HOSPITAL SERVICES FOR RURAL CHILDREN IN WASHINGTON-STATE

Objective. To examine the current delivery of inpatient hospital servi ces to a statewide population of rural children, define the types of p ediatric conditions currently treated in rural hospitals or transferre d to urban centers, and explore the role of rural pediatricians and fa mily practitioners in the care of children in rural hospitals. Design. Retrospective review of statewide hospital discharge data. Subjects. All patients younger than 18 years of age with nonsurgical diagnoses d ischarged from both urban and rural civilian hospitals in Washington S tate during 1989 and 1990. Results. Of 69 690 pediatric hospital disch arges during the study period, 16% were rural residents and 10% were f rom rural hospitals. Rural hospitals cared for 59% of hospitalized rur al children. Marked differences were found between urban and rural hos pitals in the diagnoses treated; more than two-thirds of all discharge s for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the disc harges for gastrointestinal diagnoses, respiratory conditions, or mino r problems in the neonatal period were from rural hospitals. Rural hos pitals with staff pediatricians had higher annual pediatric discharges , total charges, lengths of stay, and case mix with a higher proportio n of neonates with complications, compared to hospitals without pediat ricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was simil ar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were liste d as the attending physician for 37% and 49% of discharges, respective ly. The average rural pediatrician cared for five times as many inpati ents as a rural family practitioner. Pediatricians cared for significa ntly more neonates with birth weights of less than 2500 grams, but oth erwise had a similar case mix among inpatient discharges as rural fami ly practitioners. Conclusions. Most rural children in Washington who r equire hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians mak e a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospit als does not in itself create local referral centers. Inpatient volume s are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. Thes e data support the recommendations that family practitioners contempla ting rural practice receive training in general inpatient pediatrics ( regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Becau se systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported.