PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1068-1071
Utilization of Pediatric Hospitals in New York State
* Department of Pediatrics
College of Medicine, Upstate Medical University, State University of New York, Syracuse, New York.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Background.Little published information is available regarding the proportion of hospitals that offer pediatric services at specified levels, or the actual utilization of such services.
Objective.To determine if an existing national accreditation process created for educational purposes identifies hospitals with a distinct utilization pattern, in a sample of pediatric inpatient activity from one state.
Methods.Hospitals in New York State were classified as "pediatric" hospitals according to their sponsorship or major participation with an accredited pediatric residence program. Institutions not affiliated with pediatric residencies were considered to be the "other" hospitals. Data on hospital discharges and interhospital transfers were studied for children from 0 to 14 years old, excluding neonatal Diagnosis-Related Groups. Data were obtained from the New York Statewide Planning and Research Cooperative System for 1996, 1997, and 2000.
Results.Sixteen percent of hospitals were considered to be "pediatric" facilities (42 of 257) by study criteria. Annual pediatric inpatient activity per "pediatric" hospital significantly exceeded that in "other" institutions, including hospitalizations (2249 ± 1284 vs 258 ± 348), number of interhospital transfers received (153 ± 88 vs 18 ± 26), and number of hospitals referring interhospital transfers to each receiving hospital (36 ± 17 vs 5 ± 7; mean ± standard deviation; for each comparison). Statewide, "pediatric" hospitals served two thirds of all hospitalized children and 70% of all children’s hospital days. "Pediatric" hospitals cared for 26.5 patients per hospital day, compared with only 2.2 per day at "other" institutions. Although statewide hospitalizations of children fell by 14.3% the proportion of all pediatric hospitalizations served by "pediatric" hospitals increased by 3.8% from 1996 to 2000.
Conclusions.Although intended for educational purposes, hospital affiliation with an accredited pediatric residency program identifies a subgroup of facilities with a distinct utilization pattern, which provides care for the majority of pediatric inpatients, and serves as a resource to other hospitals.
Key Words: access • accreditation • designation • network • regionalization
Abbreviations: SD, standrd deviation
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Optimal care of severely ill or injured children requires appropriate organization of hospital resources. Emergency services must be widely distributed to provide timely care for urgent local needs. Care of the most complex problems is best handled by interdisciplinary teams at comprehensive regional pediatric hospitals. These should have a more restricted distribution to achieve the clinical volume necessary to maintain proficiency and to avoid costly redundancy. Recently, organizational principles have been outlined for a regional system of pediatric acute care services.1 An effective organizational framework would include categorization, identifying the capabilities and services that should be provided by facilities at specified levels. Based on such categories, facilities would be accredited, indicating approval from a certifying group that a facility’s intention to provide a specified level of care is justified by available resources. Finally, designation (usually by a governmental agency) would implement categorization and accreditation, by directing patients to appropriate institutions, according to facility capabilities.
Appropriate capabilities for many categories of pediatric acute care services have been addressed in the recommendations of national professional organizations.2–9 Hospitals serve as a central element in the acute care system. However, little published information is available regarding the proportion of hospitals that offer pediatric services at specified levels, or the actual utilization of such services. Although federal efforts to improve disaster preparedness are in progress, there are few nationwide examples of accreditation or designation of pediatric acute care services, so pediatric hospitals are difficult to identify.
One existing national accreditation process pertains to pediatric hospital services. Hospitals can be identified that sponsor or have a major participation with an accredited pediatric residency program.10 Pediatric residencies are accredited according to uniform national standards by the Accreditation Council for Graduate Medical Education.11 Programs are evaluated according to many criteria, only some involving acute care. Although individual hospital services are not scrutinized in sufficient detail to evaluate specific acute care capabilities, accredited programs are required to provide a range of pediatric hospital medical and surgical services, at a volume sufficient to provide residents with an adequate educational experience. Thus, hospital affiliation with an accredited pediatric residency might serve as a convenient national marker for hospitals that tend to provide pediatric care in a way that is distinguishable from other hospitals, even without local designation or regulation.
This cross-sectional study was performed to investigate the relationship between hospital affiliation with an accredited pediatric residency program, and actual utilization of these hospital resources, in observations of 1 state. Lacking published information on the impact of national efforts to provide comprehensive pediatric care, such data might provide a perspective for future investigation and improvement of the acute care system. Our observations indicate that an existing national accreditation process is associated with distinct hospital utilization patterns.
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METHODS |
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Design and Data
For purposes of the study, those hospitals sponsoring, or having a major participation with an accredited pediatric residency program, were referred to as "pediatric" hospitals.10 Hospitals without such status were considered the "others". Pediatric inpatient activity per hospital in New York State was measured as the number of hospitalized children, the number of children admitted as interhospital transfers to each receiving hospital, and the number of hospitals referring interhospital transfers to each receiving hospital. Activity per "pediatric" hospital was compared with per hospital activity at the "others". Annual activity for individual hospitals was analyzed for 1997. In addition, total annual New York statewide pediatric inpatient activity was described as the number of hospitalized patients and hospital days at "pediatric" and "other" hospitals for the most currently available data and 4-year trend (1996 and 2000). The utilization patterns identified in this study reflect choices made, or barriers faced, by providers, families, and payers. No state regulatory process requires or restricts admission of a child to any hospital.
Because health insurance coverage may influence access to certain health care services, health insurance coverage for inpatients at "pediatric" and "other" hospitals was described for 2000, along with the 4-year trend. Health insurance coverage was classified as commercial (including commercial insurance companies, health maintenance organizations, self-insured, worker’s compensation, and no fault), public (predominantly Medicaid, as well as Medicare and other governmental), none, or other (no charge, or "other").
Pediatric hospital inpatient data were analyzed for children ages 0 to 14 years, excluding neonatal Diagnosis-Related Groups (385–391). The age range was selected because most evidence supporting the benefit of pediatric-specific care involves younger age groups.12,13 Neonatal care was excluded from analysis because separate facilities usually are provided for such care. Data on hospital discharges, length of stay, and insurance coverage were obtained from the New York Statewide Planning and Research Cooperative System.14 The data, collected for administrative purposes, are publicly available, with no individual patient identifiers.
Interhospital transfers were identified as those patients with multiple admissions, having an inpatient discharge and subsequent readmission to a different hospital on the same or next day. These data do not include transfers from emergency departments at 1 hospital to inpatient care at another hospital. Random identification numbers were provided by Statewide Planning and Research Cooperative System as a substitute for the patients’ real identification numbers, allowing the recognition of sequential discharge and readmission of transferred patients, without compromising anonymity.
Analysis
Hospitals were considered to be the units of analysis. Potential differences in pediatric inpatient activity between "pediatric" and "other" hospitals were analyzed by unpaired t test. Differences were considered to be statistically significant if P < .05. Total statewide activity was summarized as patient numbers and hospital days. Percent change in activity from 1996–2000 was expressed within and between groups of hospitals or within and between types of insurance coverage.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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"Pediatric" hospitals accounted for 16% (42 of 257) of institutions in New York State. Annual pediatric inpatient activity per "pediatric" hospital significantly exceeded that in "other" institutions, including hospitalizations (2249 ± 1284 vs 258 ± 348), interhospital transfers received (153 ± 88 vs 18 ± 26), and the number of hospitals referring interhospital transfers to each receiving hospital (36 ± 17 vs 5 ± 7), respectively (P < .05; mean ± standard deviation [SD]; for each comparison; Figs1 and 2). "Pediatric" hospitals account for over 90% of institutions in the top tenth percentile for activity by each of these measures.
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) and per "other" hospital (•) (*P < .05; mean ± SD).
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Statewide, "pediatric" hospitals provided care for two thirds of hospitalized children, and for 70% of all pediatric hospital days (Tables1 and2). These hospitals cared for an average of 26.5 pediatric patients per day compared with 2.2 per day at "other" institutions. Total pediatric hospitalizations at all hospitals decreased by 14% and hospital days fell by 17% from 1996 to 2000. Because greater reductions occurred proportionately at "other" hospitals, "pediatric" facilities provided an increasing proportion of inpatient care of children (Tables 1 and 2).
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The largest single payer for pediatric hospital care statewide was Medicaid, with 45% of hospitalizations and 52% of hospital days covered by public insurance. During 1996 through 2000, the proportion of hospitalized children with commercial insurance rose by
5%, balanced by a similar reduction in the number having public insurance coverage. At "pediatric" hospitals, 47% of hospitalized children were covered by public health insurance, while 8% lacked insurance. Publicly funded and uninsured proportions were slightly lower at "other" hospitals (Table3).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Although accreditation of pediatric residency programs is intended for educational, not service-related purposes, the present study indicates that in 1 state, affiliation with an accredited residency identifies a subgroup of hospitals with a distinct utilization pattern. The majority of pediatric hospital care is conducted at hospitals easily identifiable by their sponsorship or major participation with accredited pediatric residency programs. Although no attempt could be made in the present study to evaluate quality of hospital care, higher clinical volume is often associated with better outcomes.12,13,15 Thus, the "pediatric" hospitals tend to have the clinical volume that might promote high clinical quality. In contrast, some of the "other" hospitals have such low volumes of pediatric activity it might be difficult to provide high quality care for infants and children.
Expressing utilization as the number of hospitalized children and their hospital days provides a general measure of pediatric clinical activity. Numbers of interhospital transfers, and numbers of hospitals referring transfers to each receiving hospital, provide a measure of each hospital’s role as a resource to other institutions in a regional system. If transfers are considered to represent interactions between nodes in a network, then institutions with a high number of such interactions can be considered to have a high degree of importance or "centrality" in that system.16
Most hospitalized children have health insurance coverage. Although the lack of health insurance may interfere with access to discretionary health care,17 it is less likely that mandatory care for acute illness is dependent on insurance coverage. With public insurance supporting a substantial portion of the costs of pediatric hospital activity, the public has a financial interest in the efficiency, as well as the quality and accessibility of services. For example, achieving an optimal distribution of the most expensive comprehensive services might ensure their accessibility, while avoiding costly redundancy, driven by competitive interests.18,19 Because of their dependence on public funding, "pediatric" hospitals have a financial interest in public understanding of their services. This might include an interest in identifying themselves more clearly.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A system is best understood in terms of its organization, in addition to the behavior of its components in isolation, whether the system is an organism20 or a system of hospital resources in a region. Before experiments can be designed to investigate how a system works, a preliminary description of the system is necessary to formulate testable hypotheses. The present observations describe utilization of the existing hospital system that serves children in 1 state. "Pediatric" hospitals are defined in a way that is generalizable, based on uniform national standards. "Pediatric" hospitals identified in this way care for the majority of hospitalized children, serve as a resource to other hospitals in a region, and this activity is substantially funded by public health insurance coverage.
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FOOTNOTES |
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Received for publication Jan 22, 2002; Accepted Sep 14, 2002.
Address correspondence to Robert K. Kanter, MD, Department of Pediatrics, Upstate Medical University, State University of New York, 750 E Adams St, Syracuse, NY 13210. E-mail: kanterr{at}upstate.edu
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REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Critical Care Medicine, Society of Critical Care Medicine, Pediatric Section. Consensus report for regionalization of services for critically ill or injured children. Pediatrics.2000; 105 :152 –155
2. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. Guidelines for pediatric emergency care facilities.
Pediatrics.1995; 96
:526
–537
3. American Academy of Pediatrics, Committee on Hospital Care, Pediatric Section of the Society of Critical Care Medicine. Guidelines and levels of care for pediatric intensive care units.
Pediatrics.1993; 92
:166
–175
4. American College of Surgeons, Committee on Trauma. Resources for Optimal Care of the Injured Patient: 1998. Chicago, IL: American College of Surgeons; 1998
5. American Academy of Pediatrics, Task Force on Interhospital Transport. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. Elk Grove Village, IL: American Academy of Pediatrics. 1993
6. American Academy of Pediatrics, Section on Cardiology and Cardiac Surgery. Guidelines for pediatric cardiovascular centers.
Pediatrics.2002; 109
:544
–549
7. Emergency Medical Services for Children, Task Force on Children with Special Health Care Needs. EMS for children: recommendations for coordinating care for children with special health care needs. Ann Emerg Med.1997; 30 :274 –280[CrossRef][Web of Science][Medline]
8. American Academy of Pediatrics, Committee on Hospital Care. Facilities and equipment for the care of pediatric patients in a community hospital.
Pediatrics.1998; 101
:1089
–1090
9. American Academy of Pediatrics, Committee on Hospital Care. Staffing patterns for patient care and support personnel in a general pediatric unit.
Pediatrics.1994; 93
:850
–854
10. American Medical Association. Graduate Medical Education Directory, 1996–1997, and 1999–2000. Chicago, IL: American Medical Association
11. Accreditation Council for Graduate Medical Education. Program Requirements for Residency Education in Pediatrics. Chicago, IL: Accreditation Council for Graduate Medical Education; 2001. Available at: www.acgme.org
12. Hannan EL, Racz M, Kavey RE, et al. Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality.
Pediatrics.1998; 101
:963
–969
13. Tilford JM, Simpson PM, Green JW, et al. Volume outcome relationship in pediatric intensive care units.
Pediatrics.2000; 106
:289
–292
14. New York State Department of Health. New York Statewide Planning and Research Cooperative System (SPARCS). Albany, NY: 1996, 1997, and 2001
15. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States.
N Engl J Med.2002; 346
:1128
–1137
16. Scott J. Social Network Analysis. Thousand Oaks, CA: Sage Publications, Inc; 2000
17. Berk ML, Schur CL. Measuring access to care: improving information for policymakers. Health Affairs.1998; 17 :180 –186[CrossRef][Medline]
18. Richardson DK, Reed K, Cutler C, et al. Perinatal regionalization versus hospital competition: the Hartford example.
Pediatrics.1995; 96
:417
–423
19. Goodman DC, Fisher ES, Little GA, et al. The relation between the availability of neonatal care and neonatal mortality.
N Engl J Med.2002; 346
:1538
–1544
20. Chong L, Ray LB. Whole-istic biology. Science.2002; 295 :1661[Abstract]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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