Rural Area Deprivation and Hospitalizations Among Children for Ambulatory Care Sensitive Conditions

Abstract

This study examined the intersection of rurality and community area deprivation using a nine-state sample of inpatient hospitalizations among children (<18 years of age) from 2011. One state from each of the nine US census regions with substantial rural representation and varying degrees of community vulnerability was selected. An area deprivation index was constructed and used in conjunction with rurality to examine differences in the rate of ACSC hospitalizations among children in the sample states. A mixed model with both fixed and random effects was used to test influence of rurality and area deprivation on the odds of a pediatric hospitalization due to an ACSC within the sample. Of primary interest was the interaction of rurality and area deprivation. The study found rural counties are disproportionality represented among the most deprived. Within the least deprived counties, the likelihood of an ACSC hospitalization was significantly lower in rural than among their urban counterparts. However, this rural advantage declines as the level of deprivation increases, suggesting the effect of rurality becomes more important as social and economic advantage deteriorates. We also found ACSC hospitalization to be much higher among racial/ethnic minority children and those with Medicaid or self-pay as an anticipated source of payment. These findings further contribute to the existing body of evidence documenting racial/ethnic disparities in important health related outcomes.

The Intersection of Residence, Community Vulnerability, and Premature Mortality

“…We found that the effect of residing in a rural community was more pronounced among the most deprived counties, especially at the higher percentiles of the YPLL distribution. These findings provide further evidence suggesting that many, but not all, rural communities face a double disadvantage . Altering the trajectory of mortality‐related outcomes in rural communities poses a significant challenge.…”

“…The remaining 5 measures were standardized using z‐scores distribution. Scores for each measure were summed and divided into quartiles to derive the existing deprivation index representing varying degrees of community deprivation . These quartiles were treated as categorical variables in the analysis.…”

“…Recent studies have also noted that economic and social vulnerability play important roles in mortality‐related outcomes . Higher rates of poverty and unemployment, lower levels of educational achievement, and inadequate access to affordable health care are factors that have been associated with poor health outcomes and premature mortality . Previous research also suggests that poverty has a significant impact on mortality within rural areas—noting a 6.2‐year difference in the life expectancy between those residing in affluent rural areas compared to high‐poverty rural areas …”

“…Community deprivation indices are an increasingly common approach used by researchers to characterize the intersection of social context within communities and population health outcomes . Multiple indicators reflecting key vulnerabilities within a community are collapsed into a single measure that characterizes key underlying social and economic constructs that lead to observed differences, rather than examining separate factors alone . Previous studies examining mortality‐related outcomes using various deprivation indices have noted marked differences across deprivation gradients over time …”

“…While previous research has examined differences in mortality‐related outcomes among rural communities and across levels of socioeconomic vulnerability as represented by deprivation indices, few studies have examined rural mortality within comparable levels of socioeconomic vulnerability. Previous research has noted that variation in the level of deprivation among rural communities can differ widely . While higher levels of deprivation are more common among rural communities, not all rural communities experience the same degree of deprivation, which could have implications for examining poor health outcomes within rural communities …”