Rural residence among veterans may be associated with increased 30-day mortality following hospitalization for chronic obstructive pulmonary disease (COPD), suggesting possible gaps in the care after discharge of the rural veteran population. Researchers conducted a retrospective cohort study examining COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the United States. Results of the analysis were published in the International Journal of Chronic Obstructive Pulmonary Disease

The investigators sought to explore the link between rural residency and in-hospital mortality among veterans who were hospitalized for exacerbations of COPD. They also examined whether comorbidities, demographics, transfer from another hospital, hospital-level characteristics, and travel time to the closest VHA hospital or primary care provider (PCP) could explain the disparities in mortality between rural and urban patients.

The primary study outcome was in-hospital mortality, which was defined using the date of death listed in the VHA Vital Status File and the occurrence of this date between the admission and discharge date inclusive. The secondary study outcome was 30-day mortality, which was defined as the occurrence of death within 30 days from hospital admission. Patients’ residence was classified via use of Rural Urban Commuting Area Codes as urban, rural, or isolated rural. Patient hospitalizations were stratified into quartiles based on travel time from the patient’s residence to the nearest VHA PCP and hospital.

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Among a total of 64,914 hospitalizations for COPD that were evaluated, 43,549 (67.1%), 18,673 (28.8%), and 2692 (4.1%) occurred in urban veterans, rural veterans, and isolated rural veterans, respectively. Study results showed that among the participants, in-hospital mortality was 4.9% in urban veterans, 5.5% in rural veterans, and 5.2% in isolated rural veterans (P =.008). Additionally, rates of 30-day mortality were 8.3% among urban veterans, 9.9% among rural veterans, and 9.2% among isolated rural veterans (P <.001). No significant association was reported between travel time to a PCP and VHA hospital and in-hospital morality among rural and isolated rural veterans. However, travel time was associated with increased in-hospital mortality among urban patients who were part of quartile 1 (shortest distance).

Per multivariable analysis, no increased morality was reported among urban veterans compared with isolated rural veterans. Further, although rural residence was not significantly associated with in-hospital mortality (odds ratio [OR], 0.87; 95% CI, 0.67-1.12; P =.28), it was significantly associated with increased 30-day mortality (OR, 1.13; 95% CI, 1.04-1.22; P =.002).

When outpatient admission source was used as the reference point, transfer from another acute care hospital (OR, 12.97; 95% CI, 9.80-17.16; P <.001) or from an unknown/other facility (OR, 33.05; 95% CI, 22.66-48.21; P <.001) were the strongest predictors of in-hospital mortality, whereas the presence of obstructive sleep apnea (OR, 0.51; 95% CI, 0.39-0.67; P <.001) was inversely related to in-hospital mortality.

The researchers concluded that additional research on the topic is warranted to explore the exact mechanism through which interhospital transfers affects mortality rates.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Fortis S, O’Shea AMJ, Beck BF, Comellas A, Vaughan Sarrazin M, Kaboli PJ. Association between rural residence and in-hospital and 30-day mortality among veterans hospitalized with COPD exacerbations. Int J Chron Obstruct Pulmon Dis. 2021;16:191-202.