Rural Hospital Sustainability as a Work-System Outcome: Geographic Distance, Capacity Pressure, and Bed Configuration in Nevada Frontier Hospitals

Rural and frontier hospitals are geographically distributed healthcare work systems operating under long tertiary-care distances, sparse demand, and constrained bed capacity, yet evidence linking these structural conditions to operating and financial outcomes remains limited. Using a biennial Nevada hospital panel (2009–2025; 11 hospitals, 93 observations), we estimated generalized estimating equations with hospital-level clustering, year fixed effects, and robust standard errors. Greater distance to tertiary care was associated with higher operating pressure and higher net margin. Higher service-area population per bed was associated with higher net margin only. Higher acute care bed share was associated with lower operating pressure and lower net margin, whereas higher swing bed share was associated with higher operating pressure and marginally higher net margin. Findings were directionally stable across working-correlation structures. Frontier hospital sustainability should be evaluated as a macroergonomic work-system outcome using operating strain alongside net margin.