People with epilepsy living in rural America are more likely to die in the hospital, arrive with severe seizures, or miss important diagnostic tests, highlighting persistent health care disparities that can be driven not only by geography but also by access to care.
Study: Rural-urban disparities in epilepsy outcomes in the United States. Image credit: NMK-Studio/Shutterstock.com
recent Neurology This study investigated whether rural and urban environments are associated with differences in clinical outcomes in epilepsy.
Epilepsy treatment and geographic barriers
Epilepsy is a chronic neurological disorder defined by repeated unprovoked seizures due to abnormal neural activity. Seizures vary in type and severity and require individualized and often long-term management.
Epilepsy affects an estimated 3 million adults in the United States. Despite advances in diagnosis and treatment, significant disparities in care still exist. Living in a rural area reduces access to important resources such as electroencephalogram (EEG) diagnostics and epilepsy specialty centers. However, the direct impact of rural areas on epilepsy-related health outcomes is not fully understood.
Increasing rurality is associated with increased mortality and decreased life expectancy. Effective management of epilepsy requires specialized neurological care, timely diagnosis, and consistent access to antiepileptic drugs. Delay in treatment of status epilepticus may further worsen adverse outcomes. People living in rural areas face significant barriers in accessing neurologists, epileptologists, diagnostic services, and surgical interventions.
Despite recognition of these disparities, several limitations prevent a comprehensive understanding of the impact of rurality on epilepsy outcomes. Previous studies are often limited by limited geographic coverage, heterogeneous patient populations, or insufficient longitudinal data. As a result, the relationship between rural residence and epilepsy-related mortality remains poorly defined, highlighting the need for rigorous and large-scale research.
Assessing the impact of rurality on epilepsy treatment and outcomes
The current retrospective cohort study used the National Inpatient Sample (NIS), a large U.S. hospitalization database (2016-2021) within the Healthcare Cost and Utilization Project (HCUP). NIS permitted this analysis without requiring ethical approval or informed consent, in accordance with reporting guidelines, as it does not include direct patient identifying information.
This study included patients with an initial diagnosis of epilepsy and recurrent seizures. Elective admissions and patients younger than 18 years were excluded. After applying sample weights, the data represented approximately 35 million annual hospitalizations nationwide.
The rurality of patients based on county of residence was the primary exposure and was categorized using the National Center for Health Statistics (NCHS) urban-rural classification scheme. The plan assigns counties to one of six categories: central metropolitan area, peripheral metropolitan area, medium metropolitan area, small metropolitan area, small metropolitan area, and non-core metropolitan area (most rural).
Covariates included age, gender, race/ethnicity, smoking status, hospital size, teaching status, management/ownership, census region, and income quartile by zip code. The primary outcome was inpatient mortality, and the secondary outcomes assessed were status epilepticus, prolonged hospitalization (>7 days), non-routine discharge, and use of EEG.
Rural and urban differences in epilepsy hospitalizations
The current study analyzed 841,445 people hospitalized with epilepsy across the United States. Patients in rural counties tended to be older, with a median age of 58 years, compared to patients in urban counties (median age, 55 years). Almost half of all patients were women, with a slightly higher proportion in rural areas.
Racial and ethnic composition also varied by location, with rural counties having a higher proportion of white patients, whereas urban counties had a higher proportion of black and Hispanic patients. Insurance coverage and income levels reflected similar trends. Rural patients were more likely to have Medicare and live in poor areas, while Medicaid and private insurance were less common. Most patients were admitted to urban teaching hospitals. However, in the South and Midwest, rural patients were often hospitalized.
Patients in rural areas were found to have a significantly higher risk of in-hospital death from epilepsy compared to patients in urban areas. This increased risk persisted among critically ill patients and those treated at urban teaching hospitals. Of note, the difference in mortality disappeared for patients with private insurance. Rural area was associated with increased risk of death in post-stroke epilepsy, but not in tumor-associated epilepsy.
Patients in rural areas were also more likely to present to the hospital with status epilepticus, a severe seizure, but this difference was not observed among patients with private insurance. Similarly, patients in rural areas were more likely to have a longer hospital stay, but this difference disappeared for patients with private insurance. The authors noted that these findings suggest that modifiable structural factors, such as insurance coverage and access to health care resources, may contribute significantly to rural-urban disparities beyond geographic location alone.
Rural patients were less likely than urban patients to be discharged to rehabilitation or other health care facilities. The researchers suggested that this pattern may reflect reduced availability of rehabilitation and post-acute care services in rural areas rather than improved health status at discharge. Remarkably, electroencephalography, an important diagnostic tool, was also less commonly used in rural patients, even in critically ill patients or those with private insurance. However, this difference was not observed among patients treated at urban teaching hospitals, suggesting that access to advanced hospital resources may partially alleviate diagnostic inequalities.
conclusion
We found that patients with epilepsy in rural areas had higher in-hospital mortality, less access to key diagnostic tools such as EEG, and were less likely to be discharged to rehabilitation or additional care facilities compared to patients in urban areas. This study highlights the persistent health disparities faced by rural communities and highlights the need to develop targeted strategies and policies to improve epilepsy care, resources, and outcomes in these underserved areas.
The authors cautioned that the study was observational and could not establish cause and effect. They also noted that the database lacked detailed information on attack severity, travel time, and patients who may not have been able to receive hospital treatment, factors that may influence the magnitude of the observed disparities.
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