Research Letter
February 12, 2025
Trends in Travel Time to Obtain Surgical Care for Rural Patients
Cody Lendon Mullens, Reagan A. Collins, Nicholas Kunnath, et al
JAMA. 2025;333(16):1453-1455. doi:10.1001/jama.2025.0447
Timely access to health care services is increasingly threatened for rural residents, with 151 rural hospitals closing between 2010 and 2024.1,2 Compared with nonprocedural services, provision of surgical care faces unique ongoing challenges related to the workforce, resources, and centralization of procedures.3 Although cross-sectional evaluations of travel disparities in obtaining surgical care for rural vs urban patients have been described,4 trends over time and in the recent context of emerging resource constraints in rural settings are unknown. This study quantified changes in travel times for rural patients undergoing surgical care.
Methods
We obtained 100% beneficiary-level data from the Medicare Provider Analysis and Review file, including fee-for-service and Medicare Advantage, restricted to patients aged 65 to 99 years who underwent 1 of 16 low-risk or high-risk procedures (Tables 1 and 2) between 2010 and 2020 (eTable in Supplement 1). Procedures were selected based on data availability, but represent frequently performed operations in the US. Rurality was measured at the zip code level using Rural-Urban Commuting Area codes (nonrural, 1-3; rural, 4-10).
We estimated road travel times for each admission using zip code centroids of the patient’s home and the hospital where they underwent an operation, and calculated travel times using Google Maps (eMethods in Supplement 1); the approach was unchanged throughout the study. The primary outcome was change in the percentage of rural patient admissions with travel time of more than 60 minutes between 2010 and 2020, tested using linear regression. We also assessed changes in median travel times among rural and nonrural beneficiaries using Kruskal-Wallis tests and bootstrap simulation (eMethods in Supplement 1). A 2-sided α less than .05 defined statistical significance. Analyses were performed using Stata version 18.0 (StataCorp) and SAS version 9.4 (SAS Institute). This study was exempt from review and informed consent according to the University of Michigan Institutional Review Board due to the use of retrospective deidentified data. This study adhered to the STROBE reporting guidelines.
Results
Of 12 396 649 beneficiary admissions (2 678 251 rural) across 16 procedures, the percentage of rural patients traveling more than 60 minutes for surgical care significantly increased between 2010 and 2020 for 12 of the 16 included procedures; the remaining 4 procedures were all high risk and had nonsignificant changes in the percentage of patients who traveled to undergo the operation (Table 1). Across all procedures, the percentage of rural beneficiaries traveling more than 60 minutes to obtain surgical care increased from 36.8% to 44.1% (annual change, 0.70% [95% CI, 0.68%-0.72%]; P < .001). For low-risk procedures, the percentage increased from 32.9% to 37.8%, with an annual change of 0.54% (95% CI, 0.52%-0.56%; P < .001). For high-risk procedures, the percentage increased from 53.9% to 59.2%, with an annual change of 0.64% (95% CI, 0.60%-0.69%; P < .001).
Between 2010 and 2020, the median (IQR) travel time among rural patients increased from 43 (20-72) to 48 (25-79) minutes for low-risk procedures and 64 (43-99) to 69 (47-107) minutes for high-risk procedures (both P < .001) (Table 2). The median (IQR) travel time for nonrural patients increased from 20 (13-31) to 22 (14-34) minutes for low-risk procedures and 23 (15-38) to 26 (16-42) minutes for high-risk procedures (both P < .001). The differences in travel times between rural and nonrural admissions for low-risk procedures were 23 minutes in 2010 and 26 minutes in 2020 (P < .001); for high-risk procedures, the differences were 41 minutes in 2010 and 43 minutes in 2020 (P < .001).
Discussion
The percentage of rural patients traveling more than 60 minutes to obtain surgical care significantly increased between 2010 and 2020 for both low- and high-risk operations. Additionally, increases in median travel time for rural patients outpaced changes for nonrural patients. These findings suggest a persistent and growing disparity in travel for rural patients undergoing surgical procedures. Contributing factors likely include ongoing rural hospital closures, workforce shortages, and rural patients bypassing local facilities to obtain care elsewhere.5,6 Solutions include preserving access locally for some procedures (eg, low-risk operations) and ensuring support for travel as well as transport and transfer for procedures that are increasingly centralized (eg, high-risk operations).
Study limitations include that an administrative claims database of patients 65 years and older was used. Additionally, the study period was from 2010 through 2020 based on data availability. However, this sample was geographically generalizable across the US, included fee-for-service and Medicare Advantage beneficiaries, encompassed a broad range of procedures, and assessed the entire 2010 decade, when many changes in the health care and payer environments occurred. The study was limited to 16 procedures and travel times were estimates due to the limited granularity of Medicare claims data.
