Why are pediatric services declining in major cities?

When adults get sick, they usually have multiple options for care in a single city. For kids, these options are shrinking, and more and more pediatric inpatient cases are requiring a transfer to another hospital.

According to a new study published in Pediatrics, pediatric care was significantly more limited when compared with adults across the 4 states observed.¹

Researchers combed through emergency department (ED) and administrative data in California, Florida, Massachusetts, and New York to determine the transfer frequency and where care was most often completed in pediatric cases. More than 250 million cases were studied between 2006 and 2013, and the research team found that during this time frame, pediatric admissions decreased by 9.3% but interhospital transfers increased by 24.6%. An increasing number of these transfers were for common conditions, including asthma and abdominal pain, according to the report, and this shows that even basic pediatric services are lacking in many of the facilities studied. During the same study period, adult admissions were relatively constant and the transfer rate was 24.8%.

 Pediatric transfers increased in every state studied, the researchers say, while the number of hospitals that offered pediatric services declined. For example, the study shows that the number of hospitals admitting 10 or more children in California dropped by 24 from 2006 to 2011. There were 20 fewer hospitals admitting children in Florida over a similar time frame, 7 fewer in Massachusetts, and 29 fewer hospitals in New York, according to the data. These changes were not seen in adult care, with the number of hospitals serving adults decreasing at much smaller rates or remaining unchanged.

“Although most hospitals continued to care for adults with a wide range of conditions, we observed a steady decrease in the average scope of the pediatric care they offered and an increasing dependence on referral centers,” the researchers point out. “Within all 4 states, there were similar overall and condition-specific patterns of pediatric care regionalization.”

Michael McManus, MD, MPH, associate professor at Harvard Medical School, BCH Endowed Chair for Critical Care Anesthesiology at Boston Children’s Hospital, Boston, Massachusetts, and co-author of the report, says the study makes it clear that pediatric inpatient options are decreasing and that work needs to be done to ensure that networks of care still include facilities for children. How to achieve this remains a question, he notes.

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“This is a complex question that we are actively trying to answer,” McManus says. “From a care perspective, some conditions clearly benefit from regionalization while others probably do not. From an institutional perspective, some institutions may clearly benefit from increased market share, while others may be overcrowded or, in risk-sharing environments, lose money caring for simple conditions on high-cost platforms. From a systems perspective, increasing care concentration leaves large regions dependent on a small number of providers, so more vulnerable to problems within those providers.”

McManus says he hopes stakeholders will take note of the study results and help ensure appropriate services for this population. “I hope policymakers concerned with hospital care will specifically consider the needs of children and not simply generalize experiences drawn from adults,” he says. “For clinical practice, I hope we can maintain and improve access to quality hospital care for children.”