Research articleRural–Urban Differences in Injury Hospitalizations in the U.S., 2004
Introduction
Unintentional injuries are the leading cause of death in the U.S. among individuals aged 1–53 years and the fifth leading cause of death overall.1 Additionally, suicide and homicide rank as the second and third leading causes of death, respectively, among individuals aged 1–40 years.1 Prior research has demonstrated important differences in injury mortality between rural and urban populations. In general, rural populations have disproportionately high injury-mortality rates, and decreasing population density is the strongest predictor of county-specific trauma death rates in the U.S.2, 3, 4 Although homicide rates are higher among urban populations, the rates of suicide and unintentional injury are higher among rural populations, resulting in an overall higher injury-mortality rate among rural residents.2
Few studies have explored nonfatal injuries among rural populations. Published reports have generally been limited to individual states, specific mechanisms of injury, or both. Prior research, using survey methods, has examined the epidemiology of unintentional adult injury in a single rural county within Iowa5 and the prevalence and characteristics of nonfatal injury in urban and rural counties in Colorado.6 Results from Colorado suggested no significant difference between rural and urban areas. A second study7 of Colorado, also using survey methods, reported conflicting results, with the AOR for injury being 1.3 (95% CI=1.01, 1.68) for rural compared to urban residents. A third study8 from Colorado, focusing on traumatic brain injury (TBI) and using combined mortality and hospital-discharge data, found more significant rural–urban differences, with reported average annual age-adjusted rates of TBI of 97.8 per 100,000 population for the most-urban group to 172.1 per 100,000 population for residents of remote rural counties.
Emerging research has begun to provide some national estimates of injury morbidity among rural populations. Using 8 years of National Health Interview Survey (NHIS) data to examine nonfatal injury among children and youth, Danseco and colleagues9 reported a higher incidence and cost per injured child among those living in nonmetropolitan areas. This analysis, however, was limited to individuals aged ≤21 years. The analyses were also constrained by the lack of cause-of-injury coding within the NHIS, preventing an examination of differing injury mechanisms. Other investigators, using a redesigned NHIS, have recently reported findings of injury rates 26% higher in rural counties than in large urban counties in those aged ≥18 years.10
These valuable new findings have begun to shed some light on the substantial morbidity associated with nonfatal injuries and the disparate risk among rural populations. They are, however, based on survey methods, and they include data on all medically attended injuries leading to contact with a healthcare professional, either in person for treatment or by telephone for advice.10, 11 Because survey data are limited by potential self-report bias,12, 13 nonresponse error,14 and reliance on subject recall,15 a recent study16 concluded that surveys do not necessarily provide a method for ascertaining the burden of injuries that is as accurate or efficient as hospital-based encounter data. Additionally, hospital-discharge data add another dimension to the understanding of the total injury burden by identifying the most serious nonfatal injuries.17
This study utilized the largest sample of hospitalization data in the U.S. to derive population-based national estimates of injury-hospitalization rates, comparing the causes, characteristics, and costs of injuries between rural and urban populations. It was hypothesized that rural populations would demonstrate an overall increased risk of injury hospitalization and that the mechanisms of injury would vary, based on geographic residence.
Section snippets
Data Source
Data were obtained from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) maintained by the Agency for Healthcare Research and Quality. HCUP data are derived from hospital-discharge summaries and abstracts, which are created by hospitals primarily for billing and payment purposes. Details of the HCUP process and methods have been previously described.18, 19
The NIS is a stratified probability sample of hospitals included in the HCUP and is designed to
Results
In 2004, there were an estimated 1.9 million (95% CI=1,800,250–1,997,801) injury-related hospitalizations in the U.S. Injury hospitalizations were equally distributed according to gender (Table 1). Approximately 51% of all patients hospitalized for injuries resided in large urban counties, whereas those residing in small urban, large rural, and small rural counties accounted for 28%, 12%, and 9% of cases, respectively (Table 1).
Nationwide in 2004, the estimated injury-hospitalization rate was
Discussion
The current findings confirm that those in rural counties experience a significantly increased risk for serious injury compared to those in large urban counties. Because these analyses are derived from hospital-discharge data, they represent injury cases serious enough to warrant hospitalization and, therefore, likely to incur substantial morbidity, lost productivity, or both. Residents of small rural counties had an injury-hospitalization rate that was 35% higher than the rate for those
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