Purpose: Suicide is the second leading cause of death among youth age 10-to-19 years in the U.S., with youth living in rural areas nearly twice as likely to die by suicide. Although emergency department (ED) visits for suicidal ideation and self-harm represent a critical opportunity for initiation of preventive interventions, urban-rural differences in these visits have not been well characterized. Our objective was to study urban-rural differences in ED visit rates for youth suicidal ideation and self-harm. Methods: We conducted a retrospective, cross-sectional analysis of ED visits for suicidal ideation and self-harm by youth age 5-to-19 years in the 2016 Nationwide Emergency Department Sample (NEDS). NEDS contains an all-payer, nationally-representative sample of U.S. ED visits. We identified visits for suicidal ideation or self-harm using diagnostic codes. We classified the location of patient residence using National Center for Health Statistics (NCHS) Urban-Rural Codes. From the U.S. Census Bureau, we obtained population totals stratified by age, sex, and NCHS urban-rural classification. We used sampling and discharge weights to produce national estimates of ED visits rates in each urban-rural category. We collapsed NCHS classifications to a dichotomous measure, with micropolitan and noncore residences classified as rural and all others classified as non-rural. We compared ED visit rates per 10,000 youth across age, sex, and urban-rural categories using incidence rate ratios (IRR). We compared ED visit characteristics using Chi-square tests. Results: In 2016, there were 297,640 ED visits (47.8 ED visits per 10,000 youth) for suicidal ideation and self-harm by youth age 5-to-19 years. Visit rates were higher among youth age 15-to-19 vs. 5-to-9 years (IRR 24.0, 95% CI 19.1, 30.1) and higher among females than males (IRR 2.02, 95% CI 1.74, 2.34). Across NCHS urban-rural categories, the largest number of ED visits (85,393 visits) occurred in large-central metropolitan areas and the highest ED visit rate (58.1 visits per 10,000 youth) occurred in micropolitan areas. The ED visit rate was higher in rural areas (54.5 visits per 10,000 youth) than non-rural areas (46.8 visits per 10,000 youth; IRR 1.16, 95% CI 1.00, 1.36) (Table 1). Compared with ED visits in non-rural areas, visits in rural areas were significantly more likely to involve older youth (age 15-to-19 years), public insurance, lower median household income, and Midwest and Southern U.S. Census regions (p<0.001 for each). Visits in rural areas were less likely to result in admission and more likely to result in transfer to another short-term hospital (p<0.001) (Table 2). Conclusions: More total ED visits for youth suicidal ideation and self-harm occur in non-rural areas, but youth living in rural areas have a higher ED visit rate. This knowledge may inform allocation of community mental health resources and suicide prevention efforts initiated in the ED setting.

Table 1

Weighted estimates and rates of ED visits for youth suicidal ideation and self-harm in 2016 by age, sex, and urban-rural location of patient residence

Table 1

Weighted estimates and rates of ED visits for youth suicidal ideation and self-harm in 2016 by age, sex, and urban-rural location of patient residence

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Table 2

ED visit characteristics for youth suicidal ideation and self-harm in 2016 by rural location of patient residence

Table 2

ED visit characteristics for youth suicidal ideation and self-harm in 2016 by rural location of patient residence

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