Characteristics of Patients Hospitalized in Rural and Urban ICUs From 2010 to 2019.

OBJECTIVES: Rural hospitals are threatened by workforce shortages and financial strain. To optimize regional critical care delivery, it is essential to understand what types of patients receive intensive care in rural and urban hospitals. DESIGN: A retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries in the United States who were 65 years old or older hospitalized in an ICU between 2010 and 2019 were included. Rural and urban hospitals were classified according to the 2013 National Center For Health Statistics Urban-Rural Classification Scheme for Counties. Patient comorbidities, primary diagnoses, organ dysfunction, and procedures were measured using the International Classification of Diseases, 9th and 10th revisions diagnosis and procedure codes. Standardized differences were used to compare rural and urban patient admission characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 12,224,097 ICU admissions between 2010 and 2019, and 1,488,347 admissions (12.2%) were to rural hospitals. The most common diagnoses in rural hospitals were cardiac (30.3%), infectious (24.6%), and respiratory (10.9%). Patients in rural ICUs had similar organ dysfunction compared with urban hospitals (mean organ failures in rural ICUs 0.5, sd 0.8; mean organ failures in urban ICUs 0.6, sd 0.9, absolute standardized mean difference 0.096). Organ dysfunction among rural ICU admissions increased over time (0.4 mean organ failures in 2010 to 0.7 in 2019, p < 0.001). CONCLUSIONS: Rural hospitals care for an increasingly complex critically ill patient population with similar organ dysfunction as urban hospitals. There is a pressing need to develop policies at federal and regional healthcare system levels to support the continued provision of high-quality ICU care within rural hospitals.

Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care.

Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.

Availability of cancer care services and the organization of care delivery at critical access hospitals.

INTRODUCTION: Critical access hospitals (CAHs) provide an opportunity to meet the needs of individuals with cancer in rural areas. Two common innovative care delivery methods include the use of traveling oncologists and teleoncology. It is important to understand the availability and organization of cancer care services in CAHs due to the growing population with cancer and expected declines in oncology workforce in rural areas. METHODS: Stratified random sampling was used to generate a sample of 50 CAHs from each of the four U.S. Census Bureau-designated regions resulting in a total sample of 200 facilities. Analyses were conducted from 135 CAH respondents to understand the availability of cancer care services and organization of cancer care across CAHs. RESULTS: Almost all CAHs (95%) provided at least one cancer screening or diagnostic service. Forty-six percent of CAHs reported providing at least one component of cancer treatment (chemotherapy, radiation, or surgery) at their facility. CAHs that offered cancer treatment reported a wide range of health care staff involvement, including 34% of respondents reporting involvement of a local oncologist, 38% reporting involvement of a visiting oncologist, and 28% reporting involvement of a non-local oncologist using telemedicine. CONCLUSION: Growing disparities within rural areas emphasize the importance of ensuring access to timely screening and guideline-recommended treatment for cancer in rural communities. These data demonstrated that CAHs are addressing the growing need through a variety of approaches including the use of innovative models that utilize non-local providers and telemedicine to expand access to crucial services for rural residents with cancer.

Nurse Practitioner Autonomy and Complexity of Care in Rural Primary Care.

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.

Disparities in Geographic Access to Hospital Outpatient Pulmonary Rehabilitation Programs in the United States.

BACKGROUND: For individuals with COPD, pulmonary rehabilitation (PR) improves outcomes in terms of exercise capacity, severity of dyspnea, and health-related quality of life. However, many US patients with COPD do not use PR services. There has been limited research on geographic access to needed health-care services for individuals who live in rural communities in the United States. This study: (1) examines the geographic distribution of hospital-based outpatient PR programs in the US; and (2) compares the organizational characteristics of hospitals that offer PR programs and those that do not. METHODS: A multistep process supported the determination of whether a hospital provided PR services and included: program directory data from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) website and websites for AACVPR state affiliates and other COPD-relevant organizations; searches of hospital websites; e-mails with state contacts and other state organizations; and phone calls with hospital staff and state contacts. The study population included all Medicare-certified short-term acute care general medical and surgical hospitals. Data were collected and analyzed from January to November 2018. Medicare Provider of Service and American Hospital association data were used to compare the characteristics of hospitals with and without PR programs, using descriptive and bivariate statistics. RESULTS: 1,776 US counties do not have a hospital outpatient PR program located in a short-term acute care general medical or surgical hospital in the county, including 697 counties that do not have a hospital. The availability of a hospital outpatient PR program varies significantly by county type, hospital type and Census region. Hospitals located in a noncore county, designated as a Critical Access Hospital, or located in the South and the West were less likely to have an outpatient PR program. CONCLUSIONS: Significant geographic disparities exist in access to hospital outpatient PR. Potential strategies for addressing these disparities include: increasing clinician and patient awareness of the potential benefits of PR; offering staff training and incentives to supervise and provide PR services; improving Medicare reimbursement rates for PR services; replicating PR programs that have success serving rural areas; expanding cardiac rehabilitation programs to include PR; and assessing the use of telehealth technologies to provide PR in isolated areas.

Differences in Social Isolation and Its Relationship to Health by Rurality.

PURPOSE: Social isolation is an urgent threat to public health. Meanwhile, health outcomes across multiple measures are worse in rural areas, where distance to neighbors is often greater and opportunities for social interaction may be scarcer. Still, very little research examines rural-urban differences in social isolation. This study addresses that gap by examining differences in social isolation by rurality among US older adults. METHODS: Using Wave 2 of the National Social Life, Health, and Aging Project data (n = 2,439), we measured differences between urban and rural (micropolitan or noncore) residents across multiple dimensions of social isolation. We also conducted multivariable analysis to assess the associations between rurality, sociodemographic characteristics, and loneliness, overall and by rurality. Finally, we conducted multivariable analysis to assess the association between social isolation and self-rated health, adjusting for rurality. FINDINGS: Compared to urban residents, rural residents had more social relationships and micropolitan rural residents were more likely to be able to rely on family members (95.8% vs 91.3%, P < .05). Micropolitan rural residents reported lower rates of loneliness than urban residents after adjusting for sociodemographic and health characteristics (b = -0.32, P < .05), whereas noncore rural, non-Hispanic black residents had a greater likelihood of reporting loneliness (b = 4.33, P < .001). CONCLUSIONS: Overall, noncore and micropolitan rural residents reported less social isolation and more social relationships than urban residents. However, there were differences by race and ethnicity among rural residents in perceived loneliness. Policies and programs to address social isolation should be tailored by geography and should account for within-rural differences in risk factors.

Rural-Urban Differences in Medicare Quality Scores Persist After Adjusting for Sociodemographic and Environmental Characteristics.

PURPOSE: Quality scores are strongly influenced by sociodemographic characteristics and health behaviors, many of which lie outside of the clinician's control. As a result, there is vigorous debate about whether, and how, to risk-adjust quality measures. Yet, rurality has been largely missing from this debate, even though population and environmental characteristics are demonstrably different by rurality. We addressed this gap by examining the influence of county-level population sociodemographic, environmental, and health characteristics on 3 Medicare quality measures. METHODS: We used a cross-sectional analysis of 2016 County Health Rankings data to estimate differences in 3 Medicare quality scores (preventable hospitalizations, HbA1c monitoring, and mammography screening) by rurality. We then adjusted for county-level sociodemographic and environmental characteristics in multivariable regression models in order to see whether the association between rurality and quality was impacted. FINDINGS: Both micropolitan and noncore counties exhibited lower quality scores than metropolitan counties for all 3 measures. After adjustment, noncore counties still had poorer quality on all 3 measures, while micropolitan counties improved on 2 measures. Several county-level sociodemographic and environmental characteristics were associated with quality, although the direction of association depended on the quality measure. CONCLUSIONS: Differences in Medicare quality scores by rurality cannot be entirely explained by differences in population or environmental characteristics. Still, to the extent that clinicians are evaluated-and paid-based on measures that are influenced by both population sociodemographic characteristics and geographic location without adequate risk adjustment, the challenges of delivering care in rural areas will only be exacerbated.

Rural-urban differences in access to hospital obstetric and neonatal care: how far is the closest one?

OBJECTIVES: To quantify drive distances to hospital obstetric services and advanced neonatal care and to examine such disparities by residential rurality and insurance type. STUDY DESIGN: Data for all-payer maternal childbirth hospitalizations in 2002 (N = 661,240) and 2013 (N = 634,807) from nine geographically dispersed states were linked with the American Hospital Association annual surveys to identify maternal residence zip codes and the addresses of hospitals with obstetric services or advanced neonatal care. RESULTS: The uneven geographic distribution of hospital obstetric and advanced neonatal care increased between 2002 and 2013, varying by maternal residential rurality and insurance type. Women in rural non-core areas, with Medicaid or no insurance, and living in counties with lower income and educational attainment, had to travel farther to the nearest hospital with obstetric services or neonatal care than their counterparts. CONCLUSIONS: Women in communities that are already socioeconomically disadvantaged face increasing and substantial travel distances to access perinatal care.

Rural-Urban Differences in Medicare Quality Outcomes and the Impact of Risk Adjustment.

BACKGROUND: There has been considerable debate in recent years about whether, and how, to risk-adjust quality measures for sociodemographic characteristics. However, geographic location, especially rurality, has been largely absent from the discussion. OBJECTIVE: To examine differences by rurality in quality outcomes, and the impact of adjustment for individual and community-level sociodemographic characteristics on quality outcomes. DATA SOURCES: The 2012 Medicare Current Beneficiary Survey, Access to Care module, combined with the 2012 County Health Rankings. All data used were publicly available, secondary data. We merged the 2012 Medicare Current Beneficiary Survey data with the 2012 County Health Rankings data using county of residence. RESEARCH DESIGN: We compared 6 unadjusted quality of care measures for Medicare beneficiaries (satisfaction with care, blood pressure checked, cholesterol checked, flu shot receipt, change in health status, and all-cause annual readmission) by rurality (rural noncore, micropolitan, and metropolitan). We then ran nested multivariable logistic regression models to assess the impact of adjusting for community and individual-level sociodemographic characteristics to determine whether these mediate the rurality difference in quality of care. RESULTS: The relationship between rurality and change in health status was mediated by the inclusion of community-level characteristics; however, adjusting for community and individual-level characteristics caused differences by rurality to emerge in 2 of the measures: blood pressure checked and cholesterol checked. For all quality scores, model fit improved after adding community and individual characteristics. CONCLUSIONS: Quality is multifaceted and is impacted by individual and community-level socio-demographic characteristics, as well as by geographic location. Current debates about risk-adjustment procedures should take rurality into account.

Does the Medicare Part D Decision-Making Experience Differ by Rural/Urban Location?

PURPOSE: Although much has been written about Medicare Part D enrollment, much less is known about beneficiaries' personal experiences with choosing a Part D plan, especially among rural residents. This study sought to address this gap by examining geographic differences in Part D enrollees' perceptions of the plan decision-making process, including their confidence in their choice, their knowledge about the program, and their satisfaction with available information. METHODS: We used data from the 2012 Medicare Current Beneficiary Survey and included adults ages 65 and older who were enrolled in Part D at the time of the survey (n = 3,706). We used ordered logistic regression to model 4 outcomes based on beneficiaries' perceptions of the Part D decision-making and enrollment process, first accounting only for differences by rurality, then adjusting for sociodemographic, health, and coverage characteristics. FINDINGS: Overall, half of all beneficiaries were not very confident in their Part D knowledge. Rural beneficiaries had lower odds of being confident in the plan they chose and in being satisfied with the amount of information available to them during the decision-making process. After adjusting for all covariates, micropolitan residents continued to have lower odds of being confident in the plan that they chose. CONCLUSIONS: Policy-makers should pay particular attention to making information about Part D easily accessible for all beneficiaries and to addressing unique barriers that rural residents have in accessing information while making decisions, such as reduced Internet availability. Furthermore, confidence in the decision-making process may be improved by simplifying the Part D program.

Relationship between Hospital Policies for Labor Induction and Cesarean Delivery and Perinatal Care Quality among Rural U.S. Hospitals.

Many hospitals are adopting quality improvement strategies in obstetrics. This study characterized rural U.S. hospitals based on their hospital staffing and clinical management policies for labor induction and cesarean delivery, and assessed the relationship between policies and performance on maternity care quality. We surveyed all 306 rural maternity hospitals in nine states and used data from the Healthcare Cost and Utilization Project Statewide Inpatient Database hospital discharge database. We found staffing policies were more prevalent at lower-volume hospitals (92% vs. 86% for cesarean and 82% vs. 79%, both p < .01). Using multivariable logistic regression, we found hospitals with policies for cesarean delivery had up to 24% lower odds of low-risk cesarean (adjusted odds ratio = 0.76; 95% confidence interval=[0.67-0.86]) and non-indicated cesarean (0.78 [0.70-0.88]), with variability across birth volume. Clinical management and staffing policies are common, but not universal, among rural U.S. hospitals providing obstetric services and are generally positively associated with quality.

Why Are Obstetric Units in Rural Hospitals Closing Their Doors?

OBJECTIVES: To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods. DATA SOURCES: Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. STUDY DESIGN: Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. PRINCIPAL FINDINGS: Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. CONCLUSIONS: Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.

Rural-Urban Differences in Satisfaction with Medicare Part D: Implications for Policy.

Rural residents are more likely to be enrolled in traditional fee-for-service Part D Medicare prescription drug plans, and they face particular challenges in accessing pharmaceutical care. This study examines rural/urban differences in satisfaction with Medicare Part D coverage. Using data from the 2012 Medicare Current Beneficiary Survey (N = 3,107 beneficiaries aged 65 and older), we find that rural residents have significantly lower satisfaction with Part D coverage but that regional variation in satisfaction is largely explained by differences in health services use and type of Part D plan (stand-alone versus Medicare Advantage). We conclude by suggesting a multifaceted approach to improving satisfaction with Part D for rural residents.

Location of childbirth for rural women: implications for maternal levels of care.

BACKGROUND: A recent American Congress of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (MFM) consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVE: We sought to characterize rural women who give birth in nonlocal hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with nonlocal childbirth. STUDY DESIGN: This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in 9 states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a nonlocal hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require MFM consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS: The rate of nonlocal childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (adjusted odds ratio [AOR], 0.76; 95% confidence interval [CI], 0.68-0.86 for Medicaid vs private insurance) and by clinical conditions including multiple gestation (AOR, 1.82; 95% CI, 1.58-2.1), preterm deliveries (AOR, 2.41; 95% CI, 2.17-2.67), and conditions that may require MFM services or consultation (AOR, 1.28; 95% CI, 1.22-1.35). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a nonlocal hospital (AOR, 1.94; 95% CI, 1.64-2.31). CONCLUSION: Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in nonlocal hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at nonlocal hospitals, implying a potential access challenge for this population.

Minimum-distance requirements could harm high-performing critical-access hospitals and rural communities.

Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical-access hospitals, which entitles them to Medicare cost-based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). Several changes to eligibility for critical-access status have recently been proposed. Most of the changes focus on mandating that hospitals be located a certain minimum distance from the nearest hospital. Our study found that critical-access hospitals located within fifteen miles of another hospital generally are larger, provide better quality, and are financially stronger compared to critical-access hospitals located farther from another hospital. Returning to the PPS would have considerable negative impacts on critical-access hospitals that are located near another hospital. We conclude that establishing a minimum-distance requirement would generate modest cost savings for Medicare but would likely be disruptive to the communities that depend on these hospitals for their health care.

The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities.

PURPOSE: The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals. METHODS: We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between hospitals' annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. FINDINGS: Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships. CONCLUSIONS: Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.

Implementation of emergency department transfer communication measures in Minnesota critical access hospitals.

PURPOSE: Previously published findings based on field tests indicated that emergency department patient transfer communication measures are feasible and worthwhile to implement in rural hospitals. This study aims to expand those findings by focusing on the wide-scale implementation of these measures in the 79 Critical Access Hospitals (CAHs) in Minnesota from 2011 to 2013. METHODS: Information was obtained from interviews with key informants involved in implementing the emergency department patient transfer communication measures in Minnesota as part of required statewide quality reporting. The first set of interviews targeted state-level organizations regarding their experiences working with providers. A second set of interviews targeted quality and administrative staff from CAHs regarding their experiences implementing measures. FINDINGS: Implementing the measures in Minnesota CAHs proved to be successful in a number of respects, but informants also faced new challenges. Our recommendations, addressed to those seeking to successfully implement these measures in other states, take these challenges into account. CONCLUSIONS: Field-testing new quality measure implementations with volunteers may not be indicative of a full-scale implementation that requires facilities to participate. The implementation team's composition, communication efforts, prior relationships with facilities and providers, and experience with data collection and abstraction tools are critical factors in successfully implementing required reporting of quality measures on a wide scale.

The Use of Hospitalists by Small Rural Hospitals: Results of a National Survey.

Research on hospitalist programs has primarily focused on large, urban facilities. To fill a gap in the literature on hospitalist use in rural hospitals, the authors conducted a national survey of 402 rural hospitals with 100 or fewer beds that had reported having hospitalists. The survey examined reasons for using hospitalists, characteristics of hospitalist practices, and the impacts of hospitalist use in rural settings. Rural hospitals most commonly establish a hospitalist program to address medical staff requests, call coverage, and quality issues. Respondents report positive impacts of hospitalist programs on quality of care and primary care physician recruitment and retention, but mixed financial impacts. Assessments of the impact of hospitalists in rural hospitals need to take into account the variety of practitioner specialties functioning as hospitalists, the amount of time they spend as hospitalists, and the multiple roles they play in the rural hospital and community.

Birth volume and the quality of obstetric care in rural hospitals.

BACKGROUND: Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and hospitals in rural areas. METHODS: The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in rural hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration). RESULTS: The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume rural hospitals compared with low-volume hospitals after controlling for maternal demographic and clinical factors. In low-volume hospitals, odds of labor induction without medical indication were higher than in medium-volume hospitals, but not significantly different from medium-high or high-volume hospitals. Odds of episiotomy were greater in medium-high or high-volume hospitals than in low-volume hospitals. The likelihood of perineal laceration did not differ significantly by birth volume. CONCLUSIONS: Obstetric quality and safety outcomes vary significantly across rural hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.