Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study

Abstract

ObjectiveLittle is known about differences in hospital harm (injury, suffering, disability, disease or death arising from hospital care) when people from rural and urban locations require hospital care. This study aimed to assess whether hospital harm risk differed by patients’ rural or urban location using general practice data.DesignSecondary analysis of a 3-year retrospective cross-sectional general practice records review study, designed with equal numbers of rural and urban patients and patients from small, medium and large practices. Hospital admissions, interhospital transfer and hospital harm were identified.SettingNew Zealand (NZ) general practice clinical records including hospital discharge data.ParticipantsRandomly selected patient records from randomly selected general practices across NZ. Patient enrolment at rural and urban general practices defined patient location.OutcomesAdmission and harm risk and rate ratios by rural-urban location were investigated using multivariable analyses adjusted for age, sex, ethnicity, deprivation, practice size. Preventable hospital harm, harm severity and harm associated with interhospital transfer were analysed.ResultsOf 9076 patient records, 1561 patients (17%) experienced hospital admissions with no significant association between patient location and hospital admission (rural vs urban adjusted risk ratio (aRR) 0.98 (95% CI 0.83 to 1.17)). Of patients admitted to hospital, 172 (11%) experienced hospital harm. Rural location was not associated with increased hospital harm risk (aRR 1.01 (95% CI 0.97 to 1.05)) or rate of hospital harm per admission (adjusted incidence rate ratio 1.09 (95% CI 0.83 to 1.43)). Nearly half (45%) of hospital harms became apparent only after discharge. No urban patients required interhospital transfer, but 3% of rural patients did. Interhospital transfer was associated with over twice the risk of hospital harm (age-adjusted aRR 2.33 (95% CI 1.37 to 3.98), p=0.003).ConclusionsRural patient location was not associated with increased hospital harm. This provides reassurance for rural communities and health planners. The exception was patients needing interhospital transfer, where risk was more than doubled, warranting further research.

Urbanization level and medical adverse event deaths among US hospital inpatients over the period 2010–2019

“…In this dataset, adverse event deaths were least likely in the most urban category, and more common in the two remaining (more rural) categories. As such, the findings were generally in contrast to previous reports ( Atmore et al, 2021 , Coburn et al, 2004 , Vartak et al, 2010 ) but in line with the present hypothesis. With regard to previous reports, the differing geographical coverages, time periods, definitions of urbanity and rurality, and adverse event outcomes should be acknowledged as potential sources of discrepancy.…”

“…It is thus clear that the present findings, obtained from a national dataset extending over a period of 10 years, are relevant for a broad population base. Unlike most previous studies ( Atmore et al, 2021 , Coburn et al, 2004 ), this study focused on deaths primarily attributed to adverse events, as they arguably constitute the most severe outcome in the patient safety context. Adverse event deaths were studied in relation to total inpatient deaths to account for trends in overall mortality.…”

“…However, there currently is a paucity of up-to-date information regarding this aspect. A recent cross-sectional study from New Zealand addressed hospital harm among urban and rural patients, and found no evidence that rurality was associated with increased rates of harm ( Atmore et al, 2021 ); in older US reports, adverse events appeared less likely in rural than in urban hospitals ( Coburn et al, 2004 , Vartak et al, 2010 ). As such, the presence and nature of potential urban–rural gradients in adverse events remain ambiguous.…”

Doctors’ experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study

“…Most RH doctors asserted that the patient safety in their RH was high, even possibly higher than in a base hospital. Studies in NZ and internationally have not found any association between rural location and increased risk of hospital harm, but patients in need of interhospital transfers were at increased risk,40 41 as would be expected with patients with emergency care-sensitive conditions.…”

A retrospective observational study of critically unwell patients retrieved from Thames Hospital between April 2018 and December 2020

“…1,11 A recent study showed that in hospitalised rural patients, the only harm difference between rural and urban hospitals occurred in patients who required inter-hospital transfer. 12 Although further information was not available, critically unwell patients may have contributed to this finding, raising important questions about the burden placed on rural hospital clinicians caring for very sick patients.…”