PURPOSE: To evaluate how rural residence and health system transitions (between Veterans Affairs VA and community care) influence outpatient care fragmentation and clinical outcomes among Veterans following intensive care unit (ICU) hospitalization. METHODS: We conducted a retrospective cohort study of 80,884 Veterans hospitalized with critical illness between January 1, 2019 and December 31, 2024. Using VA Corporate Data Warehouse records linked with community care claims, we calculated within-person changes in outpatient fragmentation using the modified Continuity of Care Index (mCOCI) for the 12 months before and after ICU discharge. We used multivariable linear regression and Fine-Gray competing risk models to assess the relationship between rurality, system engagement, and 30/90-day clinical outcomes. FINDINGS: Among the cohort (38% rural; mean age 69), adjusted mCOCI increased by 0.04 (95% CI, 0.03, 0.06; p < 0.001) post-discharge and the mean number of provider visits increased by 4.1 (95% CI 3.6, 4.5, p < 0.001), indicating significantly greater care fragmentation and care utilization. Neither higher VA engagement nor rurality were associated with changes in fragmentation, however, telehealth utilization was associated with a modest reduction in fragmentation. Compared to urban Veterans, rural Veterans had lower 30-day absolute probabilities of primary care follow-up (12.7% vs. 14.4%; RD -1.7%) and ED visits, yet faced higher rates of hospital readmission (16.1% vs. 15.0%; RD 1.0%) and a minimally higher probability of death (0.15% vs. 0.14%). All trends persisted and differences increased at 90 days. CONCLUSIONS: Recovery after critical illness is marked by a substantial escalation in care fragmentation and care utilization. Compared to urban counterparts, rural veterans faced worse outcomes, but no difference in fragmentation. Telehealth offered a substantial protective effect, that may also reduce the higher travel burden faced by rural veterans. These findings emphasize the need for integrated, rural-specific care models that leverage telehealth and cross-system coordination to support high-risk ICU survivors.
Hahn et al. (2026) studied this question.