National Burden of Bicyclist Hospitalizations in the United States by Rurality, 2016-2020

Bicyclist injuries are a major public health concern in the United States, with limited understanding of variations in injury severity and discharge outcomes by rurality. This study provides a national assessment of bicycling-related hospitalizations, focusing on differences by rurality.

Using HCUP-NIS data (2016-2020), bicycling-related hospitalizations were identified. Descriptive analyses characterized demographic and regional trends. Multivariable logistic regression, stratified by rural/urban patient residence, was used to assess factors associated with non-routine discharges.

Between 2016 and 2020, an estimated 124,000 bicyclist-related hospitalizations occurred, resulting in more than $10 billion in hospital costs. Overall, 31.2% resulted in non-routine discharge, including 1.4% deaths. Hospitalizations were stable through 2019 but increased by >20% in 2020. Urban residents accounted for most cases (91.1%). Cases were predominantly male (80%); aged 31-70 (65.4%) and hospitalized in the South (31.2%) or West (36.4%). Increasing age showed a strong dose-response relationship with non-routine discharge in both settings (e.g., age ≥ 71: OR_rural = 15.71, 95% confidence interval [CI]: 9.52-25.93; OR_urban = 12.18, 95% CI: 10.21-14.52). Motor-vehicle involvement increased the odds of non-routine discharge in both settings (OR_rural = 2.53, 95% CI: 1.89-3.40; OR_urban = 1.68, 95% CI: 1.55-1.82).

Bicyclist hospitalizations persisted and slightly increased over the study period. Age was the strongest predictor of non-routine discharge across settings, whereas sex and income effects were significantly associated with outcomes in urban areas. Findings highlight the need for tailored prevention strategies and equitable infrastructure improvements across rural and urban settings.