• Kenton J Johnston, Hefei Wen, Ameya Kotwal, and Karen E Joynt Maddox.
• Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University , 3545 Lafayette Ave., Room 362, St. Louis, MO, 63104, USA. johnstonkj@slu.edu.
• J Gen Intern Med. 2021 Dec 1; 36 (12): 372837363728-3736.

BackgroundRural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time.ObjectiveCompare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade.DesignObservational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends.SettingNationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017.ParticipantsUS adults, an annual average of 241.3 million individuals.MeasurementsPreventable ED visits and hospitalizations.ResultsCompared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents.LimitationsObservational study; unable to infer causality.ConclusionsRural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.© 2021. Society of General Internal Medicine.

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