Rural Children Face Steep Healthcare Challenges

Providers need to build better links between pediatric hospitals and rural providers, and risk adjustment is warranted for patients coming from a low-income, rural areas, researchers conclude.

One enduring trope of American culture is the healthy country life. Picture the oatmeal ads of gingham-and-overall-clad youngsters, straw hats atop towheads, laughing and skipping through fields of green clover, bathed in golden sunshine, breathing farm-fresh air, far from the toxins of urban life.

Of course, this is a myth for many people living in rural America, adults and children. Studies have shown that nearly one-in-five children in rural America live in poverty. Many of these children, particularly African-American children, are at greater risk of obesity, tobacco exposure, and chronic medical conditions.

Now, a new study in Pediatrics adds to that consensus and documents less-favorable outcomes for rural children at pediatric hospitals when compared with children from non-rural areas.  

The study, led by Alon Peltz, MD, MBA, a general pediatrician and Robert Wood Johnson Foundation Clinical Scholar at Yale University, examined more than 670,000 admissions at 41 pediatric hospitals (the majority of which are located in urban settings) in 24 states throughout 2012.

The researchers measured length of stay, hospital cost, and 30-day all-cause readmissions and tracked them against ZIP codes and U.S. Census data to classify children living in urban and rural areas, family income, and Health Profession Shortage Areas.

Here's what they found:  

• Rural children accounted for more than 81,000 admissions, about 12% of the total admissions under these criteria, and the majority of these rural children lived in ZIP codes with high poverty levels.
• On average they lived 68 miles from the pediatric hospital, compared with 12 miles for non-rural children, and in some instances it was not uncommon for children to travel from other states.
• The rural children were more likely to live in a low-income ZIP code, (53% vs. 24%), and a HPSA (20% vs. 4%).
• Rural children also had a higher prevalence of complex chronic conditions (44% vs 37%); experienced higher inpatient costs (mean: $8,507 vs $7,814); and were at slightly higher odds for a 30-day readmission.
• And "despite a higher prevalence of these characteristics, rural children are more often discharged from children's hospitals to low-income and medically underserved areas."

Peltz says he and his colleagues were drawn to the study because of their own clinical experiences trying to coordinate post-discharge care for children from rural areas. "We wanted to assess who comes from rural communities and if they experience a hospitalization any differently than non-rural children," Peltz told me.

"What surprised us the most was even when we accounted for the differences in illness severity, and even when we went through and looked at who had which chronic condition, and could we standardize the level of severity between the kids from rural and non-rural communities, we were still seeing the difference in how long they stayed in the hospital and the readmissions rate."

Related: Population Health Poses Unique Challenges in Rural Areas

From a cold, hard, bottom line perspective, these findings are important for hospitals that face penalties for 30-day readmissions.

"One of the first question we asked as a study team was why are we observing differences in readmissions," Peltz says. "Even though they are not marked differences, they are still significant differences. Although we adjusted to try to make the rural and non-rural patients as similar as possible, we are still seeing a difference on the basis of geography. That should give us pause to ask why we are experiencing that disparity and think about how we develop our post-discharge care plans for rural children, especially those with multiple needs."

Peltz says the study findings also suggest that providers need to build better linkages between pediatric hospitals and rural providers, many of whom do tremendous work with limited resources.

"Advocates might use these result to ask how we can better integrate the care in terms of being more creative with telehealth, or e-consultations," Peltz says. "Can we think about policies that promote better financial integration between the entities that enhance the way that we coordinate care?"

The study makes a strong argument that risk adjustment is warranted for patients coming from a low-income, rural areas.

"It's a very complicated issue," Peltz says. "Is it a sign that the needs of a particular community are high, or is it a sign that we need to improve discharge planning? These might be informed by the finding that the readmission rate is high."

Peltz says his next research projects will attempt to provide more detail about how rural communities compare with one another on health metrics and outcomes. "There are differences between rural communities on the basis of geography and size and the next step is to identify differences between large and small rural communities to see if there are predictors of areas of higher need," he says.

Another area for study will examine the differences in how non-rural and rural children use healthcare services at pediatric hospitals. "We want to cast the net a little wider and see if we can look at patterns of care for rural children, both in terms of when they decided to use a children's hospital and when they used a local hospital," Peltz says.

"That can be informative as we think about how to build relationships between hospitals and providers within regions. A collaborative approach to meeting the needs of these families and leveraging the specialty care when it's needed, and supporting local providers is the way to move forward, and we still have a lot to learn about when rural children and rural families seek care in a more distant specialized center and when they stay closer to home."

The study also cries out for the need to improve access to primary care in rural America.

"Anytime we think about this population, particularly rural children with chronic health conditions, the thought is how do we bring more resources to these communities in a thoughtful way that complements the care they're receiving," Peltz says.

"I cannot overstate the importance of the local care providers. This is an opportunity for us to examine post-discharge care and to build relationships between primary care and hospital-based specialty care. We come away from this study thinking about how we can support local healthcare providers and linking children's hospitals within regions is definitely the next step."