Trends in Regionalization of Hospital Care for Common Pediatric Conditions

Discussion

This work extends our previous observation that options for pediatric hospital care are decreasing. Here, we report a similar pattern of care concentration in 4 states that together comprise approximately one-quarter of the US population. 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. Within all 4 states, there were similar overall and condition-specific patterns of pediatric care regionalization. The largest changes in regionalization occurred in the care of common conditions, such as abdominal pain, asthma, limb fractures, and gastroenteritis. To some degree, this was due to a decrease in the number of hospitals admitting children, but TRs also increased among hospitals that continued to admit children. Because the availability of definitive pediatric hospital care differs widely from adult care, we believe that this should be taken into consideration during disaster planning and determinations of network adequacy.

This study adds to a growing literature suggesting that pediatric hospital care is under pressure. For some time, pediatric emergency physicians in academic centers have reported seeing an increasing number of children who are referred with minor conditions.^1,2,12,13 At the same time, pediatric surgical specialists have described a gradual migration of low-risk, high-volume procedures into tertiary centers.^3–5,14 Our initial analysis of the entire Massachusetts acute-care hospital system showed a significant shift of all types of pediatric hospital care from community facilities to academic centers.⁶ This report confirms that care is also concentrating in much larger states.

The precise reasons for care concentration remain to be determined. A decrease in overall demand is suggested by Agency for Healthcare Research and Quality reports that national pediatric hospital discharges declined by ∼10% (from 6.47 million to 5.85 million) from 2003 to 2012.¹⁵ Therefore, it is possible that regionalization reflects the closure of services with marginal volume. A decrease in profitability is also suggested by our observation that Medicaid covers an increasing fraction of admitted children as well as national reports that Medicaid coverage is higher among children than adults.¹⁵ Finally, decades of medical success have led to a growing number of children with complex conditions, many of whom may now require care in specialized centers.^16,17 Although simple, common conditions accounted for the most transfers and showed the greatest change in regionalization, we did not attempt to control for comorbidities.

The short- and long-term impacts of care concentration also remain to be seen. Certainly, regionalization of care can yield economies of scale and improvements in quality as children are increasingly cared for by pediatric specialists in pediatric settings. However, the transfer of patients from low-volume to high-volume centers may improve outcomes for some conditions^18,19 but worsen them for others.²⁰ Regionalization may also bring economies of scale and decreased cost under some circumstances but waste and unnecessary expense under others.^13,21,22 Although quality can be improved when children with complex conditions are efficiently conducted to specialists, it may decline if common conditions crowd specialty centers^23–28 and if core competency is lost in firstline rural or community hospitals.^2,29 In addition, lost capacity today can be problematic in the future if US Census Bureau projections of an increasing pediatric population prove correct.³⁰

Regardless of the drivers and consequences of care concentration, it is clear that hospitals now differ widely in their delivery of pediatric care.^6,9 This being so, network experience from adult populations, such as Medicare, is not transferrable. Therefore, all Accountable Care Organizations and hospital networks should be specifically analyzed to ensure that they meet the needs of children. Because roughly half of all hospitalized children receive public insurance, Medicaid network adequacy should be particularly scrutinized. Here, we observed no large differences in the number of transfers between publically and privately insured children, but we did not evaluate differential regionalization by condition or differential capabilities of individual hospitals. However, earlier work in Massachusetts showed the greatest loss of pediatric capability among community-disproportionate share hospitals.⁶

Similarly, the differential capabilities of hospitals with respect to pediatric care should be an important part of disaster planning. Although HCI does not measure physical resources or core competency, it does reflect institutional familiarity with pediatric care. Because hospitals with low pediatric HCIs may perform unevenly in caring for children, crisis standards of care should be formulated accordingly.³¹

This analysis is limited in several ways. First, it relies on large volumes of administrative data and, as such, is subject to errors in data processing, variability in coding, and disagreements with clinical registries.³² Here, we used CCS grouper codes to reduce some of the errors inherent in the Ninth or 10th revisions of the International Classification of Diseases coding and analyzed each state separately to avoid data processing errors. Second, as noted above, we did not give attention to comorbidities, which may have driven some transfer decisions. Although such work is necessary to identify the drivers of regionalization, the degree of regionalization remains unchanged. Third, a complete analysis of care would include mental health conditions, but we excluded these because that care lies predominately outside the system of acute-care hospitals. Fourth, although the states studied here contain both urban and rural populations, they are large and predominantly urban. Although findings here may differ from less populated, more rural states, potentially avoidable pediatric interhospital transfer has been reported in Iowa,¹³ and rural residence has been identified as an independent predictor of transfer within a nationally representative sample of admissions.³³ Finally, we elected to study hospital systems at the state level, although a more granular geographical view would likely offer additional insights.