Rural Medicare Surgery Linked to Higher Postsurgical Mortality

Key Takeaways

• Among Medicare beneficiaries undergoing inpatient appendectomy, cholecystectomy, colectomy, or incisional hernia repair, rural residence was associated with higher adjusted short-term mortality than nonrural residence.
• Rural residence was also associated with higher adjusted complication rates and higher 30-day readmission rates.
• After surgery, rural beneficiaries were less often discharged directly home or with home health and more often transferred to another facility.
• Higher mortality and readmission patterns persisted in sensitivity analyses across elective and unplanned admissions and across rural and nonrural hospital settings.

Older adults in rural communities often travel farther for common inpatient operations such as appendectomy, cholecystectomy, colectomy, or incisional hernia repair. For these Medicare beneficiaries, it has remained unclear whether residence itself is associated with different postsurgical outcomes, apart from whether surgery occurs at a rural hospital.

Mullens and colleagues in JAMA Network Open conducted a retrospective cohort study using 100% Centers for Medicare & Medicaid Services (CMS) Medicare Provider Analysis and Review (MEDPAR) claims linked to American Hospital Association (AHA) Annual Survey data. From 2016 through 2023, the cohort included 2,317,497 Medicare beneficiaries aged 65 to 99 years who underwent appendectomy, cholecystectomy, colectomy, or incisional hernia repair, including 462,358 rural beneficiaries (19.9%). Rural residence was defined with Rural-Urban Commuting Area (RUCA) codes based on home ZIP code, and adjusted outcomes included 30-day mortality, in-hospital mortality, complications, 30-day readmission, discharge disposition, and length of stay. Multivariable models accounted for patient, hospital, and year factors before outcomes were compared.

Before adjustment, rural beneficiaries traveled farther to the treating hospital, with a median travel time of 45.0 minutes versus 20.0 minutes for nonrural beneficiaries, and they were more often admitted electively and more often treated at smaller, less frequently teaching hospitals. Adjusted 30-day mortality was 7% for rural versus 6% for nonrural beneficiaries, odds ratio (OR) 1.21 (95% confidence interval [CI], 1.18-1.24); P < .001. In-hospital mortality was also higher among rural patients, and the mortality pattern remained worse after adjustment.

Nonfatal outcomes also differed after adjustment. Thirty-day readmission was 14.31% for rural versus 13.57% for nonrural beneficiaries (OR, 1.07; 95% CI, 1.05-1.08; P < .001), and transfer to another facility was 1.4% versus 0.7%; OR 2.04 (95% CI, 1.92-2.17); P < .001. Overall complications were higher among rural beneficiaries, while direct-home and home-health discharge were less common; serious complications were a notable exception with slightly lower adjusted rates. Higher mortality and readmission patterns were also seen in both elective and unplanned admissions, the differences were larger in unplanned admissions, and rural beneficiaries had worse outcomes across nearly all measures whether surgery occurred at rural or nonrural hospitals.

Because this was an observational cohort based on administrative claims, outcome measurement depended on coding and RUCA ZIP-code classification could not capture every urban-rural boundary precisely. The population was limited to Medicare beneficiaries aged 65 to 99 years undergoing four common inpatient general surgery procedures, and the authors noted that several statistically significant differences were modest in absolute terms. They interpreted the persistence of worse outcomes beyond rural hospitals as consistent with upstream structural barriers such as travel burden, delayed presentation, and fragmented care.

The authors concluded that rural residence was independently associated with worse postsurgical outcomes across most measured endpoints in this Medicare surgical population, with the association tied to residence rather than hospital location alone.

Clinician Questions

How was rural residence defined for Medicare beneficiaries in this general surgery cohort?

Investigators classified residence using Rural-Urban Commuting Area codes based on each beneficiary’s home ZIP code, with codes 1 to 3 considered nonrural and 4 to 10 considered rural. The exposure was defined by patient residence rather than by hospital location.

Do the rural outcome differences extend beyond surgery performed at rural hospitals?

Yes. Stratified analyses separated rural beneficiaries by whether surgery occurred at a rural or nonrural hospital, and rural beneficiaries still had worse outcomes across nearly all measured endpoints than nonrural beneficiaries. The pattern was not limited to operations performed at rural facilities.

What did the authors identify as the main limits on interpreting worse postsurgical outcomes among rural Medicare beneficiaries?

The authors noted that interpretation is limited by the observational design and use of administrative claims, which rely on coding for outcome measurement. The cohort was restricted to Medicare beneficiaries aged 65 to 99 years undergoing appendectomy, cholecystectomy, colectomy, or incisional hernia repair, some absolute differences were modest, and RUCA ZIP-code classification may misclassify beneficiaries near urban-rural boundaries.