Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban, Micropolitan, and Rural Nursing Homes

Huiwen Xu, John R. Bowblis, Thomas V. Caprio, Yue Li, Orna Intrator

Research output: Contribution to journalArticlepeer-review


Objectives: Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3). Design: The longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs. Setting and Participants: In total, 14,600 unique NHs. Measures: Risk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File. Results: Over the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs. Conclusions/Implications: Rurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.

Original languageEnglish (US)
Pages (from-to)1101-1106
Number of pages6
JournalJournal of the American Medical Directors Association
Issue number5
StatePublished - May 2021
Externally publishedYes


  • Rurality
  • interaction effects
  • long-stay nursing home residents
  • market factors
  • nursing home characteristics
  • risk-adjusted hospitalization rates

ASJC Scopus subject areas

  • General Nursing
  • Health Policy
  • Geriatrics and Gerontology


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