Visits to the emergency department in rural areas jumped by more than 50% since 2005 even as the overall population in rural areas fell—a sign of increasing pressure on rural hospitals as safety-net providers, a recent study published in JAMA Network Open found.
Looking at a cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 2005 and 2016, researchers found ED visits increased from 36.5 to 64.5 for every 100 people in rural areas, compared with an increase in urban ED visits from 40.2 to 42.8 of every 100.
Overall, rural ED visits increased from 16.7 million to 28.4 million while urban visits increased from 98.6 million to 117.2 million, the researchers from the University of New Mexico, Albuquerque and the University of Michigan found. The increases in rural settings were specifically notable among non-Hispanic white patients, ages 18 to 64, Medicaid beneficiaries and patients without insurance.
“Increased visits by young to middle-aged white rural patients—particularly Medicaid beneficiaries and those without insurance—may indicate an increased burden of illness or challenges in access to alternative care sites,” the study authors stated. There was a nonsignificant decrease in urban ED for patients without insurance, but rural visits by patients without insurance went up from 44 to 66.6 people.
The study echoes other studies which have reported declines in health of individuals living in rural areas, with increases in mortality, higher rates of chronic diseases and more high-risk behaviors as well. Authors of the study said the ED use may also reflect that "rural EDs are increasingly serving as safety-net hospitals, potentially further destabilizing their budgets because they generally operate in the traditional fee-for-service model."
When the research began in 2005, there were about 769 rural safety-net EDs out of 2009 total hospitals, or 38.3%. By 2016, that number had increased to 1,187 out of 1,855, or 65%. A big factor in the increase was due to the rise in Medicaid visits.
“We additionally found an increase in the proportion of rural EDs classified as safety-net EDs, indicating an erosion in rural hospitals’ payer mix,” the authors stated. “These trends may be associated with Medicaid expansion in states with large rural populations, as Medicaid expansion in such states increased coverage for low-income rural adults.”