Impact of rurality on inpatient outcomes in neurofibromatosis: A National Inpatient Sample study

Rural patients face well-documented disparities across neurosurgical care, yet whether these extend to neurofibromatosis types 1 and 2 (NF1 and NF2), rare conditions whose neurosurgical care is concentrated in urban centers, remains unknown. We performed a national analysis of rurality and inpatient outcomes in neurofibromatosis (NF).

Using the 2016-2021 National Inpatient Sample, we identified adult discharges with NF1 or NF2. Survey-weighted multivariable regression examined rural residence and rural hospital location against inpatient outcomes across all NF, surgical, and neurosurgical discharges. Outcomes included in-hospital mortality, non-home discharge, interhospital transfer, length of stay, and total charges. Temporal trends and NF versus non-NF cranial tumor resection were also evaluated.

Among a weighted 25,000 NF discharges, care was highly centralized, with over 99% of neurosurgical discharges at urban hospitals. Rural patients had markedly higher adjusted odds of interhospital transfer, an association that escalated with care complexity, from threefold across all NF discharges to more than eightfold among neurosurgical discharges (both p<0.001), while rural hospitals were far less likely to receive transfers. Despite this, rural residence was not associated with higher mortality, non-home discharge, length of stay, or charges in any cohort.

Neurosurgical care for NF is heavily centralized, leaving rural patients disproportionately dependent on interhospital transfer. Yet this did not translate into worse inpatient outcomes, suggesting centralization may act less as a barrier than as a costly pathway routing rural patients to appropriate centers, with implications for other rare and complex neurosurgical conditions.