Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach.
OBJECTIVE
To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival.


METHODS
Observational cohort study.


METHODS
Emergency departments of a rural Midwestern state.


METHODS
All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data.


METHODS
Patients bypassing local rural hospitals to seek care in larger hospitals.


RESULTS
A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality.


CONCLUSIONS
Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.
1Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA. 2Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA. 3Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA. 4Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO. 5Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO. 6Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
Nicholas M
NM
Mohr
Karisa K
KK
Harland
Dan M
DM
Shane
Azeemuddin
A
Ahmed
Brian M
BM
Fuller
Marcia M
MM
Ward
James C
JC
Torner
D000367:Age Factors; D000368:Aged; D015331:Cohort Studies; D015897:Comorbidity; D048909:Diabetes Complications / Q000453:epidemiology; D004636:Emergency Service, Hospital; D006801:Humans; D007348:Insurance, Health; D017093:Liver Failure / Q000453:epidemiology; D008875:Middle Aged; D015146:Midwestern United States / Q000453:epidemiology; D009362:Neoplasm Metastasis; D010360:Patient Transfer; D012424:Rural Population; D018805:Sepsis / Q000401:mortality*; D012772:Shock, Septic / Q000401:mortality*