{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T12:03:19Z","timestamp":1790337799192,"version":"4.1.0"},"reference-count":49,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T00:00:00Z","timestamp":1790294400000},"content-version":"vor","delay-in-days":24,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100006108","name":"National Center for Advancing Translational Sciences","doi-asserted-by":"publisher","award":["UL1TR002377"],"award-info":[{"award-number":["UL1TR002377"]}],"id":[{"id":"10.13039\/100006108","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["The Journal of Rural Health"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Emergency department (ED) boarding negatively impacts patient care nationwide. Rural hospitals are uniquely challenged as ED volumes increase despite declining inpatient capacity. Interfacility transfers are a growing component of rural ED operations and remain underexamined in evaluation of ED boarding. This study assessed trends in ED boarding and interfacility transfers by rurality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>We conducted a repeated cross\u2010sectional analysis using National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2001 to 2022 and a health system from 2019 to 2025. Outcomes included (1) yearly ED boarding proportions stratified by disposition and rurality and (2) yearly interfacility transfer proportions by rurality. We defined rurality using Metropolitan Statistical Area and Rural\u2010Urban Commuting Area codes. Results were further stratified by medical and behavioral health patients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>\n                      National ED boarding increased from 5.1% in 2001 to 11.3% in 2022, significant in urban (annual percentage change [APC] 5.3%, 95% CI 3.8%\u20136.8%) and rural (APC 9.1%, 5.1%\u201313.1%) hospitals. Health system ED boarding increased from 4.1% in 2019 to 10.8% in 2025, significant in urban (APC 13.6%, 7.1%\u201320.6%) and rural (APC 31.2%, 16.3%\u201348.1%) hospitals. ED boarding was highest for behavioral health transfers and increased significantly in rural health system hospitals. Health system medical transfer ED boarding increased faster in rural hospitals (\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0=\u00a00.002), and annual medical transfer proportions were higher in rural EDs.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>ED boarding is increasing nationally. Rural transfer proportions exceed that of urban EDs and are an overlooked component of rural ED boarding. These findings have important policy implications with recent reimbursement changes and national boarding quality measures.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jrh.70222","type":"journal-article","created":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T11:33:39Z","timestamp":1790336019000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["National Trends in Emergency Department Boarding and Interfacility Transfers by Rurality"],"prefix":"10.1111","volume":"42","author":[{"given":"Elizabeth S.","family":"Bermudez","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine Mayo Clinic Health System Austin Minnesota USA"},{"name":"Department of Emergency Medicine Mayo Clinic  Rochester Minnesota USA"},{"name":"Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic  Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aidan","family":"Mullen","sequence":"additional","affiliation":[{"name":"Department of Quantitative Health Sciences Mayo Clinic  Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas M.","family":"Mohr","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine University of Iowa Carver College of Medicine  Iowa City Iowa USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Molly","family":"Jeffery","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine Mayo Clinic  Rochester Minnesota USA"},{"name":"Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic  Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,25]]},"reference":[{"issue":"5","key":"e_1_2_10_2_1","article-title":"Emergency Department Crowding: The Canary in the Health Care system","volume":"2","author":"Kelen G. 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