Dr. Katy Kozhimannil: "What’s at Stake as Rural America Loses Its Hospitals"
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Dr. Katy Kozhimannil's slides from the Center for Health Journalism webinar, "What’s at Stake as Rural America Loses Its Hospitals" 1.22.19 More info: https://www.centerforhealthjournalism.org/content/what-s-stake-rural-america-loses-its-hospitals
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Dr. Katy Kozhimannil: "What’s at Stake as Rural America Loses Its Hospitals"
- 1. Research and Stories from Moms in Rural America Katy Kozhimannil, PhD, MPA USC Annenberg’s Center for Health Journalism January 22, 2019
- 2. Overview • Our Research on Rural Obstetric Unit Closures and Media Interactions • Telling the Rural Story: Guidance and Resources
- 3. University of Minnesota Rural Health Research Center Mission
- 4. Recent RHRC Projects • Measuring the Quality of Swing- Bed Care in Critical Access Hospitals • Obstetric Unit and Hospital Closures and Maternal and Infant Health in Rural Communities • Paving the Way: Transportation as a Social Determinant of Health for Rural Residents • Skilled Nursing Facility Care for Rural Residents with Complex Care Needs • Access and Quality of Care for Rural Patients with Chronic Obstructive Pulmonary Disease (COPD) • Addressing Rural Social Isolation as a Health and Mortality Risk Factor • Caring for Caregivers: Available Support for Unpaid Caregivers in Rural Areas • Rural-Urban Differences in Opioid- Affected Pregnancies and Births
- 5. • 18 million reproductive-age women live in rural US communities • Half a million babies born in rural hospitals each year • Declining access to obstetric services at rural hospitals • And a group of women in rural Alabama asked their member of Congress if what they were seeing in their communities was unique or part of a broader pattern. The Story of This Project…
- 6. But First, Why Do Rural Hospitals Close? • Financial constraints – Fixed costs are constant, and revenue is variable and depends on volume – Payer mix and the role of Medicaid • Workforce constraints – Yes, it’s physician shortages, but also nursing and administration • Patient safety concerns – When the clinical team is worried about the ability to provide safe care. (Remember rural folks are sicker.) • Rural Hospital Closure Tracking http://bit.ly/ruralclosures • Consequences may be mixed and are not well-documented
- 7. Rural Obstetric Unit and Hospital Closures • From 2004-2014, how many rural communities lost hospital-based obstetric services?
- 8. Percent of Rural Counties with Hospital OB Services, 2004-2014
- 9. Hospital Obstetric Services in Rural Counties, 2004 - 2014 Hung, P., Henning-Smith, C., Casey, M., & Kozhimannil, K. (2017). Access to obstetrics services in rural counties still declining, with 9 percent losing services, 2004-2014. Health Affairs, 36(9), 1663-1671.
- 10. Key Findings on Closures • More than half of rural counties have no hospital-based obstetrics services – 9% of rural counties lost OB services between 2004-2014 – Most vulnerable communities: low-income, physician shortage areas, remote, black, less generous Medicaid programs • The women in rural Alabama were exactly right – their communities were more deeply affected.
- 11. What Are the Consequences of OB Unit Closures? • For rural counties that lost hospital- based obstetric services between 2004-2014, what were the associated changes in birth location and birth outcomes?
- 12. Key Findings on Changes in Birth Location and Outcomes • After losing obstetric services, rural counties that are not adjacent to urban areas had higher rates of preterm birth, out-of-hospital birth, and births in hospitals without obstetric units. • In rural counties next to urban areas, there was also an increase in births in hospitals without obstetric units, although this declined as time went on.
- 13. jamanetwork.com Available at jama.com and on The JAMA Network Reader at mobile.jamanetwork.com Kozhimannil, Hung, Henning-Smith, et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States Published online March 8, 2018
- 14. US Senate Briefing: Improving Access to Maternity Care Act • March 8, 2018, International Women’s Day • Sponsored by Sen. Baldwin, with ACOG, ACNM, Every Mother Counts • Signed into law Dec 2018
- 15. Media Coverage • Connecting research findings with people’s stories • Developing relationships with reporters and communities – Including off the record conversations • Various types of media coverage (online, newspaper print, radio, TV, magazine)
- 16. Example: Wall Street Journal • “Rural America’s Childbirth Crisis: The Fight to Save Whitney Brown” – McMinnville, Tennessee – Story of Whitney Brown in the broad context of declining rural maternity care access • Betsy McKay – 4-5 background conversations over several months
- 17. Key Take-Aways for Journalists Covering Rural Hospital Closures (and Rural Health) • Please do it! Rural stories matter, and journalism is sometimes the first or most catalytic lens on key issues. • It’s not just about doctors or money or malpractice. It’s got a soul. • Don't pity us - rural is strong, resilient, beautiful, courageous. • There is evidence - please work with us at RHRCs and check out publications on the Gateway. • There are resources (next slides!)
- 18. Key Resource on Rural Health Topics Rural Health Information Hub (RHIhub) www.ruralhealthinfo.org Ex: Am I Rural Tool?
- 20. RHRCs Across the Country Source: Rural Health Research Gateway
- 21. Where to Find Products from all RHRCs • Rural Health Research Gateway: www.ruralhealthresearch.org
- 22. Key Resource: Communities • People in rural hospitals, clinics, governments, and organizations tend to pick up the phone. • But be respectful of their privacy; what they share with you, if it becomes public, stays with them long after you leave and your story goes to print.
- 23. Thank You! Katy Kozhimannil | kbk@umn.edu | @katybkoz
Hinweis der Redaktion
- Over 18 million reproductive-age women (18-44) live in rural U.S. counties.1 Access to obstetric care in rural communities is critical to ensuring good maternal and child health outcomes. Prior research shows that greater travel distances for obstetric services are associated with higher rates of newborn morbidity and mortality.2 In 2002, 43% of rural counties in the U.S. had no hospital-based obstetric services,3 despite the fact that over 98% of births occurred in hospitals.4 Additionally, the number of rural hospitals providing obstetric care has been decreasing.5 Published reports and media coverage both indicate that these obstetric care access problems are related to recent hospital and obstetric unit closures in rural areas,6-8 but the national scope of the access problems has not been quantified. Data are needed to inform policy efforts, as no current research documents the current level and pace of hospital and obstetric unit closures. Better understanding of the extent of hospital obstetric unit closures in micropolitan and noncore rural counties nationally is a crucial first step to inform policy efforts in improving obstetric care access.
- We know that there has been a decline in rural hospitals providing obstetric care and in rural hospitals generally, but until we started this work at the Rural Health Research Center, there was very little recent research describing this phenomenon on a national scale. Project goals: The project will examine the relationship between closure of an obstetric unit or hospital and maternity care and outcomes of childbirth in rural US counties, including prenatal care, distance to delivery hospital, out-of-hospital birth, and infant health outcomes.
- As shown in Figure 3, there was a substantial downward trend in the percentage of rural noncore counties with in-county hospital obstetric services from 2004-2014. In 2004, 40.4% of rural noncore counties had in-county hospital obstetric services available; this decreased to 30.2% in 2014. In 2014, almost three-quarters of rural noncore counties did not have in-county hospital obstetric care.
- This map shows the scope of rural obstetric unit loss that we found during the study period. Those counties shaded in black lost obstetric services; those in dark blue never had services to begin with during the study period. Those with lighter blue are rural counties that had continual services between 2004-2014. The white counties are metropolitan counties and were not included in our study.
- To review, we found that more than half of all rural counties had no hospital-based obstetric services, as of 2014. Nine percent of all rural counties lost their hospital-based obstetric services between 2004-2014. Anecdotally, we know that losses have continued since 2014. The losses were not random. The communities at the highest risk of losing their hospital-based obstetric services were those that were black, low-income, more remote (non-core), and had lower birth volumes and smaller workforces.
- Building on the work of rural obstetric unit loss, we investigated what the associated changes were in where babies were being born and in birth outcomes in counties that had lost obstetric services. Up until we published these findings, there was no good, national evidence of any measurable changes following rural obstetric unit loss.
- To summarize, in rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.
- The results from this study were published in JAMA on March 8, which happens to be International Women’s Day. We were able to unveil these findings at a Congressional Briefing, building on the incredible interest in and momentum around this issue that has been building in recent years.