Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries | Emergency Medicine | JAMA Network Open | JAMA Network
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    Original Investigation
    Emergency Medicine
    November 19, 2021

    Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

    Author Affiliations
    • 1Department of Emergency Medicine, University of New Mexico, Albuquerque
    • 2Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
    • 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 4Department of Emergency Medicine, University of Michigan, Ann Arbor
    • 5Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque
    • 6Center for Healthcare Equity in Kidney Disease, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque
    • 7Department of Emergency Medicine, University of Iowa, Iowa City
    • 8Department of Anesthesia–Critical Care Medicine, University of Iowa, Iowa City
    • 9Department of Learning Health Sciences, University of Michigan, Ann Arbor
    JAMA Netw Open. 2021;4(11):e2134980. doi:10.1001/jamanetworkopen.2021.34980
    Key Points

    Question  Do 30-day outcomes differ after emergency department (ED) visits in rural vs urban settings and in the subset of rural hospitals classified as critical access?

    Findings  In this cohort study of 473 152 matched urban and rural Medicare beneficiaries, risk-adjusted all-cause mortality after rural and urban ED visits was similar, particularly for potentially life-threatening conditions. Critical access hospitals had similar outcomes.

    Meaning  These findings underscore the importance of rural and critical access EDs for treatment of life-threatening conditions among Medicare recipients and have important policy implications given the continued increase in rural hospital closures.


    Importance  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).

    Objective  To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.

    Design, Setting, and Participants  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.

    Main Outcomes and Measures  The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.

    Results  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.

    Conclusions and Relevance  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.