Corresponding Author

Rachel Hogg-Graham, DrPH, MA


Author Affiliations

1. Rachel Hogg-Graham, DrPH, MA

Associate Professor (Health Management and Policy)

College of Public Health,

University of Kentucky

Lexington KY

2. Juan Lang, PhD

Biomedical Data Scientist (Health Management and Policy)

College of Public Health,

University of Kentucky

3. Teresa M. Waters, PhD

Endowed Professor and Chair (Health Management and Policy)

College of Public Health,

University of Kentucky

Author Area of Expertise

Rachel Hogg-Graham: population health systems, collaboration and partnerships, social determinants of health

Juan Lang: statistical methods

Teresa M. Waters: health policy, value-based payment


Introduction: Previous studies have documented geographic variation in preventable hospitalizations between rural and urban areas, but much less is known about preventable hospitalization patterns between heterogeneous rural areas. Unique challenges related to access of care and poverty may put the rural Appalachian Region at risk for higher rates of preventable hospitalizations.

Purpose: This study examines whether within-rural differences in Kentucky’s preventable hospitalization rates exist and how these differences may be changing over time.

Methods: Longitudinal and geographic trends in county-level preventable hospitalization rates were examined using Kentucky hospital discharge data from 2016 to 2019. Regression models were run to determine whether changes over time in preventable hospitalization rates led to an increasing or decreasing gap in outcomes between rural Appalachian counties and their urban and rural non-Appalachian counterparts.

Results: Rural Appalachian counties consistently had significantly higher preventable hospitalizations rates compared to their rural non-Appalachian and urban counterparts (p < 0.01). A downward trend in overall preventable hospitalizations was observed for rural Appalachia over time, but trends were relatively stable for rural non-Appalachian and urban counties. Regression results indicate that there was no significant reduction in the “Appalachian gap” over time.

Implications: The analyses confirm that rural areas within Kentucky experienced highly heterogeneous rates of preventable hospitalizations. Despite Medicaid expansion, there is little evidence of any narrowing of the “Appalachian gap.” Focus on improving access to care alone may be insufficient to improve outcomes. Alternative strategies that leverage population health approaches may improve capacity to address complex health and social needs in rural Appalachia.



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This work is licensed under a Creative Commons Attribution 4.0 License.

JAH supplemental material.docx (12 kB)
Table S1. Hospitalizations included in Prevention Quality Indicators

Recommended Citation

Hogg-Graham R, Lang J, Waters TM. The Appalachian gap in preventable hospitalizations: Are we seeing any progress? J Appalach Health 2023;5(2):5–14. DOI: https://doi.org/10.13023/jah.0502.02.