Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach.

<bold>Objective: </bold>To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival.<bold>Design: </bold>Observational cohort study.<bold>Setting: </bold>Emergency departments of a rural Midwestern state.<bold>Patients: </bold>All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data.<bold>Interventions: </bold>Patients bypassing local rural hospitals to seek care in larger hospitals.<bold>Measurements and Main Results: </bold>A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality.<bold>Conclusions: </bold>Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality. [ABSTRACT FROM AUTHOR]