Health Policy Journal Club, Health Policy, Social EM

Health Policy Journal Club: Rural Care on Par?

Visit Reason Associated With Differences in Mortality at Rural vs Urban Emergency Departments

Emergency departments pride themselves on being open 24/7/365 days a year, and this accessibility is especially crucial in rural areas. Over the past decade, ED visits in U.S. rural hospitals, including critical access hospitals, have increased by 50%. Emergency departments in rural areas serve as a safety net for rural communities, which are disproportionately affected by the primary care shortage, but how do the outcomes compare with EDs in urban hospitals?

A recent JAMA study compared over 470,000 rural and urban Medicare beneficiaries across the United States who visited an emergency department between January 1, 2011 and October 31, 2015. The beneficiaries were matched by demographics, diagnoses, co-morbidities, and number of prior emergency department visits. The study showed similar all-cause 30-day mortality rates for potentially life-threatening conditions at rural and urban emergency departments (3.9% vs. 4.1%). Rates of return visits to the ED within 30 days were also similar in both settings (18.1% vs 17.8%). However, rural emergency departments had higher mortality for several symptom-based diagnoses. For example, patients who were diagnosed with abdominal pain at a rural ED had 1.73 times greater odds of mortality within the next 30 days compared to their urban counterparts.

The value of critical access hospitals has been debated due to low inpatient volumes and high health care costs. However, without an adequate safety net, it is crucial that rural communities have access to an emergency department nearby for life-threatening conditions amidst rising hospital closures. The authors showed that rural EDs provide equivalent care to that of urban EDs for many diagnoses. They indicated that the higher mortality seen in rural hospitals for symptom-based diagnoses may be due to poor access to primary care, ambiguity, and lack of standardized management, unlike life-threatening conditions such as myocardial infarction. The study also found that rural EDs transfer patients more often than urban EDs, and this may in part explain the better outcomes seen with life-threatening conditions, perhaps because of access to specialist care. There is a need for health policy initiatives to optimize the interfacility transfer system and access to primary care and specialists, perhaps through telehealth initiatives, to ensure emergency care is on par for rural communities. 


Article: Greenwood-Ericksen M, Kamdar N, Lin P, et al. Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries. JAMA Netw Open. 2021;4(11):e2134980.

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. 

PMID: 34797370

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.