Rural-Urban Disparities in Epilepsy Outcomes in the United States
Epilepsy is a common neurologic condition characterized by recurrent seizures, and its impact extends beyond the brain. It can affect safety, driving, work, school, mental health, and quality of life. While effective treatments exist, outcomes do not depend only on the type of epilepsy or the medicines used. Where a person lives can also shape how quickly they receive care, whether they are seen by a neurologist, and whether they can access specialized testing and epilepsy centers.
This study examined whether rural residence is associated with worse hospital-based epilepsy outcomes in the United States. The findings suggest that patients from the most rural counties face substantially higher risks of death during hospitalization, status epilepticus at presentation, and longer hospital stays, even after accounting for many demographic, socioeconomic, and hospital factors. The results also point to an important role for structural barriers in access to care.
Why Rurality Matters in Epilepsy Care
People living in rural areas often face fewer nearby specialists, longer travel distances, fewer large hospitals, and limited access to advanced diagnostic tools such as electroencephalography, or EEG. EEG is a test that records brain electrical activity and is commonly used to help diagnose seizures, classify epilepsy, and guide treatment. Delays in EEG or specialist evaluation can make seizure control harder and can contribute to preventable complications.
In addition, rural patients may experience barriers such as transportation challenges, fewer local neurologists, limited insurance coverage, lower income, and reduced availability of epilepsy monitoring units. These factors can delay diagnosis and treatment adjustments, increasing the chance that seizures worsen or become prolonged. Status epilepticus, one of the outcomes studied here, is a medical emergency in which seizures last too long or occur repeatedly without recovery in between. It can be life-threatening and requires urgent treatment.
How the Study Was Done
The investigators performed a retrospective cohort study using the National Inpatient Sample from 2016 through 2021. This is a large, nationally representative U.S. database that includes hospital admissions across many regions. The study included patients with a primary diagnosis of epilepsy and recurrent seizures.
The main exposure was rurality, measured using the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. This system groups counties by how urban or rural they are. The study then compared outcomes across these groups, with particular attention to the most rural counties versus the most urban counties.
The researchers used logistic regression models to examine whether rurality was associated with several outcomes: in-hospital mortality, presenting in status epilepticus, prolonged length of stay, nonroutine discharge, and receipt of EEG. They adjusted for a wide range of factors, including age, sex, socioeconomic characteristics, hospital characteristics, and Elixhauser comorbidities, which is a standard set of medical conditions used to account for overall illness burden. They also performed subanalyses among patients with status epilepticus, patients with private insurance, and patients admitted to urban teaching hospitals.
Key Findings
The study included 841,445 epilepsy admissions. The median age was 56 years, and 47.2% of patients were female. After adjustment for other factors, the most rural patients had significantly worse outcomes than the most urban patients.
Compared with patients from the most urban counties, patients from the most rural counties had higher odds of in-hospital death, with an odds ratio of 1.93. In practical terms, this means their odds of dying during hospitalization were nearly twice as high. They also had higher odds of presenting in status epilepticus, with an odds ratio of 1.32, and higher odds of a prolonged hospital stay, with an odds ratio of 1.29.
At the same time, the most rural patients had lower odds of receiving EEG, with an odds ratio of 0.88, and lower odds of nonroutine discharge, with an odds ratio of 0.90. A nonroutine discharge generally means the patient did not go directly home and instead required transfer to another facility, rehabilitation, or other arranged care. Lower rates of EEG may reflect access limitations, differences in hospital resources, or differences in care pathways.
What Happened in the Subanalyses
An important part of the study was the subgroup analysis. When the researchers looked only at patients with private insurance, the associations between rurality and mortality, status epilepticus, and prolonged length of stay were no longer seen. This is a notable finding because it suggests that geography by itself may not fully explain the disparities. Instead, modifiable structural barriers such as insurance coverage, access to specialists, and hospital resources may play a major role.
The subanalyses help refine the interpretation of the main results. If rural residence alone were the sole driver, one might expect the disparities to persist even among privately insured patients. The attenuation of the association in this group suggests that improving access and reducing system-level barriers could meaningfully improve outcomes for rural patients with epilepsy.
What These Results Mean Clinically
These findings matter because epilepsy is often treatable, and many complications are preventable with timely, appropriate care. Faster diagnosis, access to EEG, timely medication adjustments, and referral to epilepsy specialists can all improve outcomes. For patients at risk of status epilepticus or those with uncontrolled seizures, quick escalation of care can be lifesaving.
The study also highlights that hospitals and health systems should pay attention to the care pathway for rural patients. This may include tele-neurology services, faster referral networks, regional epilepsy programs, transport support, and protocols to ensure that EEG is available when clinically indicated. Public health efforts may also focus on education, early recognition of seizure emergencies, and improved access to first-line epilepsy care in underserved communities.
Limitations to Keep in Mind
As with all observational studies, this research cannot prove direct cause and effect. Some differences may remain due to residual confounding, meaning factors not fully captured in the database may still influence the results. For example, the dataset may not include detailed information about seizure type, epilepsy duration, medication adherence, outpatient follow-up, socioeconomic context at the individual level, or exact timing of tests and treatments.
Another limitation is that hospital admission data provide only a snapshot of care during hospitalization. They do not fully show what happened before admission or after discharge. Also, administrative databases depend on coding accuracy, which may not perfectly reflect clinical reality. Even so, the very large sample size and national scope make the findings important and broadly relevant.
Bottom Line
This study found that rural residence is associated with worse epilepsy outcomes in the United States, including nearly double the odds of in-hospital death in the most rural counties. Rural patients were also more likely to present in status epilepticus and to have longer hospital stays, and they were less likely to receive EEG. The fact that these disparities weakened among privately insured patients suggests that system-level barriers, not geography alone, are driving much of the difference.
The message is clear: improving epilepsy care in rural areas will likely require more than simply recognizing where patients live. It will take targeted interventions to expand specialty access, strengthen hospital resources, and reduce insurance and transportation barriers. For a condition where rapid treatment can prevent disability or death, these steps could make a major difference in patient outcomes.
Citation
Bader ER, Kemball-Cook WS, Benton JA, Killian NJ, Boro AD, Eskandar EN. Rural-Urban Disparities in Epilepsy Outcomes in the United States. Neurology. 2026-06-03;107(1):e218053. PMID: 42234954.
