Rural residence associated with receipt of recommended postdischarge chronic obstructive pulmonary disease care among a cohort of U.S. Veterans

Abstract: Rationale: Individuals with chronic obstructive pulmonary disease (COPD) in rural areas experience inequitable access to care. Objectives: To assess whether rural residence is associated with receipt of recommended postdischarge COPD care. Methods: We conducted a cohort study of all U.S. veterans discharged from a Veterans Affairs medical center after COPD hospitalization from 2010 to 2019. Rural residence was defined by rural-urban commuting area classification. Our primary outcome was the proportion of recommended care received within 90 days of hospital discharge, including smoking cessation therapy, appropriate management of supplemental oxygen, appropriate prescription of inhaled therapy, and pulmonary rehabilitation. We conducted multivariable linear regression between rural residence and the proportion of recommended care received, adjusting for age, sex, race, ethnicity, comorbidities, and primary care facility type. We tested multivariable linear probability models for each of the recommended therapies. Results: Of 67,649 patients, 7,370 (10.8%) resided in rural areas and 2,000 (3.0%) in highly rural areas. Overall, the proportion of recommended COPD treatments received was low (mean, 15.0%; standard deviation, 21.0%). Compared with urban residence, patients with rural and highly rural residence received fewer recommended COPD care treatments (rural estimate [adjusted percentage difference (95% confidence interval)], -1.1 [-1.6, -0.6]; highly rural estimate, -1.2 [-2.1, -0.3]). Rural and highly rural residence were associated with lower likelihood of receiving appropriate inhaled therapy escalation (rural estimate, -4.0 [-5.1, -3.0]; highly rural estimate, -3.0 [-5.0, -1.1]) and pulmonary rehabilitation referral (rural estimate, -1.2 [-1.6, -0.9]; highly rural estimate, -2.1 [-2.7, -1.4]) but a higher likelihood of receiving smoking cessation therapy (rural estimate, 5.4 [3.3, 7.5]; highly rural estimate, 7.2 [3.3, 11.2]). There was no significant difference in appropriate oxygen management (rural estimate, -1.0 [-2.8, 0.9]; highly rural estimate, 3.1 [-0.7, 6.9]). Conclusions: Patients across the rural-urban spectrum received few recommended postdischarge COPD treatments. Health systems approaches are needed to address widespread underuse of evidence-based COPD care.

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