TOPLINE: 

Participation in accountable care organizations (ACOs) demonstrated more favorable outcomes for patients with diabetes in rural areas compared with those in urban areas, particularly in kidney function monitoring and diabetes control.

METHODOLOGY: 

• Researchers evaluated disparities in diabetes care between rural and urban areas by analyzing how participation in ACOs among health clinics affected quality of care over time. They identified Medicare ACOs using public data and categorized clinics by their involvement in ACO programs.
• The study analyzed data from the Wisconsin Collaborative for Healthcare Quality all-patient all-payer electronic health records system from 2011 to 2018, including patients with diabetes aged 18-75 years.
• Areas were classified as rural or urban based on a validated geo-disparity model. The analysis included 14 reporting periods. Samples ranging from 18,970 observations for 5550 individuals to 152,335 observations for 34,381 individuals residing in rural areas and from 93,956 observations for 25,774 individuals to 723,190 observations for 134,451 individuals residing in urban areas.
• The study assessed eight quality measures related to diabetes, including two incentivized measures: poor A1c control (A1c > 9%) and advice for quitting tobacco for tobacco users. The six nonincentivized measures were blood glucose testing and control, blood pressure control, kidney function monitoring, and diabetes process and outcome measures.
• Difference-in-differences regression models were used to evaluate the association between participation in ACOs and the eight diabetes quality measures in rural and urban populations. Triple-difference models were utilized to evaluate the disparities in quality of diabetes care between rural and urban areas.

TAKEAWAY: 

• No significant differences were found in A1c control between patients in ACO vs those in non-ACO clinics in both rural and urban areas. However, patients in ACO clinics were less likely to receive advice to quit tobacco than were those in non-ACO clinics, with a marginal effect estimate (MEE) of -0.025 in rural areas (P = .033) and -0.231 in urban areas (P < .001).
• In urban areas, patients in ACO clinics had a lower likelihood of attaining blood glucose and blood pressure control than did those in non-ACO clinics, whereas no significant differences were observed for those residing in rural areas.
• Patients in ACO clinics, both rural and urban, were less likely than those in non-ACO clinics to undergo blood glucose testing, with a lower difference among patients in rural vs urban areas (P < .001).
• In rural areas, patients in ACO clinics showed better performance on kidney function monitoring (MEE, 0.045; P < .001) and diabetes optimal control (MEE, 0.042; P < .001) than did their non-ACO counterparts. However, in urban areas, patients in ACO clinics vs non-ACO clinics were less likely to have their kidney function monitored and diabetes optimal control (P < .001 for both).

IN PRACTICE: 

“Our findings provide insights about the potential role of ACO programs in reducing disparities in overall quality performance and diabetes quality of care, across rural and urban areas,” the authors wrote. “The study also invites policymakers to consider developing quality measures relevant to rural-urban geographical gradients and providing the necessary financial and resource support to rural organizations and communities,” they added.

SOURCE: 

The study was led by Mariétou H. Ouayogodé, PhD, of the Department of Population Health Sciences in the School of Medicine and Public Health at the University of Wisconsin-Madison. It was published online on February 2, 2026, in The Journal of Rural Health.

LIMITATIONS: 

Data were limited to the state of Wisconsin, potentially affecting applicability to other states. The primary analysis covered 2011-2018. The study could not distinguish between Medicare Advantage, Program of All-inclusive Care for the Elderly, and fee-for-service Medicare patients. Information on specific patient health risk factors was lacking.

DISCLOSURES: 

The authors did not report any specific funding. They had no conflicts of interest or disclosures to report. 

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.