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Improving access to Pediatric Urological Surgical Care in Rural settings: a model of care in collaboration with adult urologists and a community hospital
Paul A. Merguerian, MD, MS1, Carlyn Doyle, ARNP2, Karl Westenfelder, MD2, Vasillis Siomos, MD1, Mark Cain, MD1.
1Seattle Children's Hospital, Seattle, WA, USA, 2Community Medical Center, Missoula, MT, USA.

Introduction: Nearly 12 million children live in the rural US, with reduced access to pediatric specialty care. Over the past 10 years there has been a change in the specialty of pediatric urology, with a marked increase in number of training programs and pediatric urologists. This growth has been in urban settings with little growth in rural areas making access to pediatric urological care limited. This disparity is further aggravated with the increasing cost of living and cost of transportation in economically disadvantaged counties. The aim of this study is to describe a method of providing high quality pediatric urological care in rural settings. Methods: In order to provide pediatric urological care in a large rural (population 73,000) and small rural (population 24,000) location in the State of Montana we created a model of care in collaboration with local adult urologists. In the larger rural setting an APP hired by the local community hospital system was trained to manage pediatric urological patients. She provided non-surgical urological care with constant consultation with our urban academic pediatric urology program. Two pediatric urologists provided in person care based on demand. In the large rural setting one pediatric urologist provided local care every 8 weeks for 2 days where consults were seen the first day and surgery performed with the local urologists on the second day. Anesthesia care was provided by an anesthesiologist with pediatric training. Post-operative care (inpatient and outpatient) was provided by the local APP and urologists together with the pediatric urologist. In the smaller rural setting we worked together with an adult urologist without an APP. The adult urologist managed all non-surgical pediatric urological cases and every 6 months a pediatric urologist would provide local surgical care for a period of 2 days. Complex procedures such as urological reconstruction and robotic surgery from both sites were referred to the tertiary care center at our institution. We retrospectively reviewed the surgical procedures performed over a 3 year period (2019-2022) and evaluated outcomes of these patients. Results: During a 3 year period a total of 187 outpatient visits including a total of 12 prenatal consultations, and 82 surgical procedures were performed. During the period reviewed we did not provide in person care for 8 months due to the pandemic, but utilized telehealth consultation to provide continued support at both rural sites. The procedures performed and outcomes are shown in the table below.
Conclusion: Creating a team concept of pairing pediatric surgical specialists with local adult urologists and APPs, and providing in person surgical and ambulatory care based on local demand can provide the same outcomes that can be achieved at a tertiary children's hospital for many pediatric urologic surgical problems. This promotes the concept of care close to home and results in increase access of pediatric specialty care in rural areas.

Procedures performed and outcomes
ProcedureNumberComplications
Distal and midshaft hypospadiasDistal and midshaft hypospadias301 Fistula
Revision Mitrofanoff4None
Ureteral reimplantation11none
Ureteroureterostomy1None
Dismembered Pyeloplasty8None
Orchiopexy/Hernia14None
Cystoscopy valve ablation2None
Penile cases11None
Bladder augmentation in 18 yr old1None


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