Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008–2017



Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time.


Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade.


Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends.


Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008–2017.


US adults, an annual average of 241.3 million individuals.


Preventable ED visits and hospitalizations.


Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928–938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196–1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434–443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190–199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents.


Observational study; unable to infer causality.


Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.

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Data Availability

Available for purchase from the Agency for Healthcare Research and Quality (AHRQ) after execution of an approved data use agreement (see for more details).


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Role of the Sponsor

Saint Louis University had no role in the design and conduct of the study; analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.


Saint Louis University purchased and provided access to the data used in this study.

Author information




Dr. Johnston had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Johnston, Wen, Joynt Maddox

Acquisition, analysis, or interpretation of data: all authors

Drafting of the manuscript: Johnston, Joynt Maddox

Critical revision of the manuscript for important intellectual content: all authors

Statistical analysis: Johnston, Kotwal

Obtained funding: Johnston

Administrative, technical, or material support: Johnston, Kotwal

Study supervision: Johnston

Corresponding author

Correspondence to Kenton J. Johnston PhD.

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Conflict of Interest

Dr. Johnston receives grant funding from the National Institute on Aging (Grant No. R21AG065526). Dr. Joynt Maddox previously did work under contract with the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, and receives grant funding from the National Heart, Lung, and Blood Institute (Grant No. R01HL143421) and National Institute on Aging (Grant No. R01AG060935).

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Available to interested readers by contacting Dr. Kenton Johnston at

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Johnston, K.J., Wen, H., Kotwal, A. et al. Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008–2017. J GEN INTERN MED (2021).

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