HSR&D Citation Abstract
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Rural/urban Veterans with stroke: who is counting what?
Jia H, Cowper Ripley DC, Tang Y, Wu SS, Vogel B, Chen GJ, Tang Y. Rural/urban Veterans with stroke: who is counting what? Paper presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME.
BACKGROUND:The VHA and the Rural-Urban Commuting Areas (RUCA) rural-urban definitions are the most commonly used rural-urban taxonomies by VHA researchers. Do these two definitions provide the same rural-urban classification results among the Veterans who were diagnosed with stroke?
OBJECTIVES:This presentation was to compare the rural-urban classifications of stroke patients using the two taxonomies, to compare patients' travel time to the closest VHA facility between the two taxonomies, and to compare patients' poststroke rehabilitation use outcome between the two taxonomies.
METHODS:A national cohort of 9,691 VHA stroke patients were identified in the 2001 and 2002 VHA medical databases. Patients' residential ZIP codes were confirmed, travel times to the closest VHA facility and hospital were calculated, and VHA and RUCA rural-urban codes were applied. Crude concordance and Kappa statistics were calculated to measure the agreement rate and strength of rural-urban classifications between VHA and RUCA codes. Logistic regressions were applied to assess the differences in 12-month poststroke rehabilitation use between the stroke patients who lived in highly or isolated rural vs. the stroke patients who lived in rural areas, and between the stroke patients who lived in urban areas vs. the stroke patients who lived in the rural areas, adjusting for patients' social demographic and clinical factors.
FINDINGS:Although the overall agreement in the three-tier classifications (urban, rural, and highly/isolated rural) between two definitions was moderate, great variation was observed between the categories. The two systems demonstrated a strong agreement in dichotomized classification of rural and urban. When the dichotomized classification yields of the two systems were compared against patients' accessibility to the closest VHA facility, RUCA system generated in a smaller proportion of rural patients whose driving time was closer to the closest VHA facility. With both taxonomies (RUCA and VHA), we found the urban patients were significantly more likely to receive rehabilitation treatment than their counterparts who lived in rural areas. However, with the RUCA codes, we found no significance difference between isolate rural patients and rural patients. Meanwhile, with the VHA codes, we found the rural patients were significantly more likely to received rehabilitation treatment than highly rural patients poststroke.
IMPACT:These findings suggested researchers have to be cautious when selecting a rural-urban taxonomy for your study, different taxonomy may lead to different rural-urban classification yields, and different yields may lead to different outcomes and conclusions. Further, urban veterans with acute stroke were more likely to receive rehabilitation than their counterparts living the rural areas.