News Release

Study: Rural children struggle to access hospital services

Findings revealed at the Pediatric Academic Societies 2024 Meeting

Reports and Proceedings

Pediatric Academic Societies

Children in rural areas were more than six times as likely to check into a hospital without pediatric services compared to children in urban areas, a new study found. The research will be presented at the Pediatric Academic Societies (PAS) 2024 Meeting, held May 3-6 in Toronto.

Researchers studied approximately 80,000 hospital claims for nearly 37,000 children with multiple chronic conditions. The hospitalizations occurred between 2012 and 2017 in Colo., Mass., and N.H.

The study found that 41.9% of children in urban areas were first admitted to a children’s hospital for inpatient care, compared to 29.9% of children in rural areas. Nearly half of rural-residing children initially at a hospital without pediatric services were not transferred to a facility with pediatric services.

“Children with medical complexities living in rural areas are especially vulnerable when their nearest hospital closes,” said Seneca Freyleue, MS, research programmer and analyst at the Geisel School of Medicine at Dartmouth and presenting author. “Expanding access to pediatric hospital services can help children with multiple chronic conditions receive care regardless of where they live.”

Despite the type of hospital the child initially visited, the percentage of children in rural areas who died in a hospital wasn’t significantly higher than their urban peers after adjusting for specific disease criteria, researchers concluded.

The results highlight the vital role small rural hospitals play in caring for an at-risk pediatric population, study authors said.

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Seneca Freyleue will present Rural-Urban Differences in Hospital-based Care for Children with Medical Complexity and Associated Health Outcomes” on Saturday, May 4 from 2:45-3:00 PM E.T.
Reporters interested in an interview with Mr. Freyleue should contact Amber Fraley at

The PAS Meeting connects thousands of pediatricians and other health care providers worldwide. For more information, please visit

About the Pediatric Academic Societies Meeting

Pediatric Academic Societies (PAS) Meeting connects thousands of leading pediatric researchers, clinicians, and medical educators worldwide united by a common mission: Connecting the global academic pediatric community to advance scientific discovery and promote innovation in child and adolescent health. The PAS Meeting is produced through the partnership of four leading pediatric associations; the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA), the American Pediatric Society (APS), and the Society for Pediatric Research (SPR). For more information, please visit Follow us on X @PASMeeting and like us on Facebook PASMeeting.

Abstract: Rural-Urban Differences in Hospital-based Care for Children with Medical Complexity and Associated Health Outcomes

Presenting Author: Seneca Freyleue, MS

Organization: Geisel School of Medicine at Dartmouth 


Hospital Medicine: Systems/Population-based Research


Closure of pediatric inpatient units in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC).


(a) Characterize differences in pediatric services availability at acute care hospitals where rural- and urban-residing CMC receive their care; (b) describe rural-urban differences in healthcare quality and in-hospital mortality; and (c) determine if differences are explained by hospitals’ pediatric service availability. 


Non-birth hospitalizations were identified in all-payer claims data from CO, MA and NH (2012-2017). Hospitals were categorized as (i) freestanding children’s hospitals (FCH) or hospitals with (ii) comprehensive, (iii) limited, or (iv) no dedicated pediatric services using American Hospital Association survey data. Index hospitals (where CMC initially presented for care), inter-facility transfers, and definitive care hospitals (where CMC completed their care) were identified. Rural-urban differences in Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators and mortality were modeled using Poisson regression; mediation analysis assessed if index hospitals’ pediatric service availability mediated associations between rurality and these outcomes.


36,943 CMC experienced 79,906 hospitalizations (Table 1). Of these, 32,761 (41.0%) began at FCH, 21,756 (27.2%) at hospitals with comprehensive pediatric services, 23,054 (28.7%) at hospitals with limited pediatric services, and 2,335 (2.9%) at hospitals without dedicated pediatric services. Rural- and urban-residing CMC differed in where they received their initial care (Figure 1); rural-residing CMC were 6.55 times (95%CI: 6.01-7.13) more likely to present at hospitals without dedicated pediatric services. In unadjusted analysis, there were no significant differences in the AHRQ quality measures but rural-residing CMC had a 45% higher risk of in-hospital mortality (RR=1.45, 95%CI=1.03, 2.02, Table 2). Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant (RR=1.30, 95%CI=0.85, 1.76). Index hospital type was not a significant mediator of observed outcomes.


Almost 1-in-6 rural-residing CMC received initial care at hospitals without dedicated pediatric services. Although rural-residing CMC had a higher mortality risk, this difference did not persist in adjusted analysis and pediatric service availability at index hospitals was not a significant mediator of this effect.

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Figure 1 alluvial plots.jpg

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