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Charles D. Phillips, PhD, MPH, Scott Holan, PhD, Michael Sherman, PhD, Malgorzata Leyk Williams, MS and Catherine Hawes, PhD

Charles D. Phillips and Catherine Hawes are with the School of Rural Public Health, Health Science Center, Texas A&M University, Bryan. Michael Sherman is with the Department of Statistics, Texas A&M University, College Station. Scott Holan is with the Department of Statistics, University of Missouri–Columbia. Malgorzata Leyk Williams is with the Department of Statistics, Texas A&M University.

Correspondence: Requests for reprints should be sent to Charles D. Phillips, PhD, MPH, School of Rural Public Health, 3000 Briarcrest Drive, Suite 310, Bryan, TX 77802 (e-mail: phillipscd@srph.tamushsc.edu).

Objectives. We examined differences in quality of care among nursing homes in locales of varying degrees of rurality.

Methods. We classified locales into 4 classes according to rurality. We analyzed a 10% sample of nursing home admissions in the United States in 2000 (n=198613) to estimate survival models for 9 quality indicators.

Results. For postacute admissions, we observed significant differences in rates of decline for residents in facilities in large towns compared with urban areas, but differences in quality were both negative and positive. Among admissions for long-term or chronic care, rates of decline in 2 of 9 quality areas were lower for residents in isolated areas.

Conclusions. We observed significant differences in a number of quality indicators among different classes of nursing home locations, but differences varied dramatically according to type of admission. These differences did not exhibit the monotonicity that we would have expected had they derived solely from rurality. Also, quality indicators exhibited more similarities than differences across the 4 classes of locales. The results underscore the importance, in some instances, of emphasizing the effects of specific settings rather than some continuum of rurality and of moving beyond the assumption that nursing home residents constitute a homogeneous population.

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