BACKGROUND AND PURPOSE:

• Despite the reliance on EDs in rural communities, there is limited data regarding patient outcomes after ED visits in rural hospitals or critical access hospitals (CAHs)
• Greenwood-Ericksen et al. (JAMA Network Open, 2021) compared 30-day outcomes after rural vs urban ED and CAH visits

METHODS:

• Propensity-matched, retrospective cohort study
• Population
  • 20% of national Medicare fee-for-service beneficiaries from January 2011 to October 2015
• Study design
  • Compared
    • Visits to rural EDs vs visits to urban EDs
    • Visits to CAHs vs visits to non-CAHs
  • Rural and urban ED visits were matched based on demographics, patient prior use of EDs, comorbidities, and diagnoses
  • Effect size (Cohen d) was used to overcome the impact of large sample size| Effect size reflects whether there is meaningful clinical effect
• Primary outcome
  • 30-day all-cause mortality
• Secondary outcomes
  • ED revisits with and without hospitalization

RESULTS:

• 473,152 Medicare beneficiaries
  • Mean (SD) age: 75.1 (7.9) years
• Medicare beneficiaries at rural and urban EDs experienced similar
  • All-cause 30-day mortality
    • Rural EDs: 3.9%
    • Urban EDs: 4.1%
    • Effect size 0.01
  • ED revisits
    • Rural EDs: 18.1%
    • Urban EDs: 17.8%
    • Effect size 0.00
• However, rural ED visits were associated with
  • More interhospital transfer
    • Rural EDs: 6.2%
    • Urban EDs: 2.0%
    • Effect size 0.22
  • Fewer hospitalizations
    • Rural EDs: 24.7%
    • Urban EDs: 39.2%
    • Effect size 0.31
• When stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced
  • More transfers
  • Similar 30-day mortality to that of patients in urban ED
• In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses
  • Chest pain
    • OR 1.54 (95% CI, 1.25 to 1.89)
  • Nausea and vomiting
    • OR 1.68 (95% CI, 1.26 to 2.24)
  • Abdominal pain
    • OR 1.73 (95% CI, 1.42 to 2.10)
• The findings were similar for CAHs

CONCLUSION:

• Patients in rural EDs experience mortality related to potentially life-threatening conditions at similar rates to patients in urban EDs
• However, there was greater mortality for symptom-based conditions in patients from rural areas
• The authors state

As emergency care practices advance, evidence suggests that rural hospitals may not be achieving the same gains as their urban counterparts

The findings of this study underscore the importance of ensuring access to local EDs in rural communities, which are endangered by increasing rural hospital closures

Learn More – Primary Sources:

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

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