Cover: Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States

Published in: JAMDA, Volume 23, Issue 10, pages 1653.e1–1653.e13 (October 2022). doi: 10.1016/j.jamda.2022.08.011

Posted on Oct 6, 2022

by Denise D. Quigley, Ashley M. Chastain, Jung A. Kang, David Bronstein, Andrew W. Dick, Patricia Stone, Daniel B. Levin


Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs.


Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal.


Care provided by urban and rural HHAs.


We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality.


Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study).

Conclusion and Implications

This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.

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