Rural Residence and Postsurgical Outcomes Among Medicare Beneficiaries

Rural hospital-level surgical quality has been extensively evaluated. However, rural people in the US face growing inequities in care, and quality of surgical care experienced by rural patients nationally remains poorly defined.

To evaluate surgical quality among rural vs nonrural Medicare beneficiaries undergoing common general surgery procedures.

This retrospective cohort study used 100% Medicare inpatient claims linked with the American Hospital Association Annual Survey between 2016 and 2023. The cohort included beneficiaries aged 65 to 99 years who underwent admission for appendectomy, cholecystectomy, colectomy, or incisional hernia repair. This analysis was undertaken between August and October 2025.

Rural vs nonrural residence, defined using Rural-Urban Commuting Area codes based on patient home zip code (1-3: nonrural; 4-10: rural).

Risk-adjusted 30-day mortality, in-hospital mortality, complications, 30-day readmission, discharge disposition, and hospital length of stay. Multivariable logistic regression models adjusted for patient factors, hospital factors, and year of surgery.

Among 2 317 497 beneficiaries (55.5% female; mean [SD] age, 75.2 [7.2] years), 462 358 (19.9%) were rural. Rural patients were more often male (46.4% vs 44.1%) and traveled longer for surgery (median, 45.0 [IQR, 22.0-77.0] minutes vs 20.0 [IQR, 13.0-31.0] minutes). Rural patients had higher adjusted 30-day mortality (6.78% [95% CI, 6.65%-6.90%] vs 5.84% [95% CI, 5.76%-5.93%]; odds ratio [OR], 1.21 [95% CI, 1.18-1.24]; P < .001), in-hospital mortality (3.65% [95% CI, 3.56%-3.74%] vs 3.20% [95% CI, 3.14%-3.25%]; OR, 1.17 [95% CI, 1.14-1.21]; P < .001), and 30-day readmission (14.31% [95% CI, 14.14%-14.48%] vs 13.57% [95% CI, 13.45%-13.69%]; OR, 1.07 [95% CI, 1.05-1.08]; P < .001). Complication rates were higher (29.31% [95% CI, 29.04%-29.57%] vs 28.58% [95% CI, 28.40%-28.76%]; OR, 1.05 [95% CI, 1.03-1.07]; P < .001). Rural patients were less likely to be discharged home (75.56% [95% CI, 75.24%-75.88%] vs 77.61% [95% CI, 77.36%-77.86%]; OR, 0.85 [95% CI, 0.83-0.88]; P < .001) and more likely to be transferred to another facility (1.40% [95% CI, 1.33%-1.47%] vs 0.70% [95% CI, 0.67%-0.73%]; OR, 2.04 [95% CI, 1.92-2.17]; P < .001).

In this cohort study of Medicare beneficiaries undergoing common general surgery procedures, rural residence was independently associated with worse clinical outcomes across most measures. These findings identify significant opportunities for quality improvement focused on common rural surgical needs.