Supply-Side Differences Only Modestly Associated With Inpatient Hospitalizations Among Medicare Beneficiaries in the Last Six Months of Life.

Context: Inpatient hospitalizations are a driver of expenditures at the end of life and are a useful proxy for the intensity of care at that time.

Objectives: Our study profiled rural and urban Medicare decedents to examine whether they differed in rates of inpatient hospital admissions in the last six months of life.

Methods: Using a sample of 35,831 beneficiaries from the 2013 Medicare Research Identifiable Files, we examined inpatient hospital utilization patterns for a full six months before death. Supply-side variables included the number of hospital beds, certified skilled nursing facility beds, and hospice beds per 1000 residents, plus primary care provider/population ratios. Patient characteristics included age, sex, race/ethnicity, dual eligibility status, region, and chronic conditions.

Results: In both adjusted and unadjusted analysis, rural vs. urban residence was not associated with an increased risk for hospitalization at the end of life among Medicare beneficiaries nor was there a relationship between the supply of hospital, skilled nursing, and hospice services and the rate of hospitalization. Within rural residents alone, modest effects were found for facility supply. Rural residents in a county without a hospital were slightly less likely than other rural decedents to have been hospitalized during their last six months of life but were no less likely to have used skilled nursing facilities or hospice.

Conclusions: The absence of major disparities in utilization suggests that end-of-life care is reasonably equitable for rural Medicare beneficiaries.