BACKGROUND
With nearly 150 rural hospital closures since 20101 and projections that over 25% of rural hospitals are at immediate risk of financial insolvency,2 the Rural Emergency Hospital designation of the 2021 Consolidated Appropriations Act represents one of the most significant federal interventions impacting rural trauma and emergency surgical care in decades. This policy aims to reduce the number of future rural hospital closures by introducing a new type of hospital designation: a Rural Emergency Hospital (REH). Under this policy, eligible hospitals will be able to close their inpatient units while maintaining emergency and outpatient services in exchange for additional federal funding ($3.3M per year) and enhanced public payor reimbursement rates (additional 5% on top of Medicare’s Outpatient Prospective Payment System rates).3 As intended, this policy would preserve access to emergency services in rural areas, a key component of care for people with surgical emergencies.4-6
However, implementation of the REH designation is proceeding without an evidence-based understanding of the potential impact of this policy on patients with surgical conditions, particularly those who require hospitalization due to a surgical emergency. To date, 42 hospitals have adopted REH designation; however, prior studies have estimated that at least 68 hospitals share similar characteristics with those that have already converted to a REH and additional hospitals may ultimately decide to convert.7,8 Rural facilities are critical to the provision of emergency surgical care in the United States given their pivotal role in triage, diagnosis, and stabilization of patients. Surgical services in particular play a key role in the financial stability of rural hospitals.9 As such, policymakers and healthcare systems must understand the potential impact of the REH designation policy on the delivery of surgical care. To date, there is a paucity of information about emergency surgical care at facilities eligible for REH conversion to inform this policy analysis.
Within this context, we sought to describe emergency surgical care provided by REH-eligible hospitals. First, we aimed to describe the volume of emergency general surgery and trauma care performed at REH-eligible hospitals. Second, we aimed to determine the proportion of statewide inpatient care for emergency general surgery and trauma currently spent in REH-eligible hospitals. Finally, we described the characteristics of the populations and communities served by hospitals eligible for REH designation compared with those served by REH-ineligible hospitals.
METHODS
Data Source
We performed a retrospective study using claims data from the 2021 Healthcare Cost and Utilization project (HCUP). We used State Inpatient (IP) and Emergency Department (ED) databases from California, Florida, Iowa, Maryland, and Wisconsin. These states were selected because they offer unique patient identifiers that allow for tracking individuals over time and identification of transfer episodes. Using linkage variables provided by HCUP, data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services were used to identify hospital characteristics.
Cohort Identification
We included all adult patients (≥18 years old) who presented with an emergency general surgery condition or injury. Our cohort of patient encounters were identified using International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, adopting coding methodology from previously published work.15,16 Our emergency general surgery cohort included those with eight conditions that account for the majority of emergency general surgery admissions and morbidity in the US: appendicitis, cholecystitis, acute complications of hernia, mesenteric ischemia, intestinal obstruction, acute perirectal disease, perforated peptic ulcer disease, and acute diverticulitis.10,11 Our trauma cohort included patients with eligible ICD-10 diagnosis codes based on the National Trauma Data Bank standard (see eExhibit 2 in Supplement).12 Encounters that were flagged as “elective” and those where primary emergency general surgery or injury diagnoses were not flagged as “Present on Admission” in HCUP were excluded from analysis.
Facilities were then categorized as REH-eligible or -ineligible. We defined eligible hospitals as those that fit the criteria established by the 2021 Consolidated Appropriations Act – critical access hospitals and rural hospitals with fewer than 50 inpatient beds. Centers for Medicare and Medicaid Services hospital data were used to establish these classifications, including hospital rurality.
Hospital Characteristics
Hospital characteristics were identified through linkage of HCUP databases to the American Hospital Association annual survey and Centers for Medicare and Medicaid Services data. We identified whether hospitals had interventional radiology, advanced gastroenterology (GI) capabilities (capable of endoscopic retrograde cholangiopancreatography, ERCP), ultrasound, and computed tomography (CT) available. These characteristics were selected a priori by the authors due to their utility in the management of emergency surgical patients. We also identified level 1 trauma centers, hospitals in rural, micropolitan, and metropolitan environments (based on core-based statistical area of hospital location from CMS data), and facilities categorized by hospital and intensive care unit (ICU) size based on quartiles of the included hospitals in our merged database. Finally, we evaluated characteristics of eligibility for REH designation, including critical access hospital status and small (fewer than 50 beds), rural facilities.
Patient and Episode Characteristics
Sociodemographic and clinical characteristics included age (categorized into 18-39, 40-64, 65-79, and 80+ years old), sex, and insurance payor type (private, Medicare, Medicaid, and other). Medical comorbidities were aggregated into binary indicators of lung disease, diabetes, cancer or immunosuppression, cardiovascular disease, severe (stage IV+) chronic kidney disease, obesity, and history of bariatric surgery using ICD-10 diagnosis codes. The surgical reason for presentation (trauma or emergency general surgery) was identified. For patients presenting with a primary emergency general surgery diagnosis, we identified both their primary diagnosis as well as their disease complexity at the time of presentation, using previously published ICD-10 codes that have been used to clinically validate the disease grading system published by the American Association for the Surgery of Trauma.11,13
Hospital Encounter Characteristics and Resource Utilization
Each inpatient or emergency department visit was then characterized further based on several episode characteristics recorded in HCUP. These included length of stay (inpatient days) and performance of major and minor diagnostic and therapeutic procedures as defined by HCUP.14 Using previously published methodology, we identified episodes that resulted in a transfer from one hospital to another.15,16
Statewide Inpatient-Days and Eligible Beds per Capita
To evaluate the proportion of statewide inpatient-days that were spent at REH-eligible hospitals, we first calculated the sum of all encounter lengths of stay in days for all emergency surgical patients. After, we calculated the encounter lengths of stay in hospitals that were eligible for REH designation. This process was repeated for each state included in our analysis and was compared with proportion of state residents living within each state, using publicly available census data.17 As a supplementary analysis, we also evaluated the available beds in REH-eligible facilities per 1,000 residents using census populations for each state.
Community Characteristics
Patients’ home ZIP codes were identified in our source data. These were cross-walked to ZIP code tabulation areas and then merged with tabulation area-level social vulnerability indices using census data from 2020. The Social Vulnerability Index incorporates neighborhood social markers under four domains: 1) socioeconomics; 2) household composition and disability; 3) minority status and language; and 4) housing type and transportation.18 Each is scored and normalized at a national level by the Centers for Disease Control from the 1st to 100th percentile, with higher scores indicating increased social vulnerability. A composite score incorporating all four domains was also included. For each encounter, we identified patients who came from areas with high social vulnerability, using a cutoff of the 90th percentile to identify highly vulnerable areas in accordance with previously published thresholds.18 The Social Vulnerability Index has been linked to disparities in healthcare access and outcomes in surgical emergencies and was selected for this reason.19-21 Finally, American Community Survey data was used to identify the population of patients’ home ZIP code tabulation areas and the proportion of the populations in these areas over age 65 years.
Statistical Analyses
We used univariate comparison statistics to identify differences in characteristics of hospitals, patient populations, episode characteristics, and community characteristics across REH-eligible and -ineligible hospitals. P-values were calculated using Chi-squared tests for categorical variables and t-tests for continuous variables. No imputation was required given little to no data missingness. Statistical significance was determined at a p-value of p<0.05. All analyses were conducted using Stata Statistical Software (version 18.0; StataCorp LLC, College Station, Texas), and R (R Project for Statistical Computing, Vienna, Austria).
Reporting and Ethics
The Strengthening of Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed (eExhibit 1 in Supplement).22 This study was approved by our Institutional Review Board (STUDY00016776).
RESULTS
Characteristics of REH-Eligible versus -Ineligible Hospitals
A total of 2,060,070 encounters for emergency general surgery conditions or injury were evaluated across 722 hospitals, including 153,298 (7.4%) that occurred at one of 206 REH-eligible hospitals. (Table 1). REH-eligible hospitals were more likely to be government-funded, and less likely to be private, for-profit hospitals. Ninety-eight percent of REH-eligible hospitals were level III or IV trauma centers or not designated as trauma centers, compared with 82% of REH-ineligible hospitals. Fewer REH-eligible hospitals had resources like advanced gastroenterology or interventional radiology; however, most REH-eligible hospitals had access to imaging resources including computed tomography and ultrasound. REH-eligible hospitals were smaller and had smaller intensive care units.
TABLE 1:
Hospital Characteristics Across REH-Eligible and -Ineligible Facilities
REH Ineligible
REH Eligible
Total
p
n (No. hospitals)
516
206
722
Hospital type
p<0.001
Government, nonprofit
56 (10.9%)
80 (39.0%)
136 (18.9%)
Nongovernment, nonprofit
339 (65.8%)
120 (58.5%)
459 (63.8%)
Private, for-profit
120 (23.3%)
5 (2.4%)
125 (17.4%)
Hospital rurality
p<0.001
Metropolitan
494 (95.7%)
48 (23.4%)
542 (75.2%)
Micropolitan
19 (3.7%)
42 (20.5%)
61 (8.5%)
Rural
3 (0.6%)
115 (56.1%)
118 (16.4%)
Trauma level
p<0.001
Nondesignated
366 (70.9%)
80 (38.8%)
446 (61.8%)
Level I
31 (20.7%)
1 (0.8%)
32 (11.6%)
Level II
58 (38.7%)
3 (2.4%)
61 (22.1%)
Level III
55 (36.7%)
49 (38.9%)
104 (37.7%)
Level IV
6 (4.0%)
73 (57.9%)
79 (28.6%)
Hospital resources
Emergency department
369 (98.1%)
176 (100.0%)
545 (98.7%)
p=0.068
ERCP available
307 (81.6%)
4 (2.3%)
311 (56.3%)
p<0.001
IR available
287 (55.6%)
29 (14.1%)
316 (43.8%)
p<0.001
CT available
373 (99.2%)
174 (98.3%)
547 (98.9%)
p=0.342
Ultrasound available
371 (98.7%)
159 (89.8%)
530 (95.8%)
p<0.001
Hospital size (quartile)
p<0.001
Smallest (≤152)
186 (36.0%)
202 (98.5%)
388 (53.8%)
2nd (153–385)
240 (46.5%)
3 (1.5%)
243 (33.7%)
3rd (386–432)
22 (4.3%)
0 (0.0%)
22 (3.1%)
Largest (>432)
68 (13.2%)
0 (0.0%)
68 (9.4%)
ICU size (quartile)
p<0.001
Smallest (≤12)
146 (38.8%)
176 (99.4%)
322 (58.2%)
2nd (13–22)
93 (24.7%)
1 (0.6%)
94 (17.0%)
3rd (23–38)
88 (23.4%)
0 (0.0%)
88 (15.9%)
Largest (>38)
49 (13.0%)
0 (0.0%)
49 (8.9%)
REH eligibility
Critical access hospital
0 (0.0%)
180 (87.4%)
180 (24.9%)
p<0.001
Small hospital (<50 beds)
20 (3.9%)
206 (100.0%)
226 (31.3%)
p<0.001
Rural hospital
75 (14.5%)
191 (92.7%)
266 (36.8%)
p<0.001
Reason for REH eligibility
p<0.001
Ineligible
516 (100.0%)
0 (0.0%)
516 (71.5%)
Small rural hospital
0 (0.0%)
26 (12.6%)
26 (3.6%)
Critical access hospital
0 (0.0%)
15 (7.3%)
15 (2.1%)
Small rural hospital + critical access hospital
0 (0.0%)
165 (80.1%)
165 (22.9%)
State
p<0.001
California
249 (48.3%)
39 (18.9%)
288 (39.9%)
Florida
153 (29.7%)
12 (5.8%)
165 (22.9%)
Iowa
22 (4.3%)
89 (43.2%)
111 (15.4%)
Maryland
40 (7.8%)
2 (1.0%)
42 (5.8%)
Wisconsin
52 (10.1%)
64 (31.1%)
116 (16.1%)
Characteristics of Patients Treated at REH-Eligible versus -Ineligible Hospitals
A comparison of patients treated at REH-eligible versus -ineligible hospitals is shown in Table 2. Patients cared for at REH-eligible hospitals were more likely to be non-Hispanic and white, with slightly fewer uninsured and Medicaid-insured patients, but with more patients in the lowest two income quartiles compared with their counterparts cared for at REH-ineligible hospitals (all p<0.001). Patients cared for at REH-eligible hospitals had fewer comorbidities, and most of them (79%) lived in rural areas. A larger proportion of patients first who presented to REH-eligible hospitals had small bowel obstructions and appendicitis, and fewer had cholecystitis, hernias, diverticulitis, or perforated peptic ulcer disease (Table 3). While 19% of patients who presented with emergency surgical conditions to an REH-eligible hospital had complex disease at presentation, slightly more (21%) had complex disease at presentation to REH-ineligible hospitals (p<0.001). There were no substantial trends across states with regard to disease at presentation or disease complexity (eExhibit 3 in Supplement).
TABLE 2:
Comparison of Patient Characteristics Among Those Adult Patients Evaluated for Surgical Emergency Care at REH Eligible- Versus Ineligible Facilities
REH Ineligible
REH Eligible
Total
p
n (No. patients)
1,906,772
153,298
2,060,070
Age, mean (SD), y
51.7 (21.5)
51.7 (21.3)
51.7 (21.5)
p=0.329
Female
938,979 (49.2%)
72,896 (47.6%)
1,011,875 (49.1%)
p<0.001
Race and ethnicity
p<0.001
Asian/Pacific Islander
85,638 (4.5%)
1,312 (0.9%)
86,950 (4.2%)
Black
238,610 (12.5%)
3,461 (2.3%)
242,071 (11.8%)
Hispanic
447,366 (23.5%)
11,926 (7.8%)
459,292 (22.3%)
Native American
5,293 (0.3%)
2,254 (1.5%)
7,547 (0.4%)
Other
65,932 (3.5%)
1,561 (1.0%)
67,493 (3.3%)
White
1,040,887 (54.6%)
130,574 (85.2%)
1,171,461 (56.9%)
Payor
p<0.001
Private
570,934 (30.0%)
47,355 (30.9%)
618,289 (30.0%)
Medicaid
441,407 (23.2%)
31,096 (20.3%)
472,503 (23.0%)
Medicare
600,091 (31.5%)
50,143 (32.8%)
650,234 (31.6%)
Uninsured
156,411 (8.2%)
9,072 (5.9%)
165,483 (8.0%)
Other
136,592 (7.2%)
15,440 (10.1%)
152,032 (7.4%)
Comorbidities
Cardiovascular disease
532,567 (27.9%)
28,242 (18.4%)
560,809 (27.2%)
p<0.001
Diabetes
210,705 (11.1%)
11,386 (7.4%)
222,091 (10.8%)
p<0.001
Lung disease
158,620 (8.3%)
8,333 (5.4%)
166,953 (8.1%)
p<0.001
Elixhauser Comorbidity Index
p<0.001
<0
283,987 (14.9%)
16,529 (10.8%)
300,516 (14.6%)
0
1,344,829 (70.5%)
123,878 (80.8%)
1,468,707 (71.3%)
1–5
167,449 (8.8%)
8,878 (5.8%)
176,327 (8.6%)
6–13
46,599 (2.4%)
1,846 (1.2%)
48,445 (2.4%)
14+
63,908 (3.4%)
2,167 (1.4%)
66,075 (3.2%)
Income quartile
p<0.001
Lowest
214,512 (26.6%)
21,590 (21.2%)
236,102 (26.0%)
2nd
258,709 (32.0%)
53,581 (52.6%)
312,290 (34.3%)
3rd
204,803 (25.4%)
22,646 (22.2%)
227,449 (25.0%)
Highest
129,467 (16.0%)
3,979 (3.9%)
133,446 (14.7%)
Rural
150,442 (7.9%)
120,843 (78.8%)
271,285 (13.2%)
p<0.001
Presenting concern
Emergency general surgery
249,624 (13.1%)
12,005 (7.8%)
261,629 (12.7%)
p<0.001
Trauma
1,657,148 (86.9%)
141,293 (92.2%)
1,798,441 (87.3%)
p<0.001
TABLE 3:
Primary Diagnosis and Disease Complexity at Presentation Among Emergency General Surgery Patients Evaluated at REH Eligible- Versus Ineligible Facilities
REH Ineligible
REH Eligible
Total
p
n (No. patients)
249,624
12,005
261,629
Primary diagnosis
p<0.001
Cholecystitis
40,377 (16.2%)
1,423 (11.9%)
41,800 (16.0%)
Appendicitis
35,638 (14.3%)
2,027 (16.9%)
37,665 (14.4%)
Hernia
50,569 (20.3%)
2,205 (18.4%)
52,774 (20.2%)
Diverticulitis
48,469 (19.4%)
2,147 (17.9%)
50,616 (19.3%)
Bowel obstruction
57,227 (22.9%)
3,529 (29.4%)
60,756 (23.2%)
Perforated peptic ulcer disease
1,929 (0.8%)
104 (0.9%)
2,033 (0.8%)
Perirectal abscess
11,224 (4.5%)
406 (3.4%)
11,630 (4.4%)
Intestinal ischemia
3,914 (1.6%)
144 (1.2%)
4,058 (1.6%)
Higher-complexity disease at presentation
52,747 (21.1%)
2,290 (19.1%)
55,037 (21.0%)
p<0.001
Encounter Characteristics and Resource Utilization at REH-Eligible versus -Ineligible Hospitals
Patients cared for at REH-eligible hospitals had shorter lengths of stay compared with those seen at REH-ineligible hospitals (0.28±1.4 days versus 1.04±3.7 days, p<0.001). Encounters at REH-eligible facilities were less likely to involve major or minor therapeutic or diagnostic procedures and were more likely to result in an interfacility transfer (5% versus 2.9%, p<0.001). (Table 4)
TABLE 4:
Hospital Resource Utilization at REH-Eligible Versus -Ineligible Hospitals
REH Ineligible
REH Eligible
Total
p
n (No. patients)
1,906,772
153,298
2,060,070
Length of stay, mean (SD), d
1.04 (3.7)
0.28 (1.4)
0.98 (3.6)
p<0.001
Procedures
Major therapeutic
209,951 (11.0%)
3,598 (2.3%)
213,549 (10.4%)
p<0.001
Minor therapeutic
135,444 (7.1%)
1,560 (1.0%)
137,004 (6.7%)
p<0.001
Major diagnostic
11,693 (0.6%)
216 (0.1%)
11,909 (0.6%)
p<0.001
Minor diagnostic
49,856 (2.6%)
465 (0.3%)
50,321 (2.4%)
p<0.001
Interfacility transfer
55,631 (2.9%)
7,762 (5.1%)
63,393 (3.1%)
p<0.001
Proportion of State Inpatient Days at REH-Eligible Hospitals
Figure 1 demonstrates the proportion of inpatient-days spent at REH-eligible hospitals in 2021 for each state included in our study, plotted alongside each state’s proportion of rural residents. With increasing rural populations, there was a trend toward a larger proportion of state inpatient-days at REH-eligible facilities. This varied substantially across states, with Florida having only 0.1% of its state inpatient days occurring at REH-eligible hospitals, but Iowa having nearly 17% (over 1 in 6 inpatient hospital days statewide). Similarly, states with a greater number of REH-eligible facility beds per capita provided a greater proportion of their statewide inpatient emergency surgical care at REH-eligible facilities (eExhibit 4 in Supplement).
Figure 1.
X-axis represents statewide rural population (%). Y-axis represents proportion (%) of statewide inpatient-days spent at hospitals eligible for rural emergency hospital conversion.
Community Characteristics of Populations Served by REH-Eligible versus -Ineligible Hospitals
By mapping the home ZIP codes of patients cared for at each hospital type to ZIP code tabulation area, we were able to evaluate differences in domains of the social vulnerability index and other population characteristics for the communities served by REH-eligible versus -ineligible hospitals (Table 5). Vulnerability based on socioeconomic status, household composition, minority status, and housing/transportation availability was significantly lower among communities served by REH-eligible hospitals, as was the composite social vulnerability index (all p<0.001). Populations served by REH-eligible hospitals tended to have a greater proportion of citizens over the age of 65 years (p<0.001).
TABLE 5:
Social Vulnerability Indices of Patient Home Communities Seen at REH-Eligible Versus -Ineligible Facilities
REH Ineligible
REH Eligible
Total
p
n (No. patients)
1,906,772
153,298
2,060,070
Components of SVI, mean (SD)
Socioeconomic status
0.65 (0.28)
0.52 (0.27)
0.64 (0.28)
p<0.001
Household composition
0.67 (0.22)
0.64 (0.25)
0.67 (0.22)
p<0.001
Minority status
0.79 (0.18)
0.50 (0.24)
0.77 (0.20)
p<0.001
Housing
0.78 (0.19)
0.69 (0.24)
0.77 (0.19)
p<0.001
Overall
0.76 (0.21)
0.63 (0.25)
0.75 (0.22)
p<0.001
SVI >90%, n (%)
616,702 (33.2)
24,997 (16.9)
641,699 (32.0)
p<0.001
ZCTA population, mean (SD)
38,456 (20,908)
13,129 (13,060)
36,585 (21,479)
p<0.001
Population older than 65 y, mean (SD)
5,876 (3,409)
2,312 (2,050)
5,613 (3,456)
p<0.001
Proportion of population older than 65 y, mean (SD), %
16.8 (8.3)
20 (6.3)
17.1 (8.2)
p<0.001
DISCUSSION
In this study, we define for the first time the substantial surgical care volumes and vulnerable patient populations at risk of access disruption if eligible hospitals adopt the REH designation across five diverse states. Our findings have several key policy and health systems implications for rural patients in need of trauma or emergency surgical care. First, we found that patients and populations served by REH-eligible hospitals are older and more financially vulnerable. Second, there was substantial variability in the proportion of inpatient care delivered by REH-eligible hospitals across states, with more than one in six inpatient-days spent at REH-eligible facilities in the most rural state evaluated. Our study represents a key first step in evaluating the implications of the policy that promotes closure of inpatient units and may impact the availability of the resources that accompany them (e.g., advanced diagnostic services, intensive care units, general surgeons, anesthesiologists, surgical and medical subspecialists) for emergency general surgery and trauma systems of care.
Conversion to REH designation will first impact those who would first seek care at these hospitals when they have an emergency condition or injury. Patient populations served by REH-eligible hospitals were typically older, had fewer comorbidities, and had lower income compared with those treated at REH-ineligible hospitals. This was also reflected in prior work examining patients who underwent emergency surgical procedures at critical access hospitals.23 While we found that the communities served by REH-eligible hospitals typically have lower social vulnerability, older, rural, and lower-income patients are at increased risk for poor access to care in surgical emergencies. Multiple large studies have determined that financial, sociodemographic, and geospatial aspects of access to care significantly impact outcomes, including morbidity, mortality, and complexity of disease at the time of presentation in both emergency general surgery and trauma.4,24-29 We determined that many of the same populations who already face significant barriers in access to care are the populations who most frequently seek care at REH-eligible hospitals. Nearly one in three Americans face unmet needs for timely, affordable, and high-quality surgical care – reflecting persistent disparities in surgical access that have worsened over the past decade due to workforce shortages, hospital closures, and structural barriers, and may be further exacerbated by proposed reductions in federal Medicaid Disproportionate Share Hospital payments.30 While European and Canadian systems that rely on robust transfer networks to deliver emergency surgical care may inform the potential impacts of REH conversion, notable differences in financial29,30 and timely4 access to care in the United States must also be considered. Communities in which rural hospitals close experience disruptions in timely access to surgical care in particular.4,31,32,32,33 Within this context, growing concerns over access in older and financially vulnerable patient populations will likely exacerbate issues related to accessible surgical care in rural communities.
In examining the volume of emergency general surgery versus trauma care at REH-eligible versus ineligible hospitals, we found that only 4.5% of emergency general surgery hospital encounters occurred at REH-eligible hospitals, in comparison with 7.8% of encounters for injury. This may reflect the ways in which patients access care in these surgical emergencies – injured patients frequently require emergency medical services for transport34 and therefore may not have a choice of which facility to which they are brought. In contrast to injured patients, individuals presenting with non-trauma emergency general surgical conditions in the United States frequently bypass their geographically nearest hospital and seek care at higher-tier referral or tertiary centers—a pattern associated with perceived differences in surgical capability, institutional reputation, and availability of specialist services.35 These bypass behaviors require further assessment: they likely already impact the delivery of care and travel time to care for emergency surgical conditions and may also make rural hospitals more financially vulnerable and, in turn, more likely to convert to REH designation. Through improved understanding of the populations treated at REH-eligible hospitals and future work focused on the ways that patients access care in rural areas, states and health systems will be in a more informed position to respond to the myriad impacts of REH conversion within their communities.
Significant interstate variation in resource utilization at REH-eligible hospitals suggests that the implementation and effectiveness of this federal designation will be mediated by local context, including state-level governance and regulatory environments as well as existing health system infrastructure. We analyzed data from states with rural populations ranging from 6 to 37% of their populus; REHs provided a greater proportion of inpatient care in states that were more rural. Importantly, rural non-trauma centers contribute greater than half of all trauma care in the United States;36 they also provide over 15% of emergency general surgical care nationally.37 Prior work has documented regional differences in the impacts of hospital closures on access to care33,36 and have identified variability in the number of financially vulnerable hospitals in different regions of the United States.8 The role of REH-designated hospitals in the context of these forces remains unclear, and requires prospective studies to characterize. While rural states will likely experience larger shifts in the distribution of inpatient care, the policy may preserve access to emergency department care (e.g., triage, basic diagnostic services, stabilization), which has been found to improve access to surgical care overall in prior work.4 Overall, prospective data will be needed to ultimately determine the impacts of preservation of emergency care in rural communities at the expense of inpatient care on health outcomes in rural communities where hospitals convert.
Our findings should be interpreted in the context of our study’s limitations. First, HCUP data describe hospital claims and our primary cohort, population characteristics, and resource utilization analyses were all based on diagnosis and procedure coding; therefore, our data are subject to potential misclassification due to inaccuracies in recording patient or encounter characteristics. We attempted to address this by using previously validated coding schemata and do not anticipate that this varies substantially across hospital types. The administrative data we used was able to identify our cohort of emergency surgical patients in this manner; however, due to heterogeneity and a general lack of granularity in our population, we were unable to reliably identify appropriate clinical outcomes among patients managed at REH-eligible and ineligible facilities and this was therefore outside of the scope of our analysis. Future work should incorporate data on clinical outcomes among specific clinical subsets of surgical patients, particularly as healthcare systems adjust to facilities that convert to rural emergency hospitals. Second, we evaluated only five states. While our findings are not directly representative of the U.S. population and other health systems that will be impacted by the REH policy, the inter-state variability we identify highlights the need for further study of the effects of this policy in regional, statewide, and local contexts. Finally, we aimed to describe surgical emergency care provided at all hospitals that are potentially eligible for REH designation rather than a subset of hospitals most likely to convert. While prior authors have attempted to identify hospital characteristics that may indicate a higher likelihood of conversion,8 these hypothetical conversions are difficult to realistically model using retrospective data, particularly in the context of recent policy changes impacting Medicare reimbursements that likely will impact the financial health of rural hospitals. Focused analyses with an emphasis on state-specific or regional contexts will be critical to evaluate the extent of rural hospital conversions to REH designation, and the downstream implications of these conversions within their systems. Nevertheless, we believe our findings can inform policymakers, particularly those working within systems where a substantial proportion of hospitals may ultimately convert to REH, of the potential impacts on trauma and emergency surgical care.
The substantial interstate variation in REH-eligible hospital utilization, combined with the distinct patient populations served by these facilities, suggest three timely and policy-relevant concerns that will need to be addressed in order to preserve surgical access while supporting sustainable rural emergency care delivery. First, states should prepare to track conversions to REH designation and the impacts on inpatient capacity at other hospitals within their trauma and health systems more broadly. In systems where nursing resources and bed availability are already scarce, the closure of small hospitals’ inpatient units may lead to capacity concerns at hospitals across the system. Given the variability in statewide inpatient volumes for emergency general surgery and trauma care, state policymakers and hospital leadership should closely monitor inpatient bed capacity and consider funding initiatives that allow for safe staffing ratios, particularly at publicly funded institutions that perform a significant amount of trauma and emergency surgical care. Second, beyond system-level capacity monitoring, the clinical care delivery infrastructure requires adaptation to accommodate changing referral patterns and patient acuity. Hospitals and physicians should therefore prepare for ongoing and increasing rural hospital strain and hospital closures by developing robust systems of care for surgical emergencies. This could include improved triage and transfer protocols, leveraging tele-triage and tele-consultation where possible, and improving outreach efforts to rural hospitals to improve access to care, triage, stabilization, and safe and timely transfers for patients in rural areas. Recent work in emergency general surgery, burn surgery, and trauma have demonstrated promising utility in reducing low-acuity interfacility transfers38-40, supporting local care41-44, and identifying patient populations that may benefit from further study to identify cases where higher levels of care are necessary.15,16,39,45,46 Surgeons and the organizations that support them can lead these efforts and advocate for improvements in systems that provide care in surgical emergencies, particularly in rural areas. Third, these alterations in patient case mix and subsequent impact on rural health systems may need additional financing mechanisms that recognize the unique economic challenges facing rural surgical care delivery. Bypass behavior for emergency conditions and systemic underfunding may push already financially vulnerable hospitals toward REH designation. Federal policies and states can support alternative payment models that recognize and reimburse standby capacity, trauma readiness, and episodic surgical care in rural hospitals regardless of inpatient admission volume.
