. Patient perceptions clustered around three main themes: (1) perceived quality of care; (2) perceived comfort; and (3) experience with technology. Overall, home hospitalized patients were satisfied with the care they received at home. This was driven by strong rapport with the care team and receiving safe and effective medical care in the comfort of their home. Patients noted perceived comfort from familiar home surroundings and improved social support, nutrition, and sleep. Patients felt technology facilitated their experience and noted it presented a learning curve and occasional barrier to care. CONCLUSIONS:RHH patients reported positive patient experiences principally across perceived quality, comfort, and technology, with some opportunity for improvement in technology interfaces for select patients. TRIAL REGISTRATION:NCT05256303.
PURPOSE:Rural communities face persistent health disparities and ongoing healthcare workforce shortages, especially in nursing. Despite national attention on strengthening the rural nursing pipeline, little synthesis exists on how rural health is integrated into nursing curricula. This narrative review provides an overview of the current landscape of rural health content within Bachelor of Science in Nursing (BSN) programs in the United States. METHODS:A comprehensive search of peer-reviewed and institutional sources was conducted using CINAHL, PubMed, ERIC, Scopus, and the Commission on Collegiate Nursing Education (CCNE) database. U.S.-based BSN programs with explicit rural health training or learning components were included. Data were extracted and synthesized using a narrative approach to identify recurring themes and institutional variations. FINDINGS:Sixty-three nursing programs met our inclusion criteria; however, many had various courses or initiatives for a total of 93 courses/initiatives. The majority of courses/initiatives were community-focused (n = 59), followed by underserved communities (n = 37). Few BSN programs had explicit rural health content (n = 20) that incorporated rural-specific courses or structured clinical experiences addressing rural practice. CONCLUSIONS:Rural health remains underrepresented in BSN curricula. Findings underscore the need for systematic integration of rural concepts through coursework, simulation, and partnerships with rural healthcare facilities to strengthen the rural nursing workforce.
PURPOSE:The United States faces a looming nationwide shortage of healthcare workers, especially in rural areas. This is particularly concerning for the Veterans Health Administration (VHA), the US' largest integrated healthcare system, which is experiencing high vacancy rates. Professional training programs can increase recruitment and retention in rural areas. We examined the 22 Advanced Fellowships offered by the VHA's Office of Academic Affiliations to assess their potential for retaining trainees in rural areas and at the VA. METHODS:Fellow surveys were administered from June 2018 through August 2023 in this cross-sectional study. Key variables included fellowship characteristics (location, topic area, length), and post-fellowship employment, including location (rural or non-rural), and type (clinical or non-clinical, VA or non-VA). We followed STROBE guidelines in reporting. FINDINGS:Six (13%) of the 47 training sites are at facilities serving primarily rural veteran populations; six of the 22 programs are offered at these sites. Of the 843 fellows trained during the study period, 55 (7%) were at rural-serving VAMCs. Fellows who trained in rural-serving areas versus non-rural areas were significantly more likely to be employed in rural areas post-fellowship (63% vs. 2%, p < 0.01), and tended to remain employed at or affiliated with the VA post-fellowship at higher rates. CONCLUSIONS:The Advanced Fellowship program is effective at retaining trainees in rural areas and should be considered as part of the VA's strategy to address rural workforce shortages. Additional research is needed to assess longitudinal retention and the potential for targeted program expansion in rural sites.
PURPOSE: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. METHODS: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. FINDINGS: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]). CONCLUSION: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.
