In rural health research, the measurement of rural residence is commonly dichotomized as urban or rural, even though researchers encourage the use of more descriptive categories to capture rural diversity. Federal categorization schemes for operationalizing rural locations include United States Census Bureau definitions, Office of Management and Budget (OMB) classifications, and categorizations developed by the United States Department of Agriculture (USDA)--Rural-Urban Continuum Codes (RUCC), Urban Influence Codes (UIC), and Rural-Urban Commuting Areas. When categorizing states by rurality, the choice of the measure used influences which states are identified as most rural. We demonstrate this premise in a study of rural home healthcare.

Rural elders have a disproportionate prevalence of illness and limited access to health services. The purpose of this study is to determine whether degree of rurality and home health care use influences home health care patient outcomes. An adaptation of the Outcomes Model for Health Care Research provided the framework for the study. A stratified random sample was selected from a database of risk-adjusted publicly reported patient outcomes from Medicare-certified home health care agencies and merged with agency factors from Medicare cost reports and U.S. Census data. Path analysis was performed to evaluate the relationships in the model. Hospitalization is the only outcome variable associated with community and agency characteristics or home health care use. Rurality does not have a direct effect on hospitalization; however, increased visits per patient and low-income community status are associated with increased hospitalization. Rurality may not have a direct effect on outcomes but instead acts through health care services.