Impact of a Critical Access Obstetric Unit Closure on Infant Pediatric Urology Referrals

Patients living in rural and underserved areas may have delayed access to healthcare. Hospital closures exacerbate these challenges. In 2022, an obstetric unit located in a critical access hospital in a rural and underresourced area closed unexpectedly. We undertook this study to describe changes in pediatric urology patterns before and after the hospital closure.

We performed a retrospective review of all infant urology patients living in zip codes served by the critical access hospital, who presented for new outpatient clinic visits at a single freestanding quaternary care children's hospital in the first three months of 2022 (before closure) and 2023 (after closure). We collected patients' demographics, diagnosis, and state Area Deprivation Index (ADI) decile based on the patient's home address. Demographics were described using measures of central tendency, and groups were compared using chi-square tests, odds ratios, and multivariate modeling, where appropriate.

In 2022 (before closure), 466 new patients were seen in three months, compared with 371 in 2023 (after closure), an 18% decrease, adjusting for birth rates. The age distribution for infants was similar (median age 0.37 versus 0.42 y) before and after closure. The proportion of patients living in the least (ADI 1-3) and most (ADI 8-10) disadvantaged areas was similar before and after the obstetric unit closure (33.6% versus 34.1% and 13.8% versus 8.4%, respectively), P = 0.62; however, the number of patients from ADI 1-2 decreased by 48%, and in ADI 9-10, it was by 68.5% after the closure. In absolute terms, referrals for hydronephrosis (-27.6%), hydroceles/hernias (-18.2%), and circumcision/penile anatomy concerns (-22.5%) decreased, while referrals for hypospadias (+68.8%) and undescended testicles (+2.9%) increased. On multivariate analysis, only hypospadias referrals showed a significant increase after adjusting for age, ADI group, race/ethnicity, and referral diagnosis group.

Unexpected closure of an obstetric unit in a rural and underserved community was associated with a substantial decrease in absolute referrals to pediatric urology, for both time-sensitive (e.g., hydronephrosis) and electively timed (e.g., circumcision/penile anomaly) referrals. Further research is needed to assess whether referrals are delayed or if patients are not receiving timely diagnoses.