Association of Rural Living with COPD-related Hospitalizations and Deaths in US Veterans

Abstract

Abstract It is unclear whether the high burden of COPD in rural areas is related to worse outcomes in patients with COPD or is because the prevalence of COPD is higher in rural areas. We assessed the association of rural living with acute exacerbations of COPD (AECOPDs)-related hospitalization and mortality. We retrospectively analyzed Veterans Affairs (VA) and Medicare data of a nationwide cohort of veterans with COPD aged ≥ 65 years with a COPD encounter between 2011 and 2014 that had a follow-up until 2017. Patients were categorized based on residential location into urban, rural, and isolated rural. We used generalized linear and Cox proportional hazards models to assess the association of residential location with AECOPD-related hospitalizations and mortality. Age, sex, race, travel time to the nearest VA hospital, and comorbidity were included as covariates in the models. Of 165,996 patients with COPD, 45,045 (27.1%) experienced at least one AECOPD-related hospitalization over the study period. Rural (relative risk-RR) = 0.93; 95%CI:0.92 to 0.94;p < 0.001) and isolated rural residence (RR = 0.85;95%CI:0.82 to 0.87;p < 0.001) were associated with fewer AECOPD-related hospitalizations relative to urban residence. Travel time to the closet VA hospital was inversely associated with AECOPD-related hospitalizations. Among patients who were alive after discharge for their second AECOPD-related hospitalization, rural residence was associated with increased mortality risk (hazard ratio = 1.06; 95%CI = 1.01 to 1.10;p = 0.011).Rural living is not associated with AECOPD-related hospitalizations, but it is associated with 6% increased risk for death among patients who were alive after discharge following a second AECOPD-related hospitalization.