By Leah Bartos
California Health Report
Babies living in California’s rural counties were less likely to be hospitalized in the first year of life than their urban counterparts, according to a recent study published in the journal Pediatrics.
Researchers analyzed records for more than 6.4 million babies born in California between 1993 and 2005, calculating the rate of non-birth hospital utilization before the babies’ first birthdays. They found that urban babies were more likely to be admitted to a hospital, had longer overall stays, and were more likely to be readmitted than rural babies. The mortality rate between the groups, however, was essentially the same.
Dr. Kristin Ray, the lead author of the study, wanted to better understand the experience of rural babies and families, and whether the difference in health-care environments — such as relatively fewer doctors and longer travel distances to get to them — was contributing to poorer outcomes. But what she found surprised her.
“I would have expected decreased access to care in rural areas to result in delays in care, and that this would translate into more hospitalizations in rural areas. We saw the opposite,” Ray said. “So, while access to care is certainly an issue in rural areas, its impact on hospitalizations appears to be more complicated than one might expect.”
Further research will be needed to determine the causes of this discrepancy in hospitalization rates.
“The underlying question is whether we’re seeing too many hospitalizations in urban areas, too few hospitalizations in rural areas, or the right amount of hospitalizations in areas with different needs and resources.”
One explanation for the discrepancy could be that babies in urban areas were simply more likely to get sick. To tease out whether there was actually a difference in medical need between the populations, researchers looked at occurrences of specific illnesses that they believed should always require hospitalization. For instance, researchers found babies affected by sepsis (bacteria in the blood stream, which is typically treated with intravenous antibiotics) do show up more often in urban hospitals.
But while the data did show a greater rate of some illnesses among urban babies, it did not translate to a higher death rate. As Ray explained, increased mortality in one group might suggest the children were sicker than the others and not getting the care they needed. “Instead, we found similar mortality rates across all county types, so mortality data does not appear to point clearly towards more illness or more foregone care in any particular area.”
Ray says the findings call for a closer look at some of the other possible factors contributing to the difference in hospitalization rate. “This study definitely raises questions about whether differences in hospitalizations are due to differences in illness or differences in hospital use for more subjective or systematic reasons.”
Some of those other factors might include a difference in the quality and quantity of care in rural areas — for instance, as previous studies have shown, patients who are seen continuously by the same doctor tend to have better health outcomes than those who experience more fragmented care. Differences in physician approach and decision-making in rural areas may also contribute to the difference in hospitalization rates, as could parents’ expectations in those areas. Ray says studying outcomes other than hospitalizations — such as collecting data on the frequency of infants’ doctor visits or how often parents stay home from work to care for sick children — could help lead to a better understanding of the different healthcare environments.
Steve Barrow, executive director of the California State Rural Health Association, has also observed social and cultural factors contributing to health outcomes — everything from attitudes toward vaccination to domestic violence at home can take a toll on a child’s health. Barrow also noted that diseases such as diabetes, obesity and asthma tend to be common in rural areas and cautions not to assume that the results of this study indicate that rural babies are facing an ideal health-care landscape.
“If there are healthier babies that need hospitalization less, is it because they just don’t have enough facilities to get hospitalized, which is often the case, or is there something else going on that whatever illness they get, they are able to deal with it before they have to get hospitalized?”
He added, “If there is something that’s going on that’s good, we’d want to understand that and replicate it.”