The purpose was to examine factors associated with transfers and readmissions among Medicare patients initially presenting at rural facilities. Data from the 2013 Medicare Claims file were used to identify fee-for-service patients with a hospital admission (n = 298,783) or an emergency department visit immediately followed by a hospital admission (117,416), for a total of 416,199. Transfers were defined as hospitalization at a different facility within 1 day of a discharge from a prior inpatient or emergency department encounter. For analysis of 30-day readmission, beneficiaries who died before discharge were excluded, for a total of 416,198 observations. Overall, 4.8% of index encounters resulted in a transfer. The transfer rate was higher for patients living in rural areas (9.8%, P < 0.0001), with the highest among residents of small rural areas (10.1%). The transfer rate was higher among those initial encounters in an urban facility (5.3%) than those admitted to a rural facility (2.7%, P < 0.0001). In adjusted analysis, beneficiaries with index encounters in rural or critical access facilities had higher odds of being transferred than those seen at urban facilities. The 30-day readmission rate was lower among patients presenting initially at rural versus urban hospitals (12.1% versus 19.2%). Although transfer status slightly increased the odds of rehospitalization in adjusted analysis, initial presentation at a rural facility was associated with reduced odds. The relatively high rate of transfers from rural hospitals to urban institutions suggests that systems must ensure that their patients' follow-up care meets their needs.
