Rural utilization of postacute rehabilitation therapies among fee-for-service Medicare beneficiaries: county-level cross-sectional analyses and comparison of rural classifications

Rural utilization of postacute rehabilitation therapies among fee-for-service Medicare beneficiaries: county-level cross-sectional analyses and comparison of rural classifications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rural utilization of postacute rehabilitation therapies among fee-for-service Medicare beneficiaries: county-level cross-sectional analyses and comparison of rural classifications Tiago S Jesus, Pedro C Monteiro, Catia S Pinho, Grace Delaney, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9706516/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: 1) To identify rural-urban therapy utilization differences among Medicare fee-for-service (FFS) beneficiaries in the USA provided by Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs). 2) To determine whether different rural classifications and their aggregation affect the results. Methods : Secondary data analysis of Medicare FFS Part A physical, occupational and speech-language-pathology therapy data for 2022. Hierarchical regressions, with States nested within Divisions, adjusted utilization rates for 29 covariates, including the Hierarchical Condition Categories (HCCs). The Rural-Urban Continuum Codes (RUCC), the Urban Influence Codes (UIC), and the Core-Based Statistical Areas (CBSA) were alternative rural classifications, using binary and non-binary aggregation options. A 3-level RUCC-derived option, with two rural levels (e.g., small rural counties: urban population of <5,000 inhabitants), was the reference classification. Findings : Small rural counties had significantly lower therapy utilization versus urban/suburban counterparts for each provider type ( p <0.0001). For example, HHAs in small rural counties had less than half (45%) of the therapy utilization in urban/suburban after HCC adjustment. After applying the fully-adjusted regression model, the RUCC classification more frequently identified lower utilization rates for small rural counties than the UIC: 27 versus 5 models. Binary rural-urban aggregations detected utilization differences less often than approaches that disaggregated levels of rurality. Conclusion : Rural-urban classifications and aggregation levels varied in the identification of postacute therapy utilization differences. These more often identified with RUCC-based non-binary options which disaggregate between two rural levels and more prevalent in small-population rural counties. Health Policy Physical Medicine & Rehab Rural Health Services Rehabilitation Medicare Healthcare Disparities Full Text Additional Declarations The authors declare no competing interests. Supplementary Files Supappendix1JAN2026.docx Sup Appendix 1 SupAppendix2JAN2026.docx Sup Appendix 2 Suptable12026.xlsx Sup Table 1 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9706516","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639885758,"identity":"af1ce17c-f977-45a5-9afd-e9a95651b58e","order_by":0,"name":"Tiago S Jesus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDACZjDJBiIYH8AEJfDp4EHSwmxAnBYkNhtcJV4t9uzMj198YOCTk5+R/qziw5/D0fwNzAdv8+DRwsPMZmY5g4HN2OBGjtnNmW2Hc2ccYEu2xq+FwcyYh4EtcYNEDttt3obDuRsYeMyk8Wth/wbSUj8f6LBinj8gLfzfCGjhMX4M1JLAcCPBjJmHDWwLG34th3nKGGcYsBluOPPGWHJmW3rujMNsxpZz8Ghh7z+++cOHimPy8u3pDz98+GOd29/e/PDGGzxaGMDRYXAMic+MXzlYyQcGhhrCykbBKBgFo2DkAgCAbkOYt5xlfwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1300-6308","institution":"School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University","correspondingAuthor":true,"prefix":"","firstName":"Tiago","middleName":"S","lastName":"Jesus","suffix":""},{"id":639885759,"identity":"ae3458b3-b03a-4902-82c3-bc4e5b323509","order_by":1,"name":"Pedro C Monteiro","email":"","orcid":"","institution":"School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"C","lastName":"Monteiro","suffix":""},{"id":639885760,"identity":"390c1a9c-5592-4ce5-ad7f-19bae4804a50","order_by":2,"name":"Catia S Pinho","email":"","orcid":"","institution":"Independent Consultant, Grove City, OH, USA.","correspondingAuthor":false,"prefix":"","firstName":"Catia","middleName":"S","lastName":"Pinho","suffix":""},{"id":639885761,"identity":"81610daf-a303-4734-9e24-c7213e032880","order_by":3,"name":"Grace Delaney","email":"","orcid":"","institution":"School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Grace","middleName":"","lastName":"Delaney","suffix":""},{"id":639885762,"identity":"75da362e-26b3-42d3-b058-d4a6199e392b","order_by":4,"name":"Allen W. 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beneficiaries: county-level cross-sectional analyses and comparison of rural classifications\u003c/strong\u003e\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[{"identity":"148fb001-2efd-4ed3-8632-8f91a7aaa89f","identifier":"10.13039/100009157","name":"National Institute on Disability, Independent Living, and Rehabilitation Research","awardNumber":"90SFGE0046-01-00","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"The Ohio State 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4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e 1) To identify rural-urban therapy utilization differences among Medicare fee-for-service (FFS) beneficiaries in the USA provided by Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs). 2) To determine whether different rural classifications and their aggregation affect the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Secondary data analysis of Medicare FFS Part A physical, occupational and speech-language-pathology therapy data for 2022. Hierarchical regressions, with States nested within Divisions, adjusted utilization rates for 29 covariates, including the Hierarchical Condition Categories (HCCs). The Rural-Urban Continuum Codes (RUCC), the Urban Influence Codes (UIC), and the Core-Based Statistical Areas (CBSA) were alternative rural classifications, using binary and non-binary aggregation options. A 3-level RUCC-derived option, with two rural levels (e.g., \u003cem\u003esmall rural\u003c/em\u003e counties: urban population of \u0026lt;5,000 inhabitants), was the reference classification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e: \u003cem\u003eSmall rural \u003c/em\u003ecounties had significantly lower therapy utilization versus \u003cem\u003eurban/suburban\u003c/em\u003ecounterparts for each provider type (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.0001). For example,\u003cem\u003e \u003c/em\u003eHHAs in \u003cem\u003esmall rural\u003c/em\u003e counties had less than half (45%) of the therapy utilization in \u003cem\u003eurban/suburban\u003c/em\u003e after HCC adjustment. After applying the fully-adjusted regression model, the RUCC classification more frequently identified lower utilization rates for\u003cem\u003e small rural\u003c/em\u003e counties than the UIC: 27 versus 5 models. Binary rural-urban aggregations detected utilization differences less often than approaches that disaggregated levels of rurality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Rural-urban classifications and aggregation levels varied in the identification of postacute therapy utilization differences. These more often identified with RUCC-based non-binary options which disaggregate between two rural levels and more prevalent in small-population rural counties.\u003c/p\u003e","manuscriptTitle":"Rural utilization of postacute rehabilitation therapies among fee-for-service Medicare beneficiaries: county-level cross-sectional analyses and comparison of rural classifications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-14 07:20:49","doi":"10.21203/rs.3.rs-9706516/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d29c90bb-0da6-4c09-93e8-a41a280a57e6","owner":[],"postedDate":"May 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":68108649,"name":"Health Policy"},{"id":68108650,"name":"Physical Medicine \u0026 Rehab"}],"tags":[],"updatedAt":"2026-05-14T07:20:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-14 07:20:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9706516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9706516","identity":"rs-9706516","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}