Abstract
Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
Highlights
Visits to rural and critical access hospital (CAH) emergency departments (EDs) have risen 50% in the US in the last 10 years,[1] for acute, unscheduled care.[2]
All findings were similar for CAHs. The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings
These findings underscore the importance of ensuring access to treatment of lifethreatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures
Summary
Visits to rural and critical access hospital (CAH) emergency departments (EDs) have risen 50% in the US in the last 10 years,[1] for acute, unscheduled care.[2] This growth reflects the safety net role of EDs in US rural communities, which disproportionately experience primary care shortages[3,4] and poor health outcomes.[5] Ongoing rural hospital and CAH closures[6] are linked to greater rural patient mortality.[7] the value of rural hospitals— CAHs, a subset of rural hospitals that receive enhanced Medicare reimbursement—is frequently debated, pitting health care costs and falling rural hospital inpatient volumes[8] against the need for 24/7 emergency care access in rural communities.[9,10] With EDs increasingly serving as sites of care access for rural communities and the only source of emergency care, hospital closures and loss of ED services has a substantial impact on the health of rural residents. Previous analyses have found higher mortality for inpatient care at rural hospitals[11] and CAHs12,13 compared with urban hospitals, but these analyses did not include the ED setting, and little is known about patient outcomes tied to ED visits. Interhospital transfer could mitigate rural mortality risk, the challenges associated with patient transfer[20] may contribute to delays to definitive care and worsen outcomes for rural patients
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