NCHS Data Brief ■ No. 159 ■ July 2014

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Rural Residents Who Are Hospitalized in Rural and Urban 

Hospitals: United States, 2010

Margaret Jean Hall, Ph.D., and Maria F. Owings, Ph.D.

Key findings

Data from the National 

Hospital Discharge 

Survey, 2010

• Sixty percent of the

6.1 million rural residents who 

were hospitalized in 2010 went 

to rural hospitals; the remaining 

40% went to urban hospitals.

• Rural residents who 

remained in rural areas for 

their hospitalization were 

more likely to be older and on 

Medicare compared with those 

who went to urban areas.

• Almost three-quarters of 

rural residents who traveled to 

urban areas received surgical or 

nonsurgical procedures during 

their hospitalization (74%), 

compared with only 38% 

of rural residents who were 

hospitalized in rural hospitals.

• More than 80% of rural 

residents who were discharged 

from urban hospitals had 

routine discharges (81%), 

generally to their homes, 

compared with 63% of rural 

residents discharged from rural 

hospitals.

In 2010, 17% of the U.S. population lived in rural (nonmetropolitan) areas 

(1). Many rural areas are medically underserved due to physician (especially 

specialist) shortages (2–4). Rural hospitals often are small, with a low volume 

of services, and have difficulty remaining financially viable under the regular 

hospital prospective payment system (3). Special Medicare hospital payment 

categories have been established so that rural residents have access to hospital 

care without traveling to urban areas (2,5). The share of rural residents’ 

hospitalizations that take place in urban (metropolitan) compared with rural 

hospitals has been of interest for a number of years (3,6,7). Those who go to 

urban hospitals have been described as “bypassing” rural hospitals. This data 

brief compares characteristics of rural residents who stay in rural areas with 

those who travel to urban areas for their inpatient care.

Keywords: National Hospital Discharge Survey • inpatient hospital utilization 

procedures • bypass

Hospitalized rural residents were more likely to receive care 

in a rural rather than an urban hospital.

Rural hospitals

3.7 million

(60%)

Urban hospitals

2.5 million

(40%)

6.1 million hospitalizations

Figure 1. Percent distribution of hospitalized rural residents, by hospital location: United States, 2010

NOTE: Estimates may not add to totals due to rounding.

SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2010.
NCHS Data Brief ■ No. 159 ■ July 2014

■  2  ■

• In 2010, 60% (3.7 million) of rural residents who were hospitalized were in rural hospitals, 

while the other 40% (2.5 million) were in urban hospitals (Figure 1).

The age distribution of rural residents hospitalized in rural hospitals was 

different from the age distribution of those hospitalized in urban hospitals.

• About one-half of rural residents hospitalized in rural hospitals were aged 65 and over 

(51%), compared with 37% of those hospitalized in urban hospitals (Figure 2).

• No significant difference was observed in the percentage of hospitalized rural residents 

under age 45 who were in rural hospitals compared with urban hospitals.

• Twenty-four percent of rural residents hospitalized in rural hospitals were aged 45–64 

compared with 32% of those hospitalized in urban hospitals.

Age (years)

4 6

In rural hospitals In urban hospitals 

21

25 24

32

51

37

Percent

Under 15 15–44 145–64 165 and over

0

10

20

30

40

50

60

Figure 2. Age distribution of hospitalized rural residents, by hospital location: United States, 2010

1

Difference between rural and urban hospitals is statistically significant at the 0.05 level.

SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2010.
NCHS Data Brief ■ No. 159 ■ July 2014

■  3  ■

The expected payment source for hospitalized rural residents differed 

depending on whether they were hospitalized in rural or urban hospitals.

• Reflecting the larger percentage of hospitalized rural residents aged 65 and over in rural 

hospitals (Figure 2), more than one-half of these patients had Medicare as their principal 

expected source of payment (53%), compared with 44% of those who were hospitalized in 

urban hospitals (Figure 3).

• Whether they were in rural or urban hospitals, similar proportions of hospitalized rural 

residents had Medicaid or private insurance as their principal expected payment source.

Percent

In urban hospitals

In rural hospitals

0 10 20 30 40 50 60

Medicare1

Medicaid

Private insurance

All other1

12

8

28

23

44

53

16

15

1Difference between rural and urban hospitals is statistically significant at the 0.05 level.

NOTE: Estimates may not add to 100% due to rounding.

SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2010.

Figure 3. Percent distribution of expected source of payment for hospitalized rural residents, by hospital location: 

United States, 2010
NCHS Data Brief ■ No. 159 ■ July 2014

■  4  ■

Rural residents hospitalized in urban hospitals were more likely to have at 

least one surgical or nonsurgical procedure than those hospitalized in rural 

hospitals.

• Seventy-four percent of hospitalized rural residents who were in urban hospitals received a 

surgical or nonsurgical procedure during their hospitalization, compared with only 38% of 

those hospitalized in rural hospitals (Figure 4).

• Rural residents hospitalized in urban hospitals were more than three times as likely to have 

three or more procedures as rural residents hospitalized in rural hospitals. 

0

10

20

30

40

50

60

70

In rural hospitals In urban hospitals

0 1 2 3 4 or more

Percent

Number of procedures

62

26

18

24

9

17

5

11

5

22

Figure 4. Number of procedures received by hospitalized rural residents, by hospital location: United States, 2010

NOTE: For each number-of-procedures category, the difference is statistically significant at the 0.05 level. 

SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2010.
NCHS Data Brief ■ No. 159 ■ July 2014

■  5  ■

The discharge status of hospitalized rural residents differed depending on 

whether they were hospitalized in a rural or an urban hospital.

• Rural residents hospitalized in rural hospitals were less likely to be discharged home (63%) 

compared with those hospitalized in urban hospitals (81%) (Figure 5).

• Rural residents hospitalized in rural hospitals were twice as likely (7%) as those hospitalized 

in urban hospitals (3%) to be discharged to another short-stay hospital.

• A significantly higher proportion of rural residents who were hospitalized in rural (14%) 

rather than urban (8%) hospitals were discharged to a long-term care institution.

• Regardless of where rural residents were hospitalized, 2% of them died during their 

hospitalization.

0

20

40

60

80

100

Home1

Short-stay

hospital1

Long-term care

institution1

Dead

All other

In rural hospitals In urban hospitals

14

14

7

63

81

8

6

Percent

2 3

2

Figure 5. Percent distribution of discharge status of hospitalized rural residents, by hospital location: United States, 2010

1

Difference between rural and urban hospitals is statistically significant at the 0.05 level.

NOTE: Estimates may not add to 100% due to rounding.

SOURCE: CDC/NCHS, National Hospital Discharge Survey, 2010.
NCHS Data Brief ■ No. 159 ■ July 2014

■  6  ■

Summary

A majority of the 6.1 million hospitalizations of rural residents (60%) occurred in rural hospitals 

in 2010. Rural residents hospitalized in rural hospitals were more likely to be aged 65 and over 

and on Medicare. Prior research has shown that patients in this age group were less likely to 

leave rural areas for their hospitalization due, in part, to the barriers imposed by traveling to 

urban areas, and to their preference for remaining closer to home (7–9). The larger percentage 

of patients in the age group 65 and over could help explain why rural residents hospitalized in 

rural hospitals were more likely to be discharged to long-term care institutions following their 

hospitalization. 

Rural residents hospitalized in urban hospitals were more likely to have surgical or nonsurgical 

procedures during their hospitalization. Due to economies of scale, many rural hospitals do not 

offer sophisticated diagnostic tests or specialized treatment, including surgery, and consequently, 

patients in the areas served by these hospitals are often referred to urban hospitals (8,9). The lack 

of these services in rural areas could explain why rural residents hospitalized in rural hospitals 

were more likely to be discharged to another short-stay hospital following their hospitalization. 

Any changes in the proportion of rural residents seeking care in rural and urban hospitals, and the 

factors influencing hospital choice, merit continued study. 

Definitions

Urban and rural residents and hospitals: Using ZIP codes from National Hospital Discharge 

Survey internal files, Federal Information Processing Standards, or FIPS, county codes were 

determined for patients and hospitals. Counties were classified by the Office of Management and 

Budget (OMB) according to their metropolitan status using standards originally applied to U.S. 

Census 2000 data and then updated in 2005 (10,11). Counties identified by OMB as metropolitan 

were considered to be urban, and all other counties (nonmetropolitan) were considered to be 

rural. Metropolitan counties include large central cities, the fringes of large cities (suburbs), 

medium cities, and small cities. Nonmetropolitan counties include micropolitan statistical areas 

and noncore areas, and some combination of open countryside, rural towns (with populations less 

than 2,500), and areas with populations of 2,500–49,999 that are not part of larger labor-market 

areas (metropolitan areas) (12). 

A number of other ways of defining rural and urban areas are used, but according to the U.S. 

Department of Agriculture Economic Research Service (12), the above method is used to 

determine eligibility for a range of public programs and by researchers and others who analyze 

conditions in rural America. While the urban and rural categories reported here are very 

broad using this definition, analysis of more refined categories would not be supported by the 

sample size in this national survey. Research by analysts of the Centers for Disease Control 

and Prevention’s (CDC) National Center for Health Statistics (NCHS) has confirmed that these 

categories are meaningful for analyzing health data (13). 

Insurance coverage: Patients were considered covered by Medicare, Medicaid, or private 

insurance based on the principal expected source of payment noted in their medical record. 
NCHS Data Brief ■ No. 159 ■ July 2014

■  7  ■

Data source and methods

Data are from the National Hospital Discharge Survey (NHDS), conducted annually from 1965 

through 2010 by CDC/NCHS, Division of Health Care Statistics. NHDS is a national probability 

sample survey of discharges from nonfederal, noninstitutional short-stay hospitals and general 

hospitals in the United States. Survey data on hospital discharges were obtained from hospitals’ 

administrative data. Note that persons having multiple hospitalizations during the survey year 

may be counted more than once in NHDS. 

Because of the complex multistage design of NHDS, the survey data must be inflated or weighted 

to produce national estimates. Estimates of inpatient care presented in this report exclude 

newborns. More details about the design of NHDS have been published elsewhere (14). 

Differences among subgroups were evaluated using unrounded numbers with two-tailed t tests, 

using a p value of 0.05 as the level of significance. Percentages were computed using unrounded 

numbers, so the results may differ from what would be obtained using the rounded numbers in the 

text and figures.

Data analyses were performed using the statistical packages SAS version 9.3 (SAS Institute, 

Cary, N.C.), and SUDAAN version 11.0 (RTI International, Research Triangle Park, N.C.). 

About the authors

Margaret Jean Hall and Maria F. Owings are with CDC/NCHS, Division of Health Care Statistics.

References

1. Health Resources and Services Administration, Department of Health and Human Services. 

Area Resource File (ARF). 2012.

2. Moscovice I, Stensland J. Rural hospitals: Trends, challenges, and a future research and policy 

analysis agenda. J Rural Health 18(Suppl):197–210. 2002.

3. Escarce JJ, Kapur K. Do patients bypass rural hospitals? Determinants of inpatient hospital 

choice in rural California. J Health Care Poor Underserved 20(3):625–44. 2009.

4. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health 

care delivery system. Ch 5: Serving rural Medicare beneficiaries. Washington, DC. June 2012. 

Available from: http://www.medpac.gov/chapters/Jun12_Ch05.pdf.

5. Rosko M, Mutter RL. Inefficiency differences between critical access hospitals and 

prospectively paid rural hospitals. J Health Polit Policy Law 35(1):95–126. 2010.

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Implications for patient retention. J Rural Health 23(1):17–24. 2007.

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hospitals. National health statistics reports; no 31. Hyattsville, MD: National Center for Health 

Statistics. 2010. Available from: http://www.cdc.gov/nchs/data/nhsr/nhsr031.pdf.
NCHS Data Brief ■ No. 159 ■ July 2014

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8. Tai Wan-Tzu C, Porell FW, Adams EK. Hospital choice of rural 

Medicare beneficiaries: Patient, hospital attributes, and the patient–physician 

relationship. Health Serv Res 39(6 Pt 1):1903–22. 2004.

9. Radcliff TA, Brasure M, Moscovice IS, Stensland JT. Understanding 

rural hospital bypass behavior. J Rural Health 19(3):252–9. 2003.

10. Office of Management and Budget. Standards for defining metropolitan 

and micropolitan statistical areas; notice. Fed Regist 65(249): 82227–38. 

December 27, 2000. Available from: http://www.whitehouse.gov/sites/

default/files/omb/fedreg/metroareas122700.pdf.

11. Office of Management and Budget. Update of statistical area definitions 

and guidance on their uses. OMB bulletin no 06–01. Washington, DC. 2005. 

Available from: http://www.whitehouse.gov/sites/default/files/omb/assets/

omb/bulletins/fy2006/b06-01_rev_2.pdf.

12. Economic Research Service, U.S. Department of Agriculture. Rural 

classifications: Overview. Updated May 10, 2013. Available from: http://

www.ers.usda.gov/topics/rural-economy-population/rural-classifications.

13. Ingram DD, Franco SJ. NCHS urban–rural classification scheme for 

counties. National Center for Health Statistics. Vital Health Stat 2(154). 

2012. Available from: http://www.cdc.gov/nchs/data/series/sr_02/

sr02_154.pdf. 

14. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge 

Survey: 2007 summary. National health statistics reports; no 29. Hyattsville, 

MD: National Center for Health Statistics. 2010. Available from: http://www.

cdc.gov/nchs/data/nhsr/nhsr029.pdf.

Suggested citation

Hall MJ, Owings MF. Rural residents who 

are hospitalized in rural and urban hospitals: 

United States, 2010. NCHS data brief, no 

159. Hyattsville, MD: National Center for 

Health Statistics. 2014.

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source, however, is appreciated.

National Center for Health 

Statistics

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Jennifer H. Madans, Ph.D., Associate 

Director for Science

Division of Health Care Statistics

Clarice Brown, M.S., Director

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