Association Between Rural Residence and In-Hospital and 30-Day Mortality Among Veterans Hospitalized with COPD Exacerbations

BACKGROUND: We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations. METHODS: We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics. RESULTS: Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (P=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (P<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67–1.12, P=0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04–1.22, P=0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80–17.16, P<0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66–48.21, P<0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality. CONCLUSION: Potential gaps in post-discharge care of rural veterans may be responsible for the rural–urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.