Fewer hospitals offer pediatric services

For the study, researchers used data from the Healthcare Cost and Utilization Project Kids' Inpatient Database to identify U.S. acute care hospitals offering pediatric services between 2003 and 2022. Pediatric capability level ranged from 1 to 4, depending on how many pediatric services they offered. Level 1 hospitals offered the broadest range of services, while level 4 hospitals only offered minimal services.

A mean of 3,927 hospitals per year were included in the analysis. In 2022, 67.3% of the hospitals were nonprofit, 39.7% were urban teaching, 47% were small, and 37.4% were in the South.

"Over 2 decades, fewer pediatric services were provided across U.S. hospitals," the researchers wrote. "This resulted in level 4 hospitals, those with the fewest pediatric capabilities, more than doubling, accounting for 27% of hospitals in 2003 and 65% in 2022."

The researchers also looked at changes in the specific services offered at hospitals. The services with the greatest declines were appendectomy (-50.5%), pneumonia hospitalization (-42.3%), and asthma hospitalization (-41.1%). The services with the smallest changes were extracorporeal membrane oxygenation (+0.8%), organ transplant (0%), and Fontan surgery (-0.1%).

Commentary

According to Kenneth Michelson, the study's lead author from the Ann & Robert Lurie Children's Hospital, "[i]n the beginning of the 2000s, most families could rely on being close to a hospital with substantial pediatric services, [but] now that has flipped — most families don't live near such a hospital."

Over the last two decades, several factors have likely contributed to the decline in pediatric inpatient and surgical capabilities, including lower reimbursement for pediatric vs. adult inpatient care and staffing shortages.

Separately, Aaron Jurgaitis, VP of provider actuarial services at Optum Advisory, said there is not much supply being created for pediatric care, including specialties. This lack of pediatric-focused specialists has created a supply spiral since health systems don't want to invest in niche specialties that could be underutilized.

As the availability of pediatric care decreases, families and children will need to travel farther to access needed care — which could lead some families to forego care, Jurgaitis added.

In general, "this shrinking supply [of pediatric services] does significantly hinder readiness for anything that may be running through a pediatric population – like measles currently spreading through the country," Jurgaitis said.

As supply and demand for pediatric care continues to shift, Preble recommends providers:

•  Understand the specific local market need for pediatric care
• Create and strengthen connection points across different providers
• Partner together to fill any gaps in care
• Use technology as feasible to help expand care time and communication networks

In an accompanying commentary, Michelle Macy, from the Northwestern University Feinberg School of Medicine, and Jessica Bettenhausen, from the University of Missouri-Kansas, also outlined potential actions that could help address the decline in pediatric capabilities at hospitals.

For example, tele-emergency consultations, hospital-at-home, and other virtual care models have helped reduce unnecessary transfers between rural and community EDs and pediatric referral centers. Tools like the National Pediatric Readiness Project can also help EDs complete self-assessment and implement new programs to improve their pediatric readiness.

"Any further reduction in coverage or reimbursement is a potential threat to the financial viability of hospitals, especially those in underserved areas," Macy and Bettenhausen wrote. "In addition, the widespread growth in observation status amplifies the need to realign payment models with actual care intensity to avoid underfunding hospitals managing complex pediatric cases under this billing designation."

"In the absence of major policy changes toward building capacity, hospitals will need to fill in the loss of access with new ways of bringing pediatric expertise when it's needed," Michelson said. "I think we need real funding to study solutions to fill in the huge new gaps in pediatric hospital care."

*Advisory Board is a subsidiary of Optum. All Advisory Board research, expert perspectives, and recommendations remain independent.