Emergency departments: The gatekeepers of admissions in Pennsylvania's rural hospitals

Study objective: To analyze trends in admission rates and the proportion of admissions via the ED at rural hospitals in Pennsylvania and to identify factors that may impact admission rates. Methods: We use retrospective, longitudinal data on rural acute care hospitals in Pennsylvania for 2000–19 to investigate temporal patterns in admission rates and the proportion of admissions via the ED. Regression analysis is then used to identify factors that may impact admission rates. Results: In general admission rates, which averaged 14.5%, experienced a gradual decline (Change: −16.9%; from 15.7% to 13%) between 2000 and 2019. The proportion of hospital admissions via the ED, which averaged 64.9%, increased steadily (21%; from 57% to 69%). Critical access hospitals experienced a sharp decline in admissions via the ED (−49.1%) and admission rates (−55.3%). The fixed-effects regression model revealed several hospital- and ED-level characteristics were significantly associated with admission rate. Conclusions: Emergency departments are the gatekeepers of admissions at rural acute care hospitals in Pennsylvania. Many hospitals in rural Pennsylvania, including CAHs, are admitting most of their patients through the ED, concomitant with a significant decline in admissions and admission rates. This highlights the need to strengthen primary care practices serving rural Pennsylvania as well as the need to improve rural emergency and trauma systems. In the short to medium term, policy makers should explore innovative ways to fund smaller hospitals, especially CAHs, to develop level IV trauma center capabilities.