D93-10 Rural-Urban Divide in Critical Care Recovery: One-year Outcomes After Acute Respiratory Failure

Abstract Rationale Rural patients with critical illness often experience higher mortality, limited access to specialty services, and reduced post-acute care resources. For survivors of acute respiratory failure, these disparities may persist beyond hospitalization into long-term recovery. However, national data describing one-year outcomes among rural versus urban survivors remain limited. Methods We conducted a retrospective cohort study of fee-for-service Medicare beneficiaries aged ≥65 years hospitalized in an intensive care unit (ICU) with acute respiratory failure between 2018 and 2023. Rural or urban residence was defined using Rural-Urban Commuting Area codes. The primary outcome was one-year all-cause mortality. The secondary outcome was days alive and outside the hospital at one year. Multivariable models adjusted for age, sex, comorbidity burden, severity of illness by organ failures, receipt of mechanical ventilation, tracheostomy, and year of admission. Flexible parametric survival model with time-varying effects evaluated rural-urban differences in one-year mortality, and a two-part model estimated days alive and outside a hospital. Results We identified 1,140,099 rural and 4,229,313 urban critically ill Medicare beneficiaries with acute respiratory failure. Rural patients were slightly younger (mean 73.8 vs 74.9 years) and more frequently White (88% vs 77%), while urban beneficiaries had higher proportions of Black (13.6%) and Hispanic (3.4%) patients. Comorbidities and severity were comparable (mean comorbidities 4.6 vs 4.8; mean organ failures 1.3 vs 1.4). Use of invasive ventilation was similar (16.3% vs 16.7%), as was median hospital length of stay (13 vs 14 days). When evaluating one-year mortality, urban residence was associated with a lower hazard of death at approximately 150 days compared with rural residence (HR 0.94, 95% CI 0.94-0.94). However, mortality difference attenuated over time and converged over the year. When evaluating days alive and outside a hospital at one year, there was no significant difference between urban or rural residence in the odds of any hospitalization or death within one year (OR 0.99, 95% CI 0.97-1.00, p = 0.13), and urban beneficiaries had significantly more days alive and outside a hospital than rural beneficiaries (adjusted difference +2.83 days; 95% CI 2.45-3.21; p 0.001). Conclusion Among older adults with critical illness due to acute respiratory failure, urban residence was associated with a modest early survival advantage and slightly greater post-discharge recovery, as reflected by hospital-free days. These findings identify intervenable targets to address persistent rural-urban disparities and highlight the need to enhance rural ICU care, post-ICU care coordination, access to rehabilitation, and community health infrastructure in rural communities. This abstract is funded by: None