Date of Award

Spring 2022

Degree Type



Public Health

Director of Thesis

Dr. Peiyin Hung

First Reader

Dr. Melinda A. Merrell

Second Reader

Dr. Melinda A. Merrell


Objective. To examine rurality and other hospital characteristics associated with patient satisfaction across hospitals in the United States.

Data. Nationwide hospital data from the 2019 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the 2020 Centers for Medicare & Medicaid Services (CMS) Provider of Services (POS) file.

Study Design. Hospital ZIP-codes were categorized into urban, rural micropolitan, or small/isolated rural based on Rural-Urban Commuting Area (RUCA) codes. Patient satisfaction measures from the HCAHPS survey were linked to the CMS POS data for hospital characteristics, yielding 2,357 urban, 749 rural micropolitan, and 1,343 small/isolated rural hospitals. ANOVA and chi-square tests were conducted to compare patient satisfaction measures and hospital characteristics by rurality. Generalized linear models were employed to examine marginal differences of hospital rurality on patient satisfaction, controlling for other hospital characteristics.

Principal Findings. While small/isolated rural hospitals were less likely to be accredited, to have medical school affiliation, and to have high staffing, they were more likely to have pharmacy services collocated within a hospital, patients insured by Medicare and Medicaid, and critical access hospital (CAH) designations. Small/isolated rural hospitals had the highest average survey response rates at 3.26 percentage points above the national average. In particular, compared to urban hospitals, small/isolated rural hospitals had higher percentages of patients reporting that nurses or doctors always communicated well (average marginal effects: 1.63; 95% CI, 1.14-2.12 (nurses) and 2.61 [2.12-3.10] (doctors)), that they always received help as soon as they wanted (4.36 [3.56-5.16]), and that staff always explained possible side effects (3.28 [2.50-4.06]).

Conclusions. Safety-net, or small/isolated rural, hospitals reported higher patient satisfaction compared to non-safety-net hospitals. Many of these safety-net hospitals were designated as CAH, relied more on Medicare and Medicaid insurance, and offered on-site pharmaceutical services. These findings signal the important role that safety-net hospitals play in providing satisfactory healthcare to underserved communities.

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