Rural Residence Not a Risk Factor for In-Hospital Mortality Among Veterans With COPD

Living far from a hospital did not increase risk of in-hospital mortality, according to a recent study among veteran populations with chronic obstructive pulmonary disease (COPD).

For veterans with chronic obstructive pulmonary disease (COPD), living in a rural area was not found to be an independent risk factor for in-hospital mortality, according to a recent retrospective cohort study. However, it was associated with increased 30-day mortality compared with patients living in urban areas.

The investigators said these results suggest potential gaps in care exist among discharged patients, such as access to primary care or pulmonary rehabilitation during recovery, and that they potentially are to blame for the disparities seen between living in rural and urban areas.

Among the most common diseases in the United States, COPD is the only one where the mortality gap is growing between rural and urban communities. Veteran communities also experience higher incidences of smoking and COPD.

According to the CDC, the prevalence of COPD is higher for patients living in rural areas compared with urban areas (8% vs 5%). Additionally, compared with urban Medicare patients, rural patients experienced 27% more hospitalizations and 71% more deaths in 2015. An overall association between rural residence and in-hospital mortality remains unconfirmed.

The study, published in International Journal of Chronic Obstructive Pulmonary Disease, included retrospective data on hospitalizations for COPD exacerbations and discharges from 124 acute care Veterans Health Administration (VHA) hospitals from October 1, 2011, to September 30, 2017, collected from an integrated electronic medical system for VHA facilities.

Of the 64,914 COPD hospitalizations analyzed, 67.1% (43,549) of patients lived in urban areas, 28.8% (18,673) lived in rural areas, and 4.1% (2692) lived in isolated rural areas. More than 95% of patients hospitalized were men (P < .001), and a majority were White (P < .001).

In-hospital mortality occurred in 4.9% of urban patients, 5.5% of rural patients, and 5.2% of isolated rural patients (P = .008). In addition, although rural veterans had higher in-hospital mortality compared with urban veterans, the association went away when adjusting for demographics, socio-economic statuses, hospital resources, and admitted location. The odds ratio (OR) for in-hospital mortality among rural patients was 0.87 (95% CI, 0.67-1.12; P = .28).

However, rural residence was associated with an increased 30-day mortality (OR, 1.13; 95% CI, 1.04-1.22; P = .002), a measure that was also higher among patients living in these areas compared with urban and isolated rural patients (9.9% vs 8.3% vs 9.2%, respectively; P < .001).

“Although a primary care physician is usually available within a 10-mile distance in rural areas and almost all individuals had access to one within 50 miles, there are concerns that rural and remote health care practitioners may lack the knowledge, experience, and confidence to manage COPD patients,” said the investigators.

The results demonstrated that the strongest predictor of increased in-hospital mortality was transfer from another acute care hospital (OR, 14.97; 95% CI, 9.80-17.16; P < .001) or an unknown/other facility (OR, 33.05; 95% CI, 22.66-48.21; P < .001). Transfer from another acute care facility was also associated with increased 30-day mortality.

“Interhospital transfers increase mortality because they may result in delays in receiving appropriate care, such as antibiotics and initiating noninvasive mechanical ventilation. These delays are associated with increased COPD-related hospital mortality,” wrote the investigators.

Future studies should examine how interhospital transfers may influence mortality rates, they noted.

The use of a single health care system and a predominately male population were identified as study limitations, possibly indicating these findings may not be generalizable outside of the VHA. Data on smoking exposure or COPD severity also were not available.


Fortis S, O’Shea AMJ, Beck BF, Comellas A, Sarrazin MV, 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. doi:10.2147/COPD.S281162