Rural-Urban Differences in Medicare Quality Scores Persist After Adjusting for Sociodemographic and Environmental Characteristics

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Abstract

Purpose: Quality scores are strongly influenced by sociodemographic characteristics and health behaviors, many of which lie outside of the clinician's control. As a result, there is vigorous debate about whether, and how, to risk-adjust quality measures. Yet, rurality has been largely missing from this debate, even though population and environmental characteristics are demonstrably different by rurality. We addressed this gap by examining the influence of county-level population sociodemographic, environmental, and health characteristics on 3 Medicare quality measures. Methods: We used a cross-sectional analysis of 2016 County Health Rankings data to estimate differences in 3 Medicare quality scores (preventable hospitalizations, HbA1c monitoring, and mammography screening) by rurality. We then adjusted for county-level sociodemographic and environmental characteristics in multivariable regression models in order to see whether the association between rurality and quality was impacted. Findings: Both micropolitan and noncore counties exhibited lower quality scores than metropolitan counties for all 3 measures. After adjustment, noncore counties still had poorer quality on all 3 measures, while micropolitan counties improved on 2 measures. Several county-level sociodemographic and environmental characteristics were associated with quality, although the direction of association depended on the quality measure. Conclusions: Differences in Medicare quality scores by rurality cannot be entirely explained by differences in population or environmental characteristics. Still, to the extent that clinicians are evaluated—and paid—based on measures that are influenced by both population sociodemographic characteristics and geographic location without adequate risk adjustment, the challenges of delivering care in rural areas will only be exacerbated.

Original languageEnglish (US)
Pages (from-to)58-67
Number of pages10
JournalJournal of Rural Health
Volume35
Issue number1
DOIs
StatePublished - Jan 2019

Bibliographical note

Funding Information:
Funding: This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS) under PHS Grant No. 5U1CRH03717. The information, conclusions, and opinions expressed in this manuscript are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

Funding Information:
This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS) under PHS Grant No. 5U1CRH03717. The information, conclusions, and opinions expressed in this manuscript are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

Publisher Copyright:
© 2017 National Rural Health Association

Copyright:
Copyright 2018 Elsevier B.V., All rights reserved.

Keywords

  • Medicare
  • health services research
  • quality of health care
  • rural health services
  • social determinants of health

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