Objective. To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family 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 discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990.

Results. Of 69 690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. 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 similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners.

Conclusions. Most rural children in Washington who require 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 make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating 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. Because 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.

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