Heart failure readmissions in urban and rural hospital settings: An analysis of 30-day readmissions using the 2021...

Heart failure is a leading cause of hospital readmissions in the United States. Rural populations experience higher mortality and fragmented care, yet limited research has explored how demographic, clinical, structural, and socioeconomic factors influence 30-day readmission risk across geographic locations. This study examined predictors of 30-day heart failure readmissions and assessed how associations differ between rural and urban hospitals.

This secondary analysis used the 2021 Nationwide Readmissions Database and included adults hospitalized with a primary diagnosis of heart failure. The primary outcome was 30-day hospital readmission, defined as the first non-elective inpatient admission for heart failure occurring within 30 days of discharge from an index hospitalization. Covariates included age, sex, diabetes, chronic obstructive pulmonary disease, length of hospital stay, discharge disposition, insurance payer type, median household income, hospital bed size, teaching status, geographic location, and total charges. Hospital rural-urban classification was based on the Urban-Rural Classification Scheme (HOSP_URCAT4) provided by the Healthcare Cost and Utilization Project. Weighted multivariable logistic regression with interaction terms was used to assess geographic variation in readmission risk.

Rural hospitals had lower overall odds of readmission; however, this pattern did not extend to patients with self-pay or no-charge status. Among rural patients, those with no-charge hospitalizations had the highest risk (aOR = 1.830, 95% CI [1.059, 3.161]), followed by self-pay (aOR = 1.301, 95% CI [1.143, 1.480]). Diabetes (aOR = 1.181), COPD (aOR = 1.258), and longer hospital stays (aOR = 1.246) were strong clinical predictors. Private insurance (aOR = 0.684) and higher income (aOR = 0.917) were protective. Model performance was modest (AUC = 0.589; Brier score = 0.167).

Findings indicate that structural inequities persist in rural heart failure readmissions, warranting targeted policy and care interventions.