ABSTRACT: Importance:There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. Objective:To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. Design, Setting, and Participants:This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555?333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. Exposures:Rurality of beneficiary's county of residence. Main Outcomes and Measures:Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. Results:A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. Conclusions and Relevance:Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.
