Margaret B. Greenwood-Ericksen MD, MScDepartment of Emergency MedicineUniversity of New MexicoAlbuquerque, NM 87109

Growth in Rural Emergency Department Visits Outpace Urban Increases Interview with:

Margaret B. Greenwood-Ericksen MD, MScDepartment of Emergency MedicineUniversity of New MexicoAlbuquerque, NM 87109

Dr. Greenwood-Ericksen

Margaret B. Greenwood-Ericksen MD, MSc
Department of Emergency Medicine
University of New Mexico
Albuquerque, NM 87109 What is the background for this study?  

Response: I’m an emergency physician, so I see first-hand how emergency department use patterns provide a lens into the status of health care delivery in the communities they serve. Troubling declines in the health of rural Americans coupled with rising rural hospital closures – with little access to alternative sites of care like urgent care – all led me to hypothesize that rural populations may be engaging with the health care system differently than their urban counterparts.

Understanding the health care use of individuals in rural areas may yield insights into addressing rural health disparities. Further, this information may help healthcare systems and policymakers to make data-driven decisions informing new models of healthcare delivery for rural communities. What are the main findings? 

Response: Overall, estimated rural emergency department visit increased between 2005 to 2016 from 16.7 million to 28.4 million as compared to urban visit estimate increase from 98.6 million to 117.2 million. From these emergency department visit estimates, we calculated annual ED visit rates for both rural and urban populations using the US Census Bureau population estimates. We found a 50% increase in rural ED visit rates, outpacing urban ED visit rates which experienced a small increase. By 2016, almost one-fifth of all ED visits occurred in the rural setting. For rural visit rates, increases were driven by Medicaid beneficiaries, patients without insurance, those aged 18 to 64 years old, and non-Hispanic whites. Finally, a larger proportion of rural EDs are now categorized as safety-net status. What should readers take away from your report?

Response: Patterns of use of emergency departments by populations are important indicators of their healthcare needs. With rural ED use rates climbing, this suggests that emergency departments may play a distinct role within the healthcare systems of rural communities. The traditional perspective of ED visits as only necessary for life-threatening illness is far from reality – particularly for rural communities where few alternatives for acute, unscheduled care needs exist. Rather than maintaining a singular focus on driving down ED use in rural communities, health systems and policymakers should consider how rural emergency departments can be supported and transformed to best serve their populations. For example, some rural facilities now co-locate primary care in their emergency departments along with care coordination and behavioral health. While such models of care may drive an increased in ED utilization – with the appropriate resources in rural emergency departments, the total cost of acute care expenditures may decrease for rural communities. What recommendations do you have for future research as a result of this work? 

Response: It is known that new models of care are needed in rural communities. It is my hope that this research lays the foundation for studies investigating innovative models of rural healthcare delivery that explore the role of the emergency department in serving rural populations.

Further, this study is hypothesis generating, in that we cannot identify any local or state trends – which are critical in understanding regional nuances. State- and region-specific studies are needed that evaluate healthcare use and cost data. Combining this data with local stakeholder input may yield sustainable and locally-tailored models of rural healthcare. Is there anything else you would like to add? 

Response: With a rise in uninsured and Medicaid patient visits, rural emergency departments are increasingly serving as safety-net hospitals, which may further destabilize their budgets. To stabilize the health of rural hospitals, improved Medicaid reimbursement and innovative payment and delivery models that integrate emergency departments into local health care delivery systems may prove successful.

No disclosures. 


Greenwood-Ericksen MB, Kocher K. Trends in Emergency Department Use by Rural and Urban Populations in the United States. JAMA Netw Open. 2019;2(4):e191919. doi:10.1001/jamanetworkopen.2019.1919

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Last Updated on April 12, 2019 by Marie Benz MD FAAD