For people with epilepsy, living in counties that are more rural was associated with poorer health outcomes than for people living in more urban counties, according to a study published June 3, 2026, in Neurology® , the medical journal of the American Academy of Neurology. People living in the most rural counties hospitalized for epilepsy had nearly twice the odds of dying in the hospital than those living in the most urban counties. The study does not prove that living in rural areas causes worse health; it only shows an association.
"Living in rural areas has been linked to poor access to neurologic care in previous research," said study author Edward R. Bader, MBChB, of the Albert Einstein College of Medicine in the Bronx, New York. "Epilepsy is a complex condition that requires specialized care with consistent access to antiseizure medications, and delays in care can be critical. Our study showed living in more rural areas was linked to worse epilepsy health outcomes."
For the study, researchers reviewed a health database of hospital admissions in the United States to identify people with epilepsy who had seizures. A total of 841,445 adult epilepsy hospital admissions were included. Participants had an average age of 56. Some were insured with Medicare, Medicaid or private insurance and some were uninsured.
Participants were assigned to six groups based on the urban or rural status of their counties, ranging from urban inner city and suburban counties to counties with cities under 50,000 residents, and the most rural counties lacking any city with at least 10,000 people.
Researchers then determined which participants: died at the hospital; arrived at the hospital in status epilepticus, a seizure emergency with seizures lasting over five minutes or occurring repeatedly; had longer hospital stays; received an electroencephalogram (EEG), a test to identify seizure type; or were discharged to a rehabilitation or skilled nursing facility.
Among people living in the most rural counties, 1.6% died in the hospital compared to only 1.0% of people who lived in the most urban counties.
After adjusting for factors such as age, other health conditions and hospital size, researchers found people in the most rural counties had 93% higher odds of dying in the hospital compared to people in the most urban counties. They also found they had 32% higher odds of arriving at the hospital in status epilepticus and 29% higher odds of a prolonged hospital stay.
Researchers also found people in the most rural counties were 12% less likely to receive an EEG and 10% less likely to be discharged to a rehabilitation or skilled nursing facility.
When looking only at people with private insurance, with 16% of most rural and 17% of most urban groups having such insurance, researchers found no associations between rural living and dying in the hospital and prolonged hospital stays. Also, Bader noted, the association between rural living and arriving with status epilepticus almost entirely disappeared.
"The reduction in disparities among people with private insurance suggests that there may be other factors, not just where someone lives, that could be contributing to these differences," said Bader. "Our study highlights the need for additional research and public health efforts aimed at improving access to epilepsy care for people living in rural areas, which might include the expansion of telehealth services."
A limitation of the study was that researchers were unable to adjust for factors such as seizure frequency or account for variables such as the availability of emergency medical services.
Bader noted that the study was conducted mainly before the widespread expansion of telehealth services during the COVID-19 pandemic and it is possible that telehealth care may help mitigate some of the rural-urban disparities.
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