Rural-urban Differences in Long-term Mortality and Readmission Following COVID-19 Hospitalization, 2020 to 2023

Abstract

Background We compared long-term mortality and readmission rates after COVID-19 hospitalization based on rural-urban status and assessed the impact of COVID-19 vaccination introduction on clinical outcomes by rurality. Methods Study comprised of adults hospitalized for COVID-19 at 17 hospitals in four U.S. states between March 2020 and July 2022, followed until May 2023. The main analysis included all patients, while a sensitivity analysis focused on residents from 4 states containing 17 hospitals. Additional analyses compared the pre- and post-vaccination periods. Results The main analysis involved 9,325 COVID-19 hospitalized patients: 31% were from 187 rural counties in 31 states; 69% from 234 urban counties in 44 states; the mean age was 65 years (rural, 66 years; urban, 64 years); 3894 women (rural, 41%; urban, 42%); 8007 whites (rural, 87%; urban, 83%); 1738 deaths (rural, 21%; urban, 17%); and 2729 readmissions (rural, 30%; urban, 29%). During a median follow-up of 602 days, rural residence was associated with a 22% higher all-cause mortality (Log-rank, P<0.001; hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.10-1.34, P<0.001), and a trend toward a higher readmission rate (Log-rank, P=0.038; HR 1.06; 95% CI 0.98-1.15, P=0.130). The results remained consistent in the sensitivity analysis and in both pre- and post-vaccination time periods. Conclusions and Relevance Patients from rural counties experienced higher mortality and tended to be readmitted more frequently following COVID-19 hospitalization over the long term compared to those from urban counties, a difference that remained even after the introduction of COVID-19 vaccines.