• Nicole Villapiano, Theodore J Iwashyna, and Matthew M Davis.
• From the Robert Wood Johnson Foundation Clinical Scholars Program, Institute for Healthcare Policy and Innovation, Department of Internal Medicine, University of Michigan, Ann Arbor, MI (NV); VA Center for Clinical Management Research, Ann Arbor and Institute for Healthcare Policy and Innovation, Department of Internal Medicine, University of Michigan, Ann Arbor (TJI); Ann & Robert H. Lurie Children's Hospital, Division of Academic General Pediatrics, Mary Ann and J. Milburn Smith Child Health Research Program, Departments of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL (MMD). gergen@med.umich.edu.
• J Am Board Fam Med. 2017 Nov 1; 30 (6): 816-823.

BackgroundOne out of every 5 Americans live in rural communities. Rural Americans have higher rates of early and preventable deaths outside of the hospital than their urban counterparts. How rurality relates to hospital mortality is unknown. We sought to determine the association between rural versus urban residence and hospital mortality.MethodsThis is a retrospective observational study of 4,412,942 nonmaternal, nonneonatal hospitalizations in 2008, and 3899,464 nonmaternal, nonneonatal hospitalizations in 2013 using all-payer, all-age data from the National Inpatient Sample of the Health care Cost and Utilization Project. Using multivariable logistic regression, we report the association between rural versus urban location of residence and hospital mortality, adjusting for chronic disease burden, age, income, and insurance status.ResultsThe unadjusted probability of hospital mortality for urban patients decreased from 2.51% (95% CI, 2.40 to 2.62) in 2008 to 2.27% (95% CI, 2.22 to 2.32) in 2013 (P < .001). Hospital mortality did not change for rural patients over this same time period (2008: 2.66% [95% CI, 2.57 to 2.74], 2013: 2.66% [95% CI, 2.60 to 2.72]; P = .99). Adjusting for covariates accounted for the rural-urban hospital mortality difference in 2008 (rural: 2.13% [95% CI, 2.05 to 2.21], urban: 2.11% [95% CI, 2.02 to 2.20]; P = .67), but did not fully explain the difference in 2013 (rural: 1.92% [95% CI, 1.87 to 1.97]; urban: 1.76% [95% CI, 1.72 to 1.80], P < .001), resulting in 8416 excess deaths among hospitalized patients from rural areas.Conclusion And RelevanceIn 2013, patients living in rural areas of the United States had a greater probability of hospital mortality than their urban counterparts. Explaining excess rural hospital deaths will require further attention to the patient, community, and health system factors that distinguish rural from urban populations.© Copyright 2017 by the American Board of Family Medicine.

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