# Rural–urban disparities in diabetes quality of care with accountable care organization participation

## TL;DR

This study examines how ACO participation affects diabetes care quality in rural versus urban areas over time.

## Contribution

The study evaluates rural–urban disparities in diabetes care quality associated with ACO participation using difference-in-differences and triple-difference models.

## Key findings

- ACO participation was linked to better diabetes care in rural areas compared to urban areas for certain measures.
- Rural patients in ACO clinics had better outcomes on kidney function monitoring and diabetes testing and control.
- Disparities in tobacco cessation advice were more pronounced in urban ACO clinics.

## Abstract

To evaluate rural–urban disparities over time in the association of ACO participation and diabetes‐related quality measures among health clinics.

We used data from the Wisconsin Collaborative for Healthcare Quality all‐patient all‐payer electronic health records data system between 2011 and 2018, for patients 18–75 years. Difference‐in‐differences regression models estimated the association between ACO participation and eight diabetes quality measures among populations in rural and urban areas, separately. Triple‐difference models were also estimated to assess urban–rural disparities.

Considering the two measures used in ACO performance evaluation, patients in ACO clinics were less likely to receive tobacco cessation advice relative to those in non‐ACO clinics (rural: marginal effect estimate (MEE) = –0.025, p = 0.033; urban: MEE = –0.231, p < 0.001). The triple difference across rurality was not statistically significant (MEE = –0.007 p = 0.56). For the remaining six ACO‐non‐incentivized measures, rural patients at ACO clinics performed better relative to their non‐ACO counterparts on kidney function monitored, and diabetes all‐or‐none optimal testing and control.

ACO participation appeared to be more favorable for rural versus urban patients with diabetes. ACOs have potential to contribute to reducing existing rural–urban disparities in diabetes process measures.