Ambulatory Care and the Rural Elderly


Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.