Background: Rural patients face a greater burden of chronic conditions and higher overall mortality compared to urban counterparts. Given the risk of re-hospitalization and emergency room (ER) presentations associated with chronic conditions, we aimed to evaluate differences in hospitalization characteristics and post-discharge outcomes for rural compared to urban patients admitted for a chronic condition.
Methods: We conducted a retrospective analysis of index hospitalizations secondary to a chronic condition for adult patients discharged from any of our system hospitals between June 2022 and June 2023. We separated our cohort by rurality using Rural-Urban Commuting Area Codes. Our primary outcomes were 30 day acute care use (hospital readmission and emergency room presentation) and 30 day all cause mortality. Our secondary outcome was timely follow-up defined as 14 day transitional care management visits (TCM) and/or 30 day primary care provider follow-up. We performed descriptive statistics and post-hoc analysis using parametric and non-parametric testing where appropriate for continuous and categorical variables. Analysis was completed using R and RStudio (4.3.2). Statistical significance was defined as p-value < 0.05. This study was reviewed and approved by our institutional review board.
Results: 27,073 patients met inclusion criteria. Of the cohort, 51% were female, 3.1% were Black/African American, and 41% (n: 11,080) were from a rural defined area. Compared to patients from urban areas, rural patients were older (66.5 v. 65.9, p < 0.01) and more likely to have a public insurer (82% v. 80%, p< 0.001).Prior to hospitalization, rural patients had a higher average number of primary care visits (4.4 v. 3.7 visits, p< 0.001) but there was no difference in the average ER visits in the 3 years prior to the index admission (43.85 vs. 44.82, p=0.097). Regarding acute care access 30 days post-discharge, rural patients had a higher proportion of hospital readmissions and ER presentations than urban counterparts (10.7% v. 9.4%, p< 0.001), (12.1% vs 11.3% p< 0.05) respectively. The overall mortality rate for the cohort was 11.9% (n=3,233) with no difference in mortality differences between rural and urban patients (12.4% vs. 11.6%, p=0.08). Follow-up rates were found to be statistically significant with urban patients completing both 14 day transitional care management visits (TCM) and primary care visits within 30 days at a higher percentage than rural patients (15.3% vs. 13.4%, p< 0.001), (18.5% vs. 17.4%, p< 0.02) respectively.
Conclusions: We compared rural and urban patient characteristics and outcomes through a retrospective review of index hospitalizations secondary to a chronic condition. We found differences in demographic metrics, average PCP visits prior to admission, but no difference in ER use before the index admission. Our primary outcome of acute care use within 30 days post-discharge was significantly different between our rural and urban population both in readmissions and ER presentations while all cause 30 day mortality was not found to be different. Follow-up patterns both with 14 day TCM visits and primary care follow-up in 30 days was found to be statistically significant with urban patients presenting at a higher percentage than rural counterparts. This study although limited by available electronic medical record data highlights the importance of including locality when investigating post-hospitalization outcomes given disparities faced by our rural patient population.
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