Beyond rural versus urban: A gradient of mortality risk among injured children across a four-level rurality scale

BACKGROUND: – Children living in rural areas experience an increased incidence of injury and higher mortality relative to those in urban areas. Our aim was to better characterize rural-urban disparities in pediatric trauma outcomes among children admitted to US hospitals. METHODS: – This is a retrospective, observational study of US hospitalizations of injured children and adolescents <20 years of age using the Kids’ Inpatient Database (2016, 2019, and 2022). We categorized children’s home counties as large urban, small urban, micropolitan, and rural. We compared demographics and injury characteristics of injured children among differing levels of rurality. We determined the unadjusted and adjusted risk of inpatient mortality using quasibinomial logistic regression, accounting for survey design, by level of rurality. RESULTS: – A representative weighted 402, 255 injured children were admitted in the survey years. The median age was 13 (IQR, 5–17) years and 39.1% were female. Motor vehicle crash (21.1%) and falls (21.1%) were the most common mechanisms of injury. As the level of rurality increased, the proportion of severely injured children (ISS >25) increased (7.0% large urban, 7.9% small urban, 9.6% micropolitan, and 10.9% rural areas). When adjusted for risk of mortality, compared to large urban counties, rural county was associated with 32% higher odds [odds ratio (OR), 1.32, 95% CI, 1.16–1.51], micropolitan 30% higher odds (OR, 1.30, 95% CI, 1.16–1.46), and small urban 22% higher odds (OR, 1.22, 95% CI, 1.12–1.32) of inpatient mortality. CONCLUSIONS: – Among injured children admitted to US hospitals, children residing outside of large urban areas have a higher risk of death independent of injury severity. To address disparities in pediatric rural injury outcomes, we must further investigate the root causes of this disparity, which may include nonoptimal location of pediatric trauma centers, long transport times, and low pediatric readiness in rural hospitals. (J Trauma Acute Care Surg. 2026;00:00–00.