The rural mortality penalty in U.S. hospital patients with COVID-19

The COVID-19 pandemic brought greater focus to the rural mortality penalty in the U.S., which describes the greater mortality rate in rural compared to urban areas. Although it is widely thought that issues such as access to care, age structure of the population, and differences in behavior are likely drivers of the rural mortality penalty, few studies have attempted to tie delayed access to care in rural populations to healthcare outcomes quantitatively. Therefore, it is critical to try and understand these factors to enable more effective public health policy.

We performed a cross-sectional analysis of a population of patients with COVID-19 who were admitted to hospitals in the United States between 3/1/2020 and 2/26/2023 to better understand factors leading to outcome disparities amongst groups that all had some level of access to hospital care. Nevertheless, it is widely thought that rural populations often experience delayed access to care, due to transportation and other constraints. Therefore, we hypothesized that deteriorated patient condition at admission likely explained some of the observed difference in mortality between rural and urban populations.

Our results supported our hypothesis, showing that the rural mortality penalty persists in this population and that by multiple measures, rural patients were likely to be admitted in worse condition, had worse overall health, and were older.

Although the pandemic threw the rural mortality penalty into sharp relief, it is important to remember that it existed prior to the pandemic and will continue to exist until effective interventions are implemented. This study demonstrates the critical need to address the underlying factors that resulted in rural-dwelling patients being admitted to the hospital in worse condition than their urban-dwelling counterparts during the COVID-19 pandemic, which likely affected other healthcare outcomes as well.