Background: The influence of rural hospital location on abdominal aortic aneurysm (AAA) outcomes is unknown. We undertook a study to determine the difference in the risk of ruptured AAA presentation and outcomes after ruptured AAA between rural and urban areas. Study design: Patients in the Nationwide Inpatient Sample from 2001 to 2007, with intact AAA repair or ruptured AAA, were included. Patients transferred from another hospital, with unrecorded hospital ZIP code, or age less than 50 years were excluded. Health system variables were obtained from the Area Resource File. Vascular surgeon census was determined from the Society for Vascular Surgery online registry. Multivariable logistic regression was used to analyze outcomes in patients with AAA, adjusting for patient, hospital, and health system variables. Results: Rural hospital location was associated with higher risk of ruptured AAA presentation (odds ratio [OR] 2.46, 95% CI 1.90 to 3.19) and transfer to another hospital without ruptured AAA repair (9.3% vs 1.4%, p < 0.001). The adjusted risk of death was similar for patients with ruptured AAA admitted to rural and urban hospitals (OR 0.96, 95% CI 0.73 to 1.27). Hospital elective AAA repair volume less than 15 was a risk factor for death after ruptured AAA. Conclusions: Rural hospitals face a disproportionate burden of ruptured AAA and are more likely to transfer patients with ruptured AAA without performing repair, compared with urban hospitals. Solutions to rural disparity in ruptured AAA outcomes should focus on improving rural patients' access to vascular surgeons for elective and emergent AAA repair.
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