By 2030, over 20% of the US population will be at least 65 years old, the age at which incidence of Alzheimer's disease and related disorders (ADRD) begins to increase. In 2014, 17% of the population living in rural areas was already over the age of 65, suggesting that rural populations may be disproportionally affected by ADRD in current and coming years. There is growing evidence that disparities in disease burden as well as availability, accessibility, affordability, and acceptability of health services exist among older adults living in rural areas, likely contributing to the growing gap in life expectancy witnessed between urban and rural communities. Previous studies have found that ADRD prevalence rates vary by gender, race, and ethnicity, yet few studies have examined disparities in diagnosis and outcomes of older adults living in urban and rural areas. Studies that have examined rural health disparities related to ADRD have largely focused on issues related to access to care, and suggest that ADRD patients in rural areas are more likely to receive suboptimal healthcare. There is a gap in our knowledge on how place of residence influences diagnosis and subsequent outcomes of older adults with ADRD. Understanding if disparities exist for older adults with ADRD living in rural areas could yield important insights into the risk factors for ADRD, the variables influencing the experience of living with ADRD, and the methods by which they can be more effectively managed. The objective of this application, the first step toward this long-term goal, is to conduct a population based study and thorough analysis to identify if rural-urban disparities in the diagnostic incidence and prevalence of ADRD, healthcare utilization, and health outcomes exist. The central hypothesis of this proposal is that rural Medicare beneficiaries with ADRD will be diagnosed later in the course of their disease and experience worse health outcomes. This hypothesis is based on preliminary work that shows the prevalence rate of ADRD is lower, yet the mortality rate due to ADRD is higher in states with a higher share of its population living in rural areas. To achieve this objective, we propose two aims. First, we will compare the diagnostic incidence and prevalence of ADRD between Medicare beneficiaries living in rural and urban communities. Second, we will compare survival and trajectories of acute, nursing home and home health care use in six years following the initial diagnosis of ADRD between rural and urban beneficiaries. We propose to study fee-for-service Medicare beneficiaries in 2008-2015 integrating Medicare enrollment, claims, and resident assessment data. Findings of this study have several expected benefits for many. For policy makers, this research will enable evidence-based policy development aimed at improving rural health care. For rural health providers, this work will drive efforts to improve ADRD screening in order to ensure rural beneficiaries receive a timely diagnosis, which may delay future adverse outcomes. For rural health systems, these findings will help plan for future demand and understand gaps in our current system in meeting this population's needs.
The goal of this proposed research is to examine the rural-urban disparity in the prevalence and incidence of an ADRD diagnosis and Medicare beneficiaries' subsequent health outcomes. Our results will help policy development and improve care practice to reduce rural-urban disparity.