U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

NCHS Data Brief ■ No. 147 ■ April 2014

Rural and Urban Hospitals’ Role in Providing 

Inpatient Care, 2010

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

Key findings 

Data from the National 

Hospital Discharge 

Survey, 2010

• In 2010, 12% of the 35 

million U.S. hospitalizations 

were in rural hospitals. 

• A higher percentage of 

inpatients in rural hospitals 

were aged 65 and over (51%) 

compared with inpatients in 

urban hospitals (37%).

• The average number of 

diagnoses for rural and urban 

inpatients was similar, as was 

the average length of stay. 

• Sixty-four percent of rural 

hospital inpatients, compared 

with 38% of urban hospital 

inpatients, had no procedures 

performed while in the hospital.

• Following their 

hospitalization, a higher 

percentage of rural inpatients 

(7%) than urban inpatients 

(3%) were transferred to 

other short-term hospitals, 

and a higher percentage of 

rural (14%) than urban (11%) 

inpatients were discharged to 

long-term care institutions.

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

(1). Disparities in health care access between rural and urban areas have been 

documented (2–4). Rural hospitals not only provide inpatient care, but also 

emergency department, outpatient department, long-term care, and health care 

coordination (4,5). Rural hospitals may have difficulty remaining financially 

viable (5,6). Medicare payment policies help keep the low-volume hospitals 

solvent so that vulnerable populations have access to health care without 

traveling to urban areas (4–7). This data brief provides national data on 

patients served, and inpatient care provided, by rural hospitals in the health 

care system in 2010.

Keywords: National Hospital Discharge Survey • inpatient hospital utilization 

What share of inpatient hospital care was delivered in rural 

compared with urban hospitals? 

• In 2010, 17% of the U.S. population lived in rural areas (Figure 1). 

• Twelve percent of all hospitalizations (35 million) were in rural hospitals.

Figure 1. Population and inpatient care in rural and urban areas: United States, 2010

NOTE: Urban areas are those defined by the Office of Management and Budget as metropolitan, and rural (non-metropolitan) 

areas are defined as those outside of metropolitan areas. 

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

0 20 40 60 80 100

Urban areas Rural areas

Procedures

Days of care

Discharges

Population 17%

12%

11%

6%
NCHS Data Brief ■ No. 147 ■ April 2014

■  2  ■

• Eleven percent of the total hospital days of care (168 million) were in rural hospitals.

• Six percent of the nonsurgical and surgical inpatient procedures (51 million) performed 

nationally were in rural hospitals.

How did rural hospital inpatients differ from urban hospital inpatients

in 2010?

• One-half of the rural hospital inpatients were aged 65 and over, compared with 37% of 

urban hospital patients (Table).

• A larger percentage of rural hospital inpatients (52%) had Medicare as their principal 

expected source of payment than did urban hospital inpatients (41%).

• The average number of diagnoses did not differ significantly between rural hospital 

inpatients (7.9) and urban hospital inpatients (7.4), nor did the average length of stay for 

rural hospital inpatients (4.5 days) differ significantly from that of urban hospital inpatients 

(4.8 days).

Table. Characteristics of rural and urban hospital inpatients, 2010

Rural hospital inpatients Urban hospital inpatients

Total number 4.1 million 31.0 million

Age 65 and over1 (percent) 51 37

Medicare1

 (percent) 52 41

Medicaid (percent) 15 18

Average number of diagnoses 7.9 7.4

Average length of stay 4.5 days 4.8 days

1

Difference is statistically significant at the 0.05 level.

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

How did patients’ first-listed diagnoses differ in rural and urban hospitals? 

• Childbirth, cancer, and poisoning are examples of first-listed diagnoses that were relatively 

more frequent among urban hospital, compared with rural hospital, inpatients (Figure 2).

• Some first-listed diagnoses, including dehydration, bronchitis, and pneumonia, were 

relatively more frequent among rural hospital inpatients compared with urban hospital 

inpatients. No significant differences were observed in the relative frequency of rural and 

urban hospital inpatients with first-listed diagnoses such as septicemia, congestive heart 

failure, and heart attack.
NCHS Data Brief ■ No. 147 ■ April 2014

■  3  ■

Were rural and urban inpatients equally likely to have nonsurgical and 

surgical procedures while in the hospital?

• Sixty-four percent of inpatients at rural hospitals compared with 38% of inpatients at urban 

hospitals had no surgical or nonsurgical procedures performed during their hospital stay 

(Figure 3).

• Urban hospital inpatients were more than twice as likely to have three or more procedures 

performed than rural hospital inpatients.

Figure 2. Comparison of selected first-listed diagnoses in rural and urban hospitals: United States, 2010

1

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

NOTE: CHF is Congestive heart failure.

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

Urban hospital

Percent of hospitalizations

Rural hospital

0246 8 10 12

Heart attack

CHF

Septicemia

Pneumonia

Bronchitis

Dehydration

Poisoning

Cancer

Childbirth

Relatively more frequent1 in urban hospitals.

Relatively more frequent1

 in rural hospitals.

Similar relative frequency in rural and urban hospitals
NCHS Data Brief ■ No. 147 ■ April 2014

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Figure 3. Inpatient procedures in rural and urban hospitals, 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.

Urban hospital patients

Number of procedures

Rural hospital patients

0

10

20

30

40

50

60

70

0 1 2 3 4 or more

Percent

64

38

19

28

10

17

5

10

3

8

Were rural and urban hospital patients discharged to different locations?

• A majority of hospital inpatients, both rural (65%) and urban (78%), were discharged home 

(Figure 4).

• Rural hospital inpatients (7%) were more likely than urban hospital inpatients (3%) to be 

transferred to another short-term hospital following their hospital stay. 

• A higher percentage of rural (14%) than urban (11%) hospital inpatients were discharged to 

long-term care institutions.

• The percentage of inpatients who died in the hospital was small—2% for both rural and 

urban hospital inpatients. 

Figure 4. Discharge status following rural and urban hospitalization, 2010

1

Difference is statistically significant at the 0.05 level.

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

0

20

40

60

80

100

Home

Short-term hospital1

Long-term care institution1

Deceased

All other

Rural hospitals Urban hospitals

65

7

14

2 13

78

3

11

6
NCHS Data Brief ■ No. 147 ■ April 2014

■ 5  ■

Summary

Similarities were found between rural and urban hospital patients in the average number of 

diagnoses, average lengths of stay, proportions of inpatients with Medicaid, and percentage of 

those who died while in the hospital. Among differences, a higher percentage of rural hospital 

inpatients were over age 65 and on Medicare compared with urban hospital inpatients, and rural 

hospital inpatients were more likely than their urban counterparts to be discharged to other shortterm hospitals and to long-term care institutions. Some diagnoses were relatively more common 

in either rural or urban hospitals, while other diagnoses were equally common in both rural and 

urban settings.

Although 17% of the U.S. population lived in rural areas in 2010 (1), only 12% of total 

hospitalizations, 11% of the days of care, and 6% of the inpatient procedures were provided in 

rural hospitals. The data in this report show that patients hospitalized in urban hospitals were 

more likely to have procedures performed during their hospitalization, and to have a greater 

number of procedures performed, than those hospitalized in rural hospitals. This could be due to 

the shortage of specialty physicians in rural areas, the lack of other staff skilled in surgery, or the 

absence of costly equipment needed for many surgical and nonsurgical procedures in rural 

hospitals (6,8). Because of economies of scale, rural hospitals may forego offering many 

procedures and instead choose to focus on patients needing basic inpatient surgical care (9), and 

on patients needing medical, rather than surgical, treatment (10).

Definitions

First-listed diagnoses: The principal diagnosis considered to be the main cause or reason for the 

hospitalization. Diagnoses are coded according to the International Classification of Diseases, 9th 

Revision, Clinical Modification (ICD–9–CM) coding system (11). ICD–9–CM codes for the firstlisted diagnoses noted in this report (Figure 2), in order, are: 

Childbirth (females with deliveries)—ICD–9–CM code V27

Cancer (malignant neoplasms)—ICD–9–CM codes 140–209.36, 209.70–209.75, 209.79, 

230–234

Poisoning—ICD–9–CM codes 960–989

Dehydration (volume depletion)—ICD–9–CM code 276.5

Bronchitis (acute and chronic)—ICD–9–CM codes 466, 491

Pneumonia—ICD–9–CM codes 480–486

Septicemia—ICD–9–CM code 038 

Congestive heart failure—ICD–9–CM codes 428.0, 428.2–428.4

Heart attack (acute myocardial infarction)—ICD–9–CM code 410 

These categories were selected primarily because of their frequency in both rural and urban 

hospitals and the considerable interest in them. Figure 2 shows examples of first-listed diagnoses 
NCHS Data Brief ■ No. 147 ■ April 2014

■  6  ■

relatively more frequent in rural hospitals, those relatively more frequent in urban hospitals, and 

those with similar relative frequencies in both rural and urban hospitals. 

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

insurance based upon the principal expected source of payment noted in their medical record. 

Urban and rural hospitals: Urban or rural designation is based on the county in which hospitals 

were located. 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 updated in 2005 (12,13). 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 

include open countryside, rural towns (with population less than 2,500 people), and areas with 

populations of 2,500–49,999 that are not part of larger labor-market areas (metropolitan areas). 

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

Agriculture Department’s Economic Research Service (14), metropolitan status is used to 

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

conditions in “rural” America. While the categories within urban and rural 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 National Center for Health Statistics analysts has confirmed that 

these categories are meaningful for analyzing health data (15). 

Data source and methods

Data are from the National Hospital Discharge Survey (NHDS), a national probability sample 

survey of discharges from nonfederal, noninstitutional short-stay hospitals or general hospitals in 

the United States, conducted annually from 1965 through 2010 by the Centers for Disease Control 

and Prevention’s (CDC) National Center for Health Statistics (NCHS), Division of Health Care 

Statistics. Survey data on hospital discharges were obtained from the hospitals’ administrative 

data. Note that if a person is admitted to the hospital multiple times during the survey year, that 

person is 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 (16). 

Differences between rural and urban hospital inpatients were evaluated using unrounded 

numbers with two-tailed t-tests using a p value of 0.05 as the level of significance. Calculation 

of percentages, average length of stay, and average number of diagnoses were computed using 

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

figures in the text, figures, and tables.

Differences in first-listed diagnoses between rural and urban hospital inpatients reported in

Figure 2 were calculated based on the relative frequency of these diagnoses. The relative 

frequency was obtained by dividing the number of rural or urban inpatients with each selected 

first-listed diagnosis by the total number of either rural or urban inpatients. This gave the 
NCHS Data Brief ■ No. 147 ■ April 2014

■ 7  ■

proportion (percentage) of inpatients with each of these diagnoses in rural and in urban hospitals. 

The t test was used to determine whether the relative frequency of each of these diagnoses was 

significantly different in rural and urban hospitals.

Data analyses were performed using 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. Lipsky MS, Glasser M. Critical access hospitals and the challenges to quality care. Editorial.

JAMA 306(1):96–7. July 6, 2011.

3. Gamm L, Castillo G, Pittman S. Access to quality health services in rural areas—Primary

care: A literature review. Rural Health People 2010: A companion document to Healthy People 

2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, 

School of Rural Public Health, Southwest Rural Health Research Center. 2003.

4. 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.

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

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

6. Center for Health Reform & Modernization, UnitedHealth. Modernizing rural health care:

Coverage, quality and innovation. Working paper 6. July 2011. 

7. Rosko MD, Mutter RL. Inefficiency differences between critical access hospitals and

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

8. MEDPAC. Report to Congress: Medicare in rural America. Washington, DC: 2001.

9. Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care

at critical access hospitals in the United States. JAMA Surg 148(7):589–96. 2013.

10. Holmes GM, Karim SA, Pink GH. Trends in the provision of surgery by rural hospitals.

North Carolina Rural Health Research & Policy Analysis Center, Cecil G. Sheps Center for 

Health Services Research, UNC–Chapel Hill. Findings brief. 2011. 

11. Centers for Medicare & Medicaid Services. International classification of diseases, ninth

revision, clinical modification, 6th ed. DHHS Pub No. (PHS) 06–1260. 2006. Available from: 

http://www.cdc.gov/nchs/icd/icd9cm.htm.
NCHS Data Brief ■ No. 147 ■ April 2014

12. 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.

13. 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.

14. 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/. 

15. 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.

16. 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 M. Rural and urban 

hospitals’ role in providing inpatient care, 

2010. NCHS data brief, no 147. Hyattsville, 

MD: National Center for Health Statistics. 

2014.

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the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

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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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