Beyond Geography: Using a Cluster‐Based Analysis to Conceptualize the Rurality of Veterans Health Administration Hospitals

Alexandra B. Caloudas; Michihiko Goto; M. Bryant Howren; Zachary Burningham; Diana J. Govier; Travis I. Lovejoy; Eric R. Litt; James W. Watts; Sarah S. Ono; Kristen Wing; Peter J. Kaboli

doi:10.1111/jrh.70195

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Beyond Geography: Using a Cluster‐Based Analysis to Conceptualize the Rurality of Veterans Health Administration Hospitals

Journal article

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Beyond Geography: Using a Cluster‐Based Analysis to Conceptualize the Rurality of Veterans Health Administration Hospitals

Alexandra B. Caloudas, Michihiko Goto, M. Bryant Howren, Zachary Burningham, Diana J. Govier, Travis I. Lovejoy, Eric R. Litt, James W. Watts, Sarah S. Ono, Kristen Wing, …

The Journal of rural health, Vol.42(3), e70195

06/01/2026

DOI: 10.1111/jrh.70195

PMCID: PMC13454773

PMID: 42572496

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Abstract

Purpose Rural veterans experience challenges and strengths related to military service and rural residence. Defining rurality for healthcare facilities is vital for allocating resources, estimating impacts of rural health initiatives, and evaluating rural veteran access and outcomes. While geolocation is one way of conceptualizing rural healthcare facilities, rurality exists on a continuum and is influenced by many factors. The purpose of this work was to create an empirically informed taxonomy of VHA acute care hospitals that moves beyond a geography-based classification alone and to propose facility-level variables that can be used to measure rural veterans’ access to hospital-based care. Methods We conducted a cluster analysis of 110 Veterans Health Administration (VHA) acute care hospitals using k-means clustering. Hospital-level variables included number of enrollees, number and percentage of rural and highly rural enrollees, VHA hospital complexity classification level (low, medium, high), and mean drive times for veterans to access VHA care (primary, secondary, tertiary). Findings Three clusters emerged. The Low Rural Serving (LRS) Cluster (N = 40) comprised 39 high complexity hospitals, with an average of 16.5% of veteran enrollees residing in rural areas. The Medium Rural Serving (MRS) Cluster (N = 26) contained all high complexity hospitals, with an average of 32.8% of veteran enrollees residing in rural areas. The High Rural Serving (HRS) Cluster (N = 44) comprised 10 low, 12 medium, and 22 high complexity hospitals, with an average of 61.9% of veteran enrollees residing in rural areas. The average percentage of highly rural veteran enrollees was 1.0% for LRS, 1.6% for MRS, and 9.7% for HRS. Average drive times to primary, secondary, and tertiary care increased incrementally across clusters. Conclusions Using 9 hospital-level factors that may characterize degree of hospital rurality, we identified 3 clusters that differentiate VHA hospitals and the rural populations they serve.

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Title: Subtitle: Beyond Geography: Using a Cluster‐Based Analysis to Conceptualize the Rurality of Veterans Health Administration Hospitals
Creators: Alexandra B. Caloudas - Michael E. DeBakey VA Medical Center
Michihiko Goto - University of Iowa
M. Bryant Howren - University of Iowa
Zachary Burningham - University of Utah
Diana J. Govier - Oregon Health & Science University
Travis I. Lovejoy - Portland State University
Eric R. Litt - North Florida/South Georgia Veterans Health System
James W. Watts - District of Columbia Department of Health
Sarah S. Ono - VA Portland Health Care System
Kristen Wing - District of Columbia Department of Health
Peter J. Kaboli - University of Iowa
Resource Type: Journal article
Publication Details: The Journal of rural health, Vol.42(3), e70195
DOI: 10.1111/jrh.70195
PMID: 42572496
PMCID: PMC13454773
NLM abbreviation: J Rural Health
ISSN: 0890-765X
eISSN: 1748-0361
Publisher: Wiley
Grant note: HSR Center for Innovations in Quality, Effectiveness and Safety: CIN 13-413 Veterans Rural Health Resource Center-Iowa City Rural Health Career Development Awards: #04269 the Comprehensive Access and Delivery Research and Evaluation Center: CIN 13-412 VHA Office of Rural Health Veterans Health Administration (VHA) South Central VA Health Care Network, South Central Mental Illness Research, Education and Clinical Center. Drs. Lovejoy and Ono were supported by the VHA Office of Rural Health: PROG-0000095 U.S. Department of Veterans Affairs VHA Office of Research and Development, Health Systems Research (HSR)
This material is based upon work supported (or supported in part) by the US Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City Rural Health Career Development Awards (#04269) to Alexandra Caloudas and Diana Govier, VHA Office of Research and Development, Health Systems Research Service (HSR) through the Comprehensive Access and Delivery Research and Evaluation Center (CIN 13-412), HSR Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), and South Central VA Health Care Network, South Central Mental Illness Research, Education and Clinical Center. Drs. Lovejoy and Ono were supported by the VHA Office of Rural Health (PROG-0000095) during the conduct of this study.
Language: English
Date published: 06/01/2026
Academic Unit: Internal Medicine
Record Identifier: 9985218381402771

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