Abstract
Purpose:
We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic.
Methods:
We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children’s hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling.
Findings:
Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168.
Conclusions:
Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.
Keywords: health disparities, hospitals, utilization of health services
INTRODUCTION
Within the United States, 12 million children live in rural communities,1 where they disproportionately experience poorer health status and limited access to pediatric health care infrastructure and resources, relative to children from urban areas.2–6 In the United States, greater than 2 million children require inpatient hospital admission each year, with the majority of these admissions occurring at general hospitals, which aim to serve both adults and children, rather than children’s hospitals.7
During peaks within the COVID-19 pandemic, adults with COVID-19 often overwhelmed both urban and rural hospitals. However, hospitals in rural areas, due to limited resources at baseline, were impacted more acutely.8 As the majority of children in the United States are admitted to general hospitals, the limitations on clinical resources during the height of the pandemic may have impacted access to definitive care for children from rural communities more than for children in urban communities. Furthermore, limited pediatric bed-space availability for children at general hospitals results in increasing interfacility transfers (IFTs) to children’s hospitals for children who require inpatient hospitalization.
As IFTs may negatively impact the quality and timeliness of care,9 cause increased financial stress upon families, and lead to parental work-related job strain,10 we sought to identify trends and resulting differences in urban and rural pediatric IFTs from general hospitals to freestanding children’s hospitals before and during the COVID-19 pandemic.
METHODS
Data source and design
We conducted a cross-sectional analysis of IFTs from general hospitals to freestanding children’s hospitals among children <18 years from January 1, 2019 through June 30, 2022 using the Pediatric Health Information System (PHIS). The PHIS database is an administrative database that contains inpatient, emergency department, ambulatory surgery, and observation encounter-level data from 49 tertiary care pediatric hospitals in North America. Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. Data are subjected to a number of reliability and validity checks before being included in the database.11 We included 43 hospitals after excluding 6 hospitals that did not contribute data throughout the full study period. This study was considered exempt by the Seattle Children’s Institutional Review Board.
Exposure and outcome measures
The primary outcome was the total number of IFTs into freestanding children’s hospitals, identified using the “transfer” source-of-admission code. Transfers were excluded if the post-transfer visit was coded as ambulatory, or if the patient’s diagnosis fell into one of the following categories: labor/maternal, liveborn infant, or missing/null information. Principal diagnoses were categorized using the Pediatric Clinical Classification System,12 which used the International Classification of Diseases, Tenth Revision (ICD-10) codes to categorize diagnoses into medical, surgical, and mental health indications.
The primary exposure variable was the rurality of the patient’s home residence. Rurality was defined using Rural-Urban Commuting Area Codes (RUCA), which classifies US census tracts using measures of population density by zip code, urbanization, and daily commuting.13 We dichotomized patient geography into rural-focused (consisting of an isolated small rural town, small rural town, and large rural city) and urban-focused (Table S1).14
To examine characteristics of children experiencing IFTs, we assessed medical complexity using the Pediatric Medical Complexity Algorithm,15 disposition following initial evaluation and management at the children’s hospital (ie, discharge from emergency department after transfer, inpatient admission, and intensive-care admission), and demographic characteristics.
Statistical analyses
Demographic characteristics were summarized descriptively by diagnosis category (medical, surgical, and mental health) and rurality using counts and percentages, and were compared using Chi-squared tests. The total number of transfers were plotted monthly over time. Transfer counts for year 1 of the pandemic (March 2020-February 2021) and year 2 (March 2021-February 2022) were compared by rurality and diagnosis category to counts observed in March 2019-February 2020 (pre-pandemic). We calculated observed-to-expected (O-E) ratios (eg, year 2 count/pre-pandemic count, expressed as percentages) with 95% Poisson confidence intervals. Comparisons were made across full years to avoid confounding by seasonal trends (see Figure 1). O-E ratios for rural-residing versus urban-residing children were compared using Poisson regression models with an interaction term between year and rurality to test whether year-over-year ratios differed by rurality.
FIGURE 1.
Trends in the number of urban and rural pediatric interfacility transfers from 2019 to 2022
For high-volume diagnoses for all categories (medical, surgical, and mental health), we calculated O-E ratios with Poisson confidence intervals, and present P-values for differences in year 2/pre-pandemic count ratios among rural versus urban patients generated from the Poisson regression models. P-values <.05 were considered statistically significant. All analyses were performed using SAS 9.4 (Cary, NC).
RESULTS
IFT characteristics
There were 419,250 IFTs to participating children’s hospitals from January 1, 2019 through June 30, 2022. Of these, 300,089 (71.6%) were for medical diagnoses, 98,254 (23.4%) for surgical, and 20,907 (5.0%) for mental health. IFTs from rural-residing residents comprised 18.8% (n = 78,751) of the total IFT population. Rural children who experienced IFTs were more likely to be < 1 year of age, have public insurance, and either be discharged from the emergency department after transfer or require intensive care unit admission (Table 1). All clinical characteristics comparing urban and rural-residing children who experienced IFTs were statistically significant with a P<.001; rural-residing children were more likely to be <1 year of age, non-Hispanic White, have public insurance, and reside in the South or Midwest.
TABLE 1.
| Overall N (%) | Urban transfers N (%) | Rural transfers N (%) | |
|---|---|---|---|
| Total transfers | 419,250 | 340,499 | 78,751 |
| age | |||
| <1 | 178,615 (42.6%) | 143,492 (42.1%) | 35,123 (44.6%) |
| 1–4 | 76,232 (60.8%) | 61,768 (18.1%) | 14,464 (18.4%) |
| 5–12 | 87,787 (81.7%) | 71,597 (21.0%) | 16,190 (20.6%) |
| 13–17 | 76,616 (18.3%) | 63,642 (18.7%) | 12,974 (16.5%) |
| Sex, F | 193,318 (46.1%) | 157,446 (46.2%) | 35,872 (45.6%) |
| Race/ethnicity | |||
| Non-Hispanic White | 206,227 (49.2%) | 153,859 (45.2%) | 52,368 (66.5%) |
| Non-Hispanic Black | 69,126 (16.5%) | 61,480 (18.1%) | 7,646 (9.7%) |
| Hispanic | 90,384 (21.6%) | 80,054 (23.5%) | 10,330 (13.1%) |
| Otherc | 53,513 (12.8%) | 45,106 (13.2%) | 8,407 (10.7%) |
| Medical complexity | |||
| No complexity | 151,134 (36.0%) | 122,459 (36.0%) | 28,675 (36.4%) |
| Noncomplex chronic | 94,647 (22.6%) | 77,696 (22.8%) | 16,951 (21.5%) |
| Complex chronic | 173,469 (41.4%) | 140,344 (41.2%) | 33,125 (42.1%) |
| Insurance | |||
| Public | 236,149 (56.3%) | 187,386 (55.0%) | 48,763 (61.9%) |
| Private | 158,622 (37.8%) | 133,607 (39.2%) | 25,015 (31.8%) |
| Other | 24,479 (5.8%) | 19,506 (5.7%) | 4,973 (6.3%) |
| Disposition | |||
| ED discharge | 46,504 (11.1%) | 37,234 (10.9%) | 9,270 (11.8%) |
| Inpatient admission, not ICU | 278, 807 (66.5%) | 227,481 (66.8%) | 51,326 (65.1%) |
| ICU admission | 93,939 (22.4%) | 75,784 (22.3%) | 18,155 (23.1%) |
| Transfer type | |||
| Medical | 300,089 (71.6%) | 243,060 (71.4%) | 57,029 (72.4%) |
| Surgical | 98,254 (23.4%) | 79,626 (23.5%) | 18,628 (23.7%) |
| Mental health | 20,907 (5.0%) | 17,813 (5.2%) | 3,094 (3.9%) |
| Census region | |||
| Northeast | 34,086 (8.1%) | 30,840 (9.1%) | 3,246 (4.1%) |
| South | 173,877 (41.5%) | 135,653 (39.8%) | 38,224 (48.5%) |
| Midwest | 113,843 (27.2%) | 90,199 (26.5%) | 23,644 (30.0%) |
| West | 97,444 (23.2%) | 83,807 (24.6%) | 13,637 (17.2%) |
All comparisons significant at P < .001.
Urban-Rural Determination according to RUCA categorization Urban: 1.0, 1.1, 2.0, 2.1, 4.1, 5.1, 7.1, 8.1, and 10.1 and Rural: 3.0, 4.0, 4.2, 5.0, 5.2, 6.0, 6.1, 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.2, 10.3, 10.4, 10.5, and 10.6.
Other includes: American Indian, Asian, Native Hawaiian, multiracial, other race, and missing.
IFT trends
Starting in quarter 1 of 2020 and extending through quarter 4, there was a dramatic decline in the number of pediatric IFTs (Figure 1). The O-E ratio of IFTs in year 1 of the pandemic for urban transfers was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children when compared to pre-pandemic (Table 2). In year 2, there was a substantial rebound with higher counts of IFTs into 2022 for both urban and rural transfers. When compared to pre-pandemic, rural transfers rebounded more than urban transfers in year 2 equating to 101.7 (95% CI 100.1, 103.4) of the pre-pandemic O-E ratio for rural children compared to 89.7% (95% CI 89.0, 90.4) for urban children (P<.0001).
TABLE 2.
Volume and observed-to-expected ratio of urban and rural interfacility transfers by diagnostic category from 2019 to 2022a
| Pre-pandemic Mar 2019-Feb 2020, N (%) | Year 1: Mar 2020-Feb 2021, N (%) | % of Mar 2019-Feb 2020 volume (95% CI) | P-value | Year 2: Mar 2021-Feb 2022, N (%) | % of Mar 2019-Feb 2020 volume (95% CI) | P-value | |
|---|---|---|---|---|---|---|---|
| Total transfers | .0011 | <.0001 | |||||
| Urban | 135,473 (82.1%) | 18,928 (81.2%) | 14.0% (13.8,14.2) | 121,545 (80.2%) | 89.7 (89.0, 90.4) | ||
| Rural | 29,557 (17.9%) | 4,379 (18.8%) | 14.8% (14.4,15.3) | 30,072 (19.8%) | 101.7% (100.1, 103.4) | ||
| Medical | .0027 | <.0001 | |||||
| Urban | 98,764 (82.0%) | 12,385 (81.0%) | 12.5% (12.1,12.8) | 85,318 (79.8%) | 86.4% (85.6, 87.2) | ||
| Rural | 21,662 (18.0%) | 2,901 (19.0%) | 13.4% (12.9,13.9) | 21,556 (20.2%) | 99.5% (97.6, 101.4) | ||
| Surgical | .0636 | <.0001 | |||||
| Urban | 30,543 (81.6%) | 5,121 (80.6%) | 16.8% (16.3,17.3) | 29,217 (80.2%) | 95.7% (94.1, 97.2) | ||
| Rural | 6,882 (18.4%) | 1,230 (19.4%) | 17.9% (16.8,19.0) | 7,232 (19.8%) | 105.1% (101.7, 108.6) | ||
| Mental health | .4361 | .0168 | |||||
| Urban | 6,166 (85.9%) | 1,422 (85.1%) | 23.1% (21.8,24.4) | 7,010 (84.5%) | 113.7% (109.9, 117.6) | ||
| Rural | 1,013 (14.1%) | 248 (14.9%) | 24.5% (21.3,28.1) | 1,284 (15.5%) | 126.8% (116.7, 137.6) |
Urban-Rural Determination according to RUCA categorization Urban: 1.0, 1.1, 2.0, 2.1, 4.1, 5.1, 7.1, 8.1, and 10.1 and Rural: 3.0, 4.0, 4.2, 5.0, 5.2, 6.0, 6.1, 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.2, 10.3, 10.4, 10.5, and 10.6.
When examining reasons for IFTs, O-E ratios for medical and surgical transfers for urban-residing children remained below pre-pandemic levels in years 1 and 2. Transfers for rural-residing children, however, rebounded to pre-pandemic levels by year 2 for medical (99.5%, 95% CI 97.6, 101.4) and surgical indications (105.1%, 95% CI 101.7, 108.6). The O-E transfer ratios for mental health indications in year 2 exceeded 100% for both urban and rural-residing children, with higher ratios for rural transfers than for urban transfers: 126.8% (95% CI, 116.7, 137.6) versus 113.75% (95% CI 109.9, 117.6), respectively (P = .0168) (Table 2).
Diagnosis-specific patterns
Comparing year 2 to pre-pandemic levels, IFTs for high-volume general pediatric conditions, O-E ratios for most medical conditions remained well below the pre-pandemic levels for both urban and rural transfers, including for pneumonia (62.5%, 95% CI 56.3, 69.4), cellulitis (78.8%, 95% CI 67.8, 91.5), and dehydration (87.4%, 95% CI 71.1, 95.8) (Table S2). However, transfers for diabetes (111.2%, 95% CI 101.6, 121.7) and malnutrition (120.4%, 95% CI 101.6, 142.6) exceeded pre-pandemic levels for children from rural locations more than urban locations. A similar discrepancy was seen with transfers for acute appendicitis with and without peritonitis, where urban transfers in year 2 were below pre-pandemic levels (94.8% and 76.8%, respectively), while rural transfers exceeded pre-pandemic levels at 141.3% for acute appendicitis with peritonitis and 118.1% without peritonitis.
For both urban and rural children, O-E transfer ratios for suicide and intentional self-injury (136.2%), anorexia nervosa (167.1%), and substance-related disorders for both urban and rural children (144.5%) surpassed pre-pandemic levels in year 2.
DISCUSSION
The onset of the COVID-19 pandemic was associated with major changes in IFTs in year 1 of the pandemic, with O-E transfers less than 15% of pre-pandemic levels for both urban- and rural-residing children. During year 2, transfer ratios remained less than anticipated for medical and surgical transfers for urban-residing children, although demonstrated return-to-expected levels for rural children. Mental health indications for transfer, however, far exceeded pre-pandemic levels for both urban and rural children; O-E ratios for rural children surpassed more than 125% of pre-pandemic transfer levels.
During the early pandemic, pediatric admissions to children’s hospitals decreased significantly,16 consistent with our results demonstrating an 85% reduction in expected transfers in year 1 from pre-pandemic. Pre-pandemic, the most common pediatric diagnoses for hospitalization were virally mediated (eg, bronchiolitis and asthma). Social distancing measures, school closures, and cancellation of mass gatherings are thought to have substantially reduced the spread of viruses in children.17 The resulting rebound in year 1 is consistent with national trends of decreasing social distancing measures combined with the COVID surge in December 2020 and January 2021.18
The COVID-19 pandemic has led to increased rates of children and adolescents seeking care for acute mental health crises across all geographic locations,19–22 as corroborated by our data demonstrating increased levels of IFTs for mental health diagnoses for both urban and rural children in year 2. However, the impact of this trend is potentially more acute in children from rural communities. Pre-pandemic, children who lived in rural areas in the United States already experienced limited access to mental health care compared to children who lived within urban settings.23 Arakelyan and Leyenaar recently demonstrated increased rates of pediatric emergency visits for suicide and self-harm during the COVID-19 pandemic for children seeking care at a rural hospital.24 In addition, rural hospitals are more likely to be resourced to care for common medical conditions (such as pneumonia), but less likely to be equipped to care for children in a mental health crisis.25 With 60% of Mental Health Professional Shortage Areas being in rural communities,26 it is not surprising that IFTs for pediatric mental health conditions from rural communities have increased in the setting of an increased need for these services.
Similarly, in addition to the increased mental health needs of children through the pandemic, our findings demonstrate a shift in the medical diagnoses requiring transfer from respiratory conditions pre-pandemic to increased frequency of diabetes and malnutrition transfers during the pandemic. Past studies have shown that resources and quality of care outcomes for pediatric diabetes management in rural children are significantly worse than for urban children,27 and rural children are more likely to present with diabetic complications, such as diabetic ketoacidosis (DKA).28 These findings may be used by rural hospitals to prioritize trainings on higher frequency diagnoses.
IFTs are influenced by a variety of potential factors. While the number of children presenting for acute care for mental health conditions has increased through the pandemic,24 the availability and utilization of resources for pediatric care is dynamic.
Even prior to the COVID-19 pandemic, Cushing et al. described a decreasing capacity of pediatric inpatient units at general hospitals to care for children, with a greater proportion of pediatric bed and unit closures in rural communities.29 Closure of these units, particularly in rural settings, has created a system where providing appropriate medical care to children in rural communities is increasingly dependent upon transfer to referral centers distant from home. Furthermore, at a time when referral centers for children are operating at maximum capacity,30 rural children presenting with high-risk conditions, such as suicidality and DKA, may be at increased risk of morbidity and mortality due to delays in IFTs.
As our data are observational, it is also possible that the increase in mental health IFTs reflects increased support due to the rapid upscale of telehealth during the pandemic.31 The use of telehealth for medical conditions has been shown to improve the appropriateness of IFTs from rural hospitals to referral centers,32,33 and increased networking during the pandemic between referring and referral hospitals may have allowed more children to be referred appropriately for specialty care.
Innovative solutions to address the evolving needs for resources for children in rural hospitals are needed. Although telehealth for disease-specific care, such as for diabetes34 and mental health care,35 may represent ways to support rural hospitals to care for children in crisis, policy-level changes are needed. Children in rural areas are more likely to receive Medicaid than those in urban areas,36 and policy incentivizing Medicaid-focused reimbursement and alternative payment models may further support maintaining pediatric services in these at-risk areas.
Limitations to this study are that the data represent only the volume of transfers that were received at children’s hospitals and not the actual volume of children presenting for care at or requiring transfer from rural or urban hospitals. Administrative data are also retrospective and observational in nature and large-scale data sets are frequently over-powered to detect differences.37 We in fact see this within our data as demonstrated by all P-values in Table 1 being < .001, which are statistically but not necessarily significant on a clinical or population-health level. In addition, data are only released every 3 months, so real-time data are unavailable. Lastly, patient RUCA codes reflect the patient’s home residence and do not indicate if they went to a rurally located hospital prior to transfer.
CONCLUSIONS
Pediatric IFTs decreased dramatically during year 1 of the pandemic, and while transfers in year 2 for medical and surgical diagnoses for rural children resumed pre-pandemic volumes, transfers for mental health conditions significantly exceeded pre-pandemic levels. Children from rural areas experience proportionately increased IFT needs compared to urban children, which may illustrate the unmet need for definitive care in their local communities and potentially contributing to ongoing rural health disparities.
Supplementary Material
Funding information
Agency for Healthcare Quality, Grant/Award Number: K08HS028683
Footnotes
CONFLICTS OF INTEREST
We have no financial conflicts of interest.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
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