The Changing Landscape of Routine Pediatric Surgery for Rural and Urban Children: A report from the Child Health Evaluation of Surgical Services (CHESS) Group
Samir Gadepalli*1, Harold J. Leraas4, Katy Flynn-O'Brien2, Kyle Van Arendonk2, Matt Hall3, Elisabeth Tracy4, Robert Ricca5, Adam Goldin6, peter f. ehrlich1
1Surgery, University of Michigan, Ann Arbor, MI; 2Surgery, Childrens Hopsital of Wisconsin, Milwaukee, WI; 3Statistics, Childrens Hospital Association, Lenexa, KS; 4Surgery, Duke University, Durham, NC; 5Surgery, Eastern Carolina University, Greenville, SC; 6Surgery, University of Washington, Seattle, WA
Background Significant transformations of the health care system for children have occurred over the past two decades, including verification of children’s surgery centers and the decreasing exposure of general surgeons to pediatric surgical care. The impact and burden of these changes on children and their families is unclear especially for children living in rural environments. Methods Children (0-18) undergoing the seven most common pediatric surgeries (Figure 1) were identified using State Inpatient Databases (SID,2002-2017). Rural-Urban Commuting Area (RUCA) codes were used to classify patient and hospital zip codes as Rural (RUCA 4-10) or Urban (RUCA 1-3). Trends in demographics, hospital type, distance traveled, and need for transfer were compared for patient residence and type of procedure. Multivariable regression models for distance traveled >60 miles and transfer status were used to compare urban and rural populations, adjusting for year, age, sex, race, and insurance status.
Results Among 143,467 children, 13% lived in rural zip codes. No differences were seen by age or gender, but rural patients were more likely to be White (74% vs. 53%) and have Medicaid (47% vs. 39%). The distance traveled increased for both rural and urban children for all procedures between 2002 and 2017. For the rural cohort, distance increased 102% for cholecystectomy, 88% for appendectomy, and 58% for inguinal hernia (Figure 1). For the urban cohort, however, these increases were only 30%, 23%, and 17%, respectively (p<.001). Transfers also increased in greater numbers for rural children: In 2002, 1% of rural and urban children were transferred for appendectomy, and by 2017, 23% of rural and 13% of urban children were transferred for appendectomy (p<.001). Factors associated with the need to travel >60 miles to reach definitive care included year (adjusted odds ratio [aOR] 2.18 [1,94, 2.46] 2017 vs. 2002), rural residence (aOR 6.55 [6.11, 7.01]), age less than 5 (aOR 2.17 [1.92, 2.46]) and having Medicaid insurance (aOR 1.35 [1.26, 1.45]). Similarly, factors associated with transfer for care included year (aOR 5.77 [5.26, 6.33] 2017 vs. 2002), rural residence (aOR 1.47 [1.39, 1.56]), age less than 10 (aOR 2.34 [2.15, 2.54]), and Medicaid insurance (aOR 1.49 [1.42, 1.46]). In addition, between 2002 and 2017 the number of rural hospitals performing pediatric operations decreased. For example, for appendectomies from 228 (2002) to 150 (2017). Conclusions Over the past two decades, rural children, younger age and those on Medicaid disproportionately travelled greater distances and are more frequently transferred for common pediatric surgical procedures compared to children living in urban environments. These findings may have policy implications for decreasing travel burden and costs for families in rural areas. Furthermore, the impact of care delays and increased travel distance on outcomes needs to be assessed for rural children.
Change in mean distance travelled by operation for rural and urban children from 2002 to 2017
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