The interaction between rural/urban status and dual use status among veterans with heart failure

Rural Remote Health. 2018 May;18(2):4495. doi: 10.22605/RRH4495. Epub 2018 May 10.


Introduction: Dual healthcare system use is associated with higher rates of healthcare utilization, but the influence of rurality on this phenomenon is unclear. This study aimed to determine the extent to which rurality in the USA modifies the likelihood for acute healthcare use among veterans with heart failure (HF).

Methods: Using merged Veterans Affairs (VA), Medicare, and state-level administrative data, a retrospective cohort study of 4985 veterans with HF was performed. Negative binomial regression with interaction term for dual use and geographic location was used to estimate and compare the associations between dual use (as compared to VA-only use) and emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions in rural/highly rural veterans versus urban veterans.

Results: The association between dual use compared to VA-only use and ED visits was stronger in rural/highly rural veterans (RR=1.28 (95%CI: 1.21,1.35)) than in urban veterans (rate ratio (RR)=1.17 (95% confidence interval (CI): 1.11,1.22)) (interaction p-value=0.0109), while the association between dual use and all-cause hospitalizations was similar in rural/highly rural veterans (RR=2.00 (95%CI: 1.87, 2.14)) and in urban veterans (RR=1.87 (95%CI: 1.77,1.98)). The association between dual use and all-cause 30-day hospital readmission was also similar in rural/highly rural versus urban veterans.

Conclusion: Rurality significantly modifies the likelihood of ED visits for HF, although this effect was not observed for hospitalizations or hospital readmissions. While other patient- or system-level factors may more heavily influence hospitalization and readmission in this population, dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural veterans.

Keywords: USA; health care utilization; heart failure; hospitalization; access to care.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Health Services / statistics & numerical data*
  • Heart Failure / therapy*
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data
  • Residence Characteristics
  • Retrospective Studies
  • Rural Population / statistics & numerical data*
  • United States
  • United States Department of Veterans Affairs / statistics & numerical data*
  • Urban Population / statistics & numerical data*