Factors influencing rural residents' utilization of urban hospitals.

OBJECTIVE To examine, using nationally representative data, which patient, hospital, and county characteristics influence rural residents' urban hospitalization. METHODS Rural residents hospitalized in urban hospitals (crossovers) are compared with those hospitalized in rural hospitals (noncrossovers). National Hospital Discharge Survey data were merged with Area Resource File and Centers for Medicare & Medicaid Services data to study rural inpatients' characteristics; hospital descriptors; and county or state socioeconomic and health service variables. Multivariate logistic regression analysis identified covariates of the likelihood of being a crossover. FINDINGS About one-third of the rural resident hospitalizations in 2003 were in urban hospitals. Other factors constant, those requiring greater resources had higher odds of crossing over, as did younger inpatients, those transferred from other hospitals, receiving surgery, and with mental diagnoses or congenital anomalies. Males, emergency admissions, and intervertebral disk disorder inpatients had lower odds of crossing over compared with those who were not in these categories. Crossover patients' hospitals had higher Medicare case mix indices than hospitals used by noncrossovers. Rural inpatients in government hospitals, rather than proprietary or non-profit hospitals, had greater odds of crossing over, as did rural patients from counties with lower population density, fewer hospital beds, more hospitals, more commuters, and lower per capita income compared with those in other categories. CONCLUSIONS Rural hospitals continue to be an important source of inpatient care, but rural residents travel to urban hospitals in some specific instances.