Equivalent lengths of stay of pediatric patients hospitalized in rural and nonrural hospitals

Scott A Lorch, Xuemei Zhang, Paul R Rosenbaum, Orit Evan-Shoshan, Jeffrey H Silber
Pediatrics 2004, 114 (4): e400-8

BACKGROUND: Many children receive their care at local hospitals outside of a large urban area. There may be differences in the length of stay (LOS) between children hospitalized in rural versus urban hospitals. This study compared the differences in LOS, conditional LOS (CLOS), odds of prolonged stay, and 21-day readmission rates for children with 19 medical conditions and 9 surgical procedures admitted to rural, community, and large urban hospitals.

METHODS: Discharge records for the hospitalizations of children 1 to 17 years of age were obtained from the New York Department of Public Health Statewide Planning and Research Cooperative System and the Pennsylvania Health Care Cost Containment Council for April 1996 to July 1998. The 19 medical and 9 surgical conditions were identified with the principal condition and procedure codes. Hospitals were classified into 1 of 5 geographic categories on the basis of United States rural-urban continuum codes, ie, large urban, suburban, moderate urban, small urban, or rural. LOS was defined as the period of time between hospital admission and discharge. Readmission rates were calculated for 21 days after discharge from the hospital. A prolonged stay for each condition was defined as any admission lasting beyond the prolongation point, or the day at which the rate of discharge began to decline, as determined with the Hollander-Proschan statistic. This aspect of LOS describes the ability of providers to treat uncomplicated cases of that specific principle diagnosis. CLOS, as a marker for the management of complicated cases, was defined as the LOS beyond the prolongation point. Cox and logistic regression models were developed to describe the geographic effects on the 4 outcome variables, after severity adjustment with 32 demographic and 11 comorbidity variables and adjustment for hospital clustering.

RESULTS: Medical (N = 114,787) and surgical (N = 29,156) admissions to rural hospitals (N = 12,367) had similar outcomes, compared with all geographic categories except the large urban category. Medical patients admitted to rural hospitals had a shorter LOS (12% increase in discharge rate), a shorter CLOS (12% increase in discharge rate), and lower odds of prolonged stay (odds ratio: 0.80), compared with those in large urban hospitals. Surgical patients admitted to rural hospitals had a shorter LOS (12% increase in discharge rate) and lower odds of prolonged stay (odds ratio: 0.81), compared with those in large urban hospitals. For individual conditions, rural hospitals in general had similar or improved LOS, compared with all other hospitals in the 2 states. The addition of hospital-level variables failed to change the results of the primary models.

CONCLUSIONS: In their treatment of pediatric hospitalized patients, rural hospitals were not significantly different from hospitals in all geographic regions other than large urban areas. Rural hospitals appear to deliver similar care, compared with nonrural hospitals, for many of the common pediatric conditions included in this study. Additional research is needed to apply these results to other regions or states with different geographic distributions of hospitals and children, in order to determine the overall impact on the regionalization of pediatric care.

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