STATISTICAL BRIEF #116
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June 2011
Anika Hines, Ph.D., M.P.H., Taressa Fraze, Ph.D., Carol Stocks, M.H.S.A., R.N.
Introduction Emergency departments (EDs) are an important consideration in today’s health policy dialogue. Previous studies note that annual ED visits have increased over time,1 while reimbursement for emergency care by insurers has steadily decreased.2 These challenges are magnified in rural areas, which typically have fewer health care resources, including medical staff, facilities, adequate financing, and modern technologies. More information is needed on the patient and hospital attributes of rural ED visits to further improve the emergency and overall care of rural patients. This Statistical Brief presents data on the use of EDs in rural areas from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS). The information focuses on patient and hospital characteristics of rural and non-rural emergency department visits in the United States in 2008. Variations in the most frequently listed conditions for adults and children are also discussed. All differences between estimates noted in the text are statistically significant at the 0.05 level or better. Findings Overall In 2008, EDs in rural areas received over 8 million visits, translating to about 6.4 percent of all ED visits in the U.S., while about 117 million visits took place in non-rural EDs (table 1). EDs in rural areas admitted patients to the inpatient setting at nearly half the rate of non-rural EDs—8.3 percent versus 16.0 percent of ED visits. Hospital characteristics of rural and non-rural emergency departments, 2008 EDs in rural areas differed from non-rural EDs in type of ownership. EDs in rural areas were primarily private, not-for-profit (56.2 percent) followed by public (32.2 percent) and private, for-profit (11.6 percent) hospitals. Higher percentages of non-rural EDs were in private, not-for-profit hospitals (72.0 percent) with fewer being in public hospitals (15.1 percent) and slightly more being in private, for-profit (13.0 percent) organizations. Only 1.8 percent of EDs in rural areas were located within teaching hospitals, defined as having an AMA-approved residency program, being a member of the Council of Teaching Hospitals (COTH), or having a ratio of full-time equivalent interns and residents to beds of 0.25 or higher (data not shown), while 40.4 percent of non-rural EDs were in teaching hospitals. Only 2.4 percent of EDs in rural areas held a Level III trauma classification while 35.5 percent of non-rural hospitals were classified as Levels I, II, and III trauma centers. Nearly 98 percent of rural hospitals had no trauma designation. An estimated 50.7 percent of EDs in rural areas were certified critical access hospitals (CAHs), receiving cost-based reimbursement for services rendered. |
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Table 1. Hospital characteristics of rural and non-rural emergency departments, 2008 | ||
Rural | Non-rural | |
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Overall | ||
Number of ED visits* | 8,054,187 | 116,891,077 |
Percentage of all ED visits | 6.4 | 93.6 |
Percentage treat-and-release ED visits | 91.7 | 84.0 |
Percentage ED visits resulting in admission | 8.3 | 16.0 |
Hospital characteristics (percentage) | ||
Ownership/control* | ||
Public | 32.2 | 15.1 |
Private, not-for-profit | 56.2 | 72.0 |
Private, for-profit | 11.6 | 13.0 |
Teaching status* | ||
Non-teaching | 98.2 | 59.6 |
Teaching | 1.8 | 40.4 |
Trauma level* | ||
Levels I, II, or III | 2.4 | 35.5 |
No trauma designation | 97.6 | 64.5 |
Occupancy* | ||
Low (<33%) | 46.2 | 7.1 |
Moderate (33%-67%) | 31.9 | 31.0 |
High (>67%) | 31.9 | 31.0 |
*p-value< 0.05 (X2 testing comparing rural to non-rural). Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2008 |
Characteristics of patients visiting rural and non-rural emergency departments, 2008
As show in table 2, EDs in rural areas had higher rates of visits per 100,000 population than their non-rural counterparts in the Northeast (50,115 versus 44,464 per 100,000), South (45,420 versus 43,790 per 100,000), and West (38,470 versus 31,009 per 100,000), but lower rates in the Midwest when compared to non-rural counterparts (34,293 per 100,000 versus 45,043 per 100,000). |
Table 2. Characteristics of patients visiting rural and non-rural emergency departments, 2008 | ||
Rural | Non-rural | |
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ED visits per 100,000 population | 41,217 | 41,083 |
Population estimates per 100,000 by region of the US | ||
Northeast | 50,115 | 44,464 |
Midwest | 34,293 | 45,043 |
South | 45,420 | 43,790 |
West | 38,470 | 31,009 |
Patient characteristics (percentage) | ||
All age groups* | ||
0-17 | 22.4 | 21.1 |
18-44 | 38.0 | 40.4 |
45-64 | 21.0 | 21.5 |
65 and over | 18.6 | 17.0 |
Pediatric age groups* | ||
0-4 | 41.0 | 45.6 |
5-9 | 20.8 | 19.7 |
10-14 | 20.4 | 18.3 |
15-17 | 17.9 | 16.4 |
Gender | ||
Male | 45.5 | 45.0 |
Female | 54.5 | 55.0 |
Race*† | ||
White | 82.8 | 64.2 |
Black | 12.7 | 20.9 |
Hispanic | 3.6 | 12.7 |
Asian/Pacific Islander | 0.9 | 2.2 |
Median income of patient's ZIP Code* | ||
First quartile (lowest income) | 56.2 | 30.1 |
Second quartile | 31.7 | 29.8 |
Third quartile | 9.5 | 22.1 |
Fourth quartile (highest income) | 2.6 | 18.1 |
Payer* | ||
Private insurance | 31.3 | 37.0 |
Medicare | 24.7 | 21.3 |
Medicaid | 27.7 | 23.1 |
Uninsured/self-pay/no charge | 16.4 | 18.5 |
† Race/ethnicity: rural missing=21.5%, non-rural missing=19.7% *p-value< 0.05 (X2 testing comparing rural to non-rural); Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2008 |
Most visits to EDs in rural areas were by whites (82.8 percent), followed by blacks (12.7 percent), Hispanics (3.6 percent), and Asian/Pacific Islanders (0.9 percent). Non-rural EDs treated smaller percentages of whites (64.2 percent), but larger proportions of blacks (20.9 percent), Hispanics (12.7 percent), and Asian/Pacific Islanders (2.2 percent).
Most rural ED visits involved patients residing in ZIP Codes in lower median income quartiles (56.2 percent in the lowest quartile and 31.7 percent in the second). In contrast, fewer patients visiting non-rural EDs resided in lower income ZIP Codes. Private insurance served as the primary expected payer for 31.3 percent of visits to EDs in rural areas followed by Medicaid (27.7 percent), Medicare (24.7 percent), and the uninsured (16.4 percent). A greater percentage of visits to non-rural EDs were billed to private insurance (37.0 percent) and uninsured (18.5 percent) compared to EDs in rural areas, while smaller percentages were covered by Medicaid (23.1 percent) and Medicare (21.3 percent). Most frequent first-listed conditions for rural and non-rural EDs for adults 18 years and older, 2008 Table 3 displays top ranking conditions among adults visiting rural and non-rural EDs. The leading conditions seen in EDs in rural areas were sprains and strains (5.5 percent), contusions (5.4 percent), abdominal pain (3.7 percent), headache (3.6 percent), and back problems (3.6 percent). Sprains (5.2 percent), contusions (4.2 percent), abdominal pain (4.3 percent), and back problems (3.3 percent) were also among the top five for non-rural EDs; however, headaches (2.7 percent) ranked much lower in non-rural EDs while non-specific chest pain (4.0 percent) was top-ranking. |
Table 3. Most frequent first-listed conditions for rural and non-rural ED visits for adults 18 years and older, 2008 | ||||||
Rural | Non-rural | |||||
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First-listed condition (CCS code) | Rank | Number | Percentage of total | Rank | Number | Percentage of total |
Sprains and strains | 1 | 346,208 | 5.5 | 1 | 4,827,511 | 5.2 |
Superficial injury; contusion | 2 | 339,460 | 5.4 | 3 | 3,888,722 | 4.2 |
Abdominal pain | 3 | 233,064 | 3.7 | 2 | 3,977,790 | 4.3 |
Headache; including migraine | 4 | 223,327 | 3.6 | 7 | 2,465,250 | 2.7 |
Spondylosis; intervertebral disc disorders; other back problems | 5 | 223,248 | 3.6 | 5 | 3,077,636 | 3.3 |
Non-specific chest pain | 6 | 220,647 | 3.5 | 4 | 3,652,629 | 4.0 |
Other upper respiratory infections | 7 | 211,602 | 3.4 | 9 | 2,382,729 | 2.6 |
Open wounds of extremities | 8 | 211,587 | 3.4 | 8 | 2,418,742 | 2.6 |
Urinary tract infections | 9 | 175,221 | 2.8 | 10 | 2,295,766 | 2.5 |
Chronic obstructive pulmonary disease and bronchiectasis | 10 | 159,002 | 2.5 | 14 | 1,534,780 | 1.7 |
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2008 |
Most frequent first-listed pediatric (ages 0-17 years) conditions in rural emergency departments, 2008 Table 4 displays top ranking conditions among children (ages 0-17) visiting rural and non-rural EDs. Upper respiratory infections (12.9 percent), contusions (8.5 percent), ear infections (7.2 percent), sprains and strains (5.2 percent), and open wounds (4.4 percent) were the leading conditions among children visiting EDs in rural areas. Similar rankings existed among non-rural EDs for the top three conditions, while open wounds ranked 4th and fever ranked 5th in this population. |
Table 4. Most frequent first-listed conditions for rural and non-rural ED visits for children (0-17 years), 2008 | ||||||
Rural | Non-rural | |||||
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First-listed condition (CCS code) | Rank | Number | Percentage of total | Rank | Number | Percentage of total |
Other upper respiratory infections | 1 | 233,131 | 12.92464 | 1 | 2,623,562 | 10.65667 |
Superficial injury; contusion | 2 | 153,383 | 8.503492 | 2 | 1,570,637 | 6.379785 |
Otitis media and related conditions | 3 | 129,047 | 7.154297 | 3 | 1,434,799 | 5.828021 |
Sprains and strains | 4 | 93,817 | 5.201173 | 6 | 984,297 | 3.998123 |
Open wounds of head; neck; and trunk | 5 | 80,217 | 4.447193 | 4 | 1,172,239 | 4.761525 |
Open wounds of extremities | 6 | 67,440 | 3.738847 | 11 | 668,561 | 2.715633 |
Fever of unknown origin | 7 | 63,516 | 3.521321 | 5 | 1,079,701 | 4.385646 |
Viral infection | 8 | 60,864 | 3.374259 | 8 | 780,210 | 3.169142 |
Other injuries and conditions due to external causes | 9 | 54,521 | 3.022627 | 7 | 969,266 | 3.937071 |
Fracture of upper limb | 10 | 50,469 | 2.797952 | 9 | 701,726 | 2.850346 |
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, 2008 |
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AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below:Internet Citation: Statistical Brief #116. Healthcare Cost and Utilization Project (HCUP). June 2011. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb116.jsp. |
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Last modified 6/20/11 |