The 12 000 000 children in the United States who live in rural communities experience poorer health status and limited access to pediatric health care relative to children from urban areas.1  For mental health (MH) conditions, rural disparities are prominent with >85% of rural US counties designated MH Health Professional Shortage Areas2  and rates of mortality by suicide among rural children almost double that of urban children.3  Hospital-based stabilization can ensure the safety of children in MH crisis. To characterize geographic differences and identify disparities for pediatric MH hospitalizations, we compared the rate of MH hospitalizations in children by location of their home residence.

We performed a retrospective cohort analysis of the 2019 Kids’ Inpatient Database (KID) including all-payer encounters for hospitalizations (inpatient and observation) in 2019 for children 5-to-17 years with a primary MH diagnosis, categorized using the Child and Adolescent Mental Health Disorders Classification System.4  Only encounters from primary hospitalizations were included to avoid duplicative counting for children transferred between institutions. Hospitalization rates were calculated using national estimates of hospitalizations from the KID (numerator) and population estimates from the 2019 American Community Survey (denominator). The National Center for Health Statistics (NCHS) classification scheme was used to categorize the degree of rurality of the patient’s zip code of primary residence (Table 1). We compared hospitalization rates by NCHS categorization with unadjusted Poisson regression, and rate ratios (RR) for hospitalization were calculated by geographic location using Large Central Metropolitan as reference. Statistical analyses were performed using SAS v. 9.4 (SAS Institute, Cary, NC). This project was deemed nonhuman subjects research by the Seattle Children’s Hospital Institutional Review Board.

TABLE 1

NCHS for Urban-Rural Classifications of Counties

NCHS ClassificationDefinition
Large central metro Counties in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA; (2) have the entire population contained in the largest principal city of the MSA; or (3) contain at least 250 000 inhabitants of any principal city of the MSA 
Large fringe metro Counties in MSAs of ≥1 million population that do not qualify as large central metro counties 
Medium metro Counties in MSAs of 250 000–999 999 population 
Small metro Counties in MSAs of <250 000 population 
Micropolitan Counties in micropolitan statistical areas with populations 10 000–50 000 
Rural noncorea Counties in micropolitan statistical areas with populations <10 000 
NCHS ClassificationDefinition
Large central metro Counties in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA; (2) have the entire population contained in the largest principal city of the MSA; or (3) contain at least 250 000 inhabitants of any principal city of the MSA 
Large fringe metro Counties in MSAs of ≥1 million population that do not qualify as large central metro counties 
Medium metro Counties in MSAs of 250 000–999 999 population 
Small metro Counties in MSAs of <250 000 population 
Micropolitan Counties in micropolitan statistical areas with populations 10 000–50 000 
Rural noncorea Counties in micropolitan statistical areas with populations <10 000 
a

We define rural areas consistent with the NCHS noncore county definition, ie, nonmetropolitan counties that do not qualify as micropolitan.

In 2019, the MH hospitalization rate was 332 per 100 000 children aged 5-to-17 years (178 316 MH hospitalizations among 53 661 722 US children). The MH hospitalization rate was lowest for children from central metropolitan areas (283 [95% confidence interval (CI): 280–285]) and highest for children from medium sized metropolitan areas (386 [95% CI 382–389]). Depressive disorders (including suicidal ideation) were the most common admission MH diagnosis [62% (N = 109 362)] with the rate of hospitalization surpassing all other MH disorders by a factor of 8 across geographic areas (Table 2).

TABLE 2

Urban-Rural Hospitalization Rates per 100 000 Children for 5 Common Mental Health Conditions

N Hospitalizationsa,bLarge Central Metro, Rate (95% CI)Large Fringe Metro, Rate (95% CI)Medium Metro, Rate (95% CI)Small Metro, Rate (95% CI)Micropolitan, Rate (95% CI)Rural Noncore, Rate (95% CI)
Overall 177 849 282.8 (280.2–285.4) 341.0 (337.9–344.1) 385.2 (382.3–389.6) 348.7 (343.4–354.0) 329.3 (324.0–334.7) 318.7 (312.4–325.1) 
Depressive disorders 109 362 160.5 (158.6–162.5) 211.7 (209.3–214.2) 242.2 (239.4–245.1) 227.0 (222.8–231.4) 210.2 (205.9–214.5) 208.5 (203.5–213.7) 
Bipolar disorders 9856 16.0 (15.4–16.6) 23.2 (22.4–24.0) 17.9 (17.1–18.7) 18.5 (17.4–19.8) 15.4 (14.3–16.6) 14.9 (13.6–16.4) 
Suicide and self-injury attempt 5674 9.5 (9.1–10.0) 8.5 (8.0–8.9) 12.2 (11.6–12.8) 13.8 (12.8–14.9) 12.0 (11.0–13.0) 12.9 (11.7–14.2) 
Anxiety disorders 3513 6.4 (6.1–6.9) 7.2 (6.7–7.6) 7.1 (6.6–7.6) 5.8 (5.1–6.5) 5.6 (4.9–6.3) 5.1 (4.3–5.9) 
Eating disorders 3025 6.4 (6.0–6.8) 8.1 (7.6–8.6) 4.4 (4.0–4.8) 3.3 (2.8–3.8) 3.6 (3.0–4.2) 1.8 (1.4–2.4) 
N Hospitalizationsa,bLarge Central Metro, Rate (95% CI)Large Fringe Metro, Rate (95% CI)Medium Metro, Rate (95% CI)Small Metro, Rate (95% CI)Micropolitan, Rate (95% CI)Rural Noncore, Rate (95% CI)
Overall 177 849 282.8 (280.2–285.4) 341.0 (337.9–344.1) 385.2 (382.3–389.6) 348.7 (343.4–354.0) 329.3 (324.0–334.7) 318.7 (312.4–325.1) 
Depressive disorders 109 362 160.5 (158.6–162.5) 211.7 (209.3–214.2) 242.2 (239.4–245.1) 227.0 (222.8–231.4) 210.2 (205.9–214.5) 208.5 (203.5–213.7) 
Bipolar disorders 9856 16.0 (15.4–16.6) 23.2 (22.4–24.0) 17.9 (17.1–18.7) 18.5 (17.4–19.8) 15.4 (14.3–16.6) 14.9 (13.6–16.4) 
Suicide and self-injury attempt 5674 9.5 (9.1–10.0) 8.5 (8.0–8.9) 12.2 (11.6–12.8) 13.8 (12.8–14.9) 12.0 (11.0–13.0) 12.9 (11.7–14.2) 
Anxiety disorders 3513 6.4 (6.1–6.9) 7.2 (6.7–7.6) 7.1 (6.6–7.6) 5.8 (5.1–6.5) 5.6 (4.9–6.3) 5.1 (4.3–5.9) 
Eating disorders 3025 6.4 (6.0–6.8) 8.1 (7.6–8.6) 4.4 (4.0–4.8) 3.3 (2.8–3.8) 3.6 (3.0–4.2) 1.8 (1.4–2.4) 
a

Geographic location is based on the National Center for Health Statistics’ urban-rural classification scheme: central counties (ie, “large central metro”) = counties in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA; (2) have their entire population contained in the largest principal city of the MSA; or (3) contain at least 250 000 inhabitants of any principal city of the MSA; fringe counties (ie, “large fringe metro”) = counties in MSAs of ≥1 million population that do not qualify as large central metro counties; medium metro = counties in MSAs of 250 000–999 999 population; small metro = counties in MSAs of <250 000 population; micropolitan counties = counties in micropolitan statistical areas; rural counties (ie, “noncore”) = nonmetropolitan counties that do not qualify as micropolitan.

b

All comparisons significant at P < .001.

Geographic variation in hospitalization existed across common MH conditions (depressive disorders, suicide-attempt, bipolar, anxiety, and eating disorders) (Fig 1). Compared with large central metropolitan areas, children from rural noncore areas had significantly lower rates of hospitalizations for anxiety (RR 0.8 [95% CI 0.7–0.9]) and eating disorders (RR 0.3 [95% CI 0.2–0.4]), but higher rates of suicide and self-injury (RR 1.4 [95% CI 1.2–1.5]).

FIGURE 1

Rate ratios of pediatric hospitalizations for 5 common mental health conditions compared with large central metropolitan areas. Geographic location is based on the National Center for Health Statistics’ urban-rural classification scheme: Central Counties (ie, “large central metro”) = counties in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA; (2) have their entire population contained in the largest principal city of the MSA; or (3) contain at least 250 000 inhabitants of any principal city of the MSA; fringe counties (ie, “large fringe metro”) = counties in MSAs of ≥1 million population that do not qualify as large central metro counties; medium metro = counties in MSAs of 250 000 to 999 999 population; small metro = counties in MSAs of <250 000 population; micropolitan counties = counties in micropolitan statistical areas; rural counties (ie, “noncore”) = nonmetropolitan counties that do not qualify as micropolitan.

FIGURE 1

Rate ratios of pediatric hospitalizations for 5 common mental health conditions compared with large central metropolitan areas. Geographic location is based on the National Center for Health Statistics’ urban-rural classification scheme: Central Counties (ie, “large central metro”) = counties in metropolitan statistical areas (MSAs) of ≥1 million population that (1) contain the entire population of the largest principal city of the MSA; (2) have their entire population contained in the largest principal city of the MSA; or (3) contain at least 250 000 inhabitants of any principal city of the MSA; fringe counties (ie, “large fringe metro”) = counties in MSAs of ≥1 million population that do not qualify as large central metro counties; medium metro = counties in MSAs of 250 000 to 999 999 population; small metro = counties in MSAs of <250 000 population; micropolitan counties = counties in micropolitan statistical areas; rural counties (ie, “noncore”) = nonmetropolitan counties that do not qualify as micropolitan.

Close modal

Hospitalizations for depression outpaced all other mental health hospitalizations across geographic areas. However, when compared with children from metropolitan areas, children from rural areas demonstrated increasing hospitalization rates for suicide and self-injury but decreasing for anxiety and eating disorders.

Geographic differences in access to outpatient MH services may have contributed to lower MH hospitalization in children from metropolitan areas, compared with children from more rural areas. With most rural counties having severe shortages of MH professionals,2  rural hospitals are constrained in resources and bedspace to support children presenting in MH crisis. Innovative collaborations between hospitals across geographic areas for sharing inpatient and outpatient resources may represent ways to better care for children experiencing a MH crisis. Implementing models such as Project ECHO (Extension for Community Healthcare Outcomes), a hub-and-spoke learning collaborative between primary-care and subspecialists using telehealth,5  are lower cost, high-impact interventions that improve capacity and access to specialty care in under-resourced areas, like acute-care MH.6 

Our study has several limitations, including that the KID does not contain outpatient MH services, permit tracking across hospitalizations, or include measures of quality of care. As such, we could not characterize which children required recurrent utilization of inpatient resources or the chronicity of the MH challenges. In addition, we were unable to quantify emergency department boarding for MH needs, which may disproportionately impact children in rural areas because of limited inpatient resources. Lastly, patients frequently have co-occurring MH conditions; in only analyzing primary diagnoses, we are likely underrepresenting the scope of hospitalizations for MH conditions. Further work should investigate resource utilization and quality of care across MH hospitalizations, coordination with outpatient MH services, and the impact of the pandemic upon geographic differences in MH hospitalizations.

Drs McDaniel, Hall, and Berry conceptualized and designed the study, conducted the analyses, and drafted the initial manuscript; Drs Markham and Bettenhausen participated in the conceptualization of the study; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: Dr McDaniel’s time was supported by The Agency for Healthcare Research and Quality under award K08HS028683. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The sponsor had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or decision to submit the article for publication.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

CI

confidence interval

KID

Kids’ Inpatient Database

MH

mental health

NCHS

National Center for Health Statistics

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Supplementary data