People with epilepsy living in rural America were more likely to die in hospital, arrive with severe seizures, and miss key diagnostic testing, highlighting persistent healthcare gaps that may be driven more by access to care than geography alone.
Study: Rural-Urban Disparities in Epilepsy Outcomes in the United States. Image credit: NMK-Studio/Shutterstock.com
A recent Neurology study investigated whether rural and urban settings are associated with differences in clinical outcomes in epilepsy.
Epilepsy care and geographical barriers
Epilepsy is a chronic neurological disorder defined by recurrent, unprovoked seizures due to abnormal neuronal activity. It presents as a spectrum of seizure types and severities, requiring individualized and often long-term management.
An estimated 3 million adults in the United States are affected by epilepsy. Despite advances in diagnosis and therapy, considerable disparities in care persist. Living in rural areas is associated with reduced access to critical resources, such as electroencephalogram (EEG) diagnostics and epilepsy specialty centers. However, the direct impact of rurality on epilepsy-related health outcomes has not been thoroughly defined.
Heightened rurality is linked to increased mortality rates and shortened life expectancy. Effective epilepsy management necessitates specialized neurologic care, timely diagnosis, and consistent access to antiseizure medications. Delays in the treatment of status epilepticus can further exacerbate adverse outcomes. Individuals residing in rural areas face pronounced obstacles accessing neurologists, epilepsy specialists, diagnostic services, and surgical interventions.
Despite recognition of these disparities, several limitations hinder a comprehensive understanding of rurality’s effect on epilepsy outcomes. Prior studies are often restricted by limited geographic coverage, heterogeneous patient populations, or insufficient longitudinal data. Consequently, the relationship between rural residency and epilepsy-related mortality remains incompletely defined, highlighting the need for rigorous, large-scale investigations.
Assessing the impact of rurality on epilepsy care and outcomes
The current retrospective cohort study used the National Inpatient Sample (NIS), a large U.S. hospital admission database (2016–2021) within the Healthcare Cost and Utilization Project (HCUP). The NIS, which contains no direct patient identifiers, allowed this analysis without the need for ethical approval or informed consent, in accordance with reporting guidelines.
The study included patients with a primary diagnosis of epilepsy and recurrent seizures. Elective admissions and patients under 18 years of age were excluded. After applying sample weights, the data represented approximately 35 million annual admissions nationwide.
Patient rurality, based on county of residence, was the main exposure and was classified using the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme. This scheme assigns counties to one of six categories, including large central metropolitan, large fringe metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore (most rural).
Covariates included age, sex, race/ethnicity, smoking status, hospital size, teaching status, control/ownership, census region, and income quartile by ZIP code. The primary outcome was inpatient mortality, while the secondary outcomes assessed were status epilepticus, prolonged stay (>7 days), nonroutine discharge, and EEG use.
Rural-urban differences in epilepsy admissions
The current study analyzed 841,445 epilepsy admissions across the United States. Patients from rural counties tended to be older, with a median age of 58 years, compared to those from urban counties (median age 55 years). Nearly half of all patients were female, with a slightly higher proportion in rural areas.
The racial and ethnic makeup also differed by location: rural counties had a higher percentage of White patients, while urban counties had greater proportions of Black and Hispanic patients. Insurance coverage and income levels reflected similar trends. Rural patients were more likely to have Medicare and to live in poorer areas, while Medicaid and private insurance were less common. Most patients were admitted to urban teaching hospitals. Rural patients, however, were more often admitted in the South and Midwest.
Patients from rural areas were found to experience a significantly higher risk of in-hospital death from epilepsy compared to their urban counterparts. This increased risk persisted even for severe cases and among those treated at urban teaching hospitals. Notably, the mortality gap disappeared for patients with private insurance. Rurality was also associated with higher mortality risk in poststroke epilepsy, but not in tumor-associated epilepsy.
Rural patients were also more likely to arrive at the hospital in status epilepticus, a severe form of seizure, though this disparity was not observed among those with private insurance. Similarly, rural patients had a higher likelihood of prolonged hospital stays, but this difference disappeared for those with private insurance. The authors noted that these findings suggest that modifiable structural factors, including insurance coverage and access to healthcare resources, may contribute substantially to rural-urban disparities rather than geographic location alone.
Patients from rural areas were less likely to be discharged to rehabilitation or another healthcare facility compared to urban patients. The researchers suggested this pattern may reflect reduced availability of rehabilitation and post-acute care services in rural communities rather than better health at discharge. Notably, EEG, a key diagnostic tool, was also used less often for rural patients, even in severe cases and among those with private insurance. However, this disparity was not observed among patients treated at urban teaching hospitals, suggesting that access to advanced hospital resources may partially reduce diagnostic inequities.
Conclusions
Rural patients with epilepsy were found to be more likely to experience higher in-hospital mortality, less access to key diagnostic tools like EEG, and fewer discharges to rehabilitation or additional care facilities compared to urban patients. The current study highlighted persistent healthcare disparities faced by rural communities and highlighted the need to develop targeted strategies and policies to improve epilepsy care, resources, and outcomes in these underserved areas.
The authors cautioned that the study was observational and could not establish causation. They also noted that the database lacked detailed information on seizure severity, travel times, and patients who may have been unable to access hospital care, factors that could influence the magnitude of the observed disparities.
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