Post by Nadica (She/Her) on Nov 27, 2024 4:12:56 GMT
US Pediatric Inpatient Care Loss Before and During the COVID-19 Pandemic - Published Nov 22, 2024
Introduction
Early in the COVID-19 pandemic, many hospital pediatric units were repurposed to expand adult capacity in a restructuring process endorsed by the Children’s Hospital Association.1 During the pandemic, pediatric COVID-19 was mild, while school closures and social distancing reduced regular pediatric admissions, so remaining pediatric facilities were financially strained.2 The impact of this dynamic on access to pediatric hospital care has not been assessed, to our knowledge. In this study, we compare prepandemic with 2021 data to estimate changes in the number of hospitals admitting children.
Methods
This retrospective, cross-sectional study was approved by the Boston Children’s Hospital Committee on Clinical Investigation and informed consent was waived because we used deidentified aggregate data. This study is reported in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
We used 2019 and 2021 National Inpatient Sample (NIS) Databases from the Healthcare Cost and Utilization Project. The NIS draws from all Healthcare Cost and Utilization Project hospitals using a self-weighted, cross-sectional sample design that ensures representation across diverse factors, including hospital, census division, ownership, urban-rural location, teaching status, and bed size. We identified all hospitals with at least 1 pediatric (age <15 years) admission, excluding those caring only for infants younger than 1 year. Bootstrapping with 1000 iterations within each NIS strata set of admissions was used to estimate the medians and 95% CIs for the number of hospitals. Sensitivity analyses were performed by removing hospitals with 1 to 100 sampled admissions. Comparisons between hospital characteristics across years were assessed using the χ2 test. P values were 2-sided, and statistical significance was set at P ≤ .05. Analyses were conducted using Python version 3.10 (Python Software Foundation) from May to July 2024.
Results
In the final dataset, 2169 hospitals had at least 1 pediatric admission in 2019 and 1795 hospitals had at least 1 pediatric admission in 2021, a reduction of 17.2% (P < .001). Almost half of this decline (181 of 374 hospitals [48.4%]) was in hospitals with more than 60% of admissions among Medicaid patients (Figure). These reductions were largest in number for hospitals that were private, nonprofit (206 of 374 [55.1%]); small (178 of 374 [47.6%]); or rural (182 of 374 [48.7%]). Compared with 2019, the largest proportional declines were in hospitals that were private, investor owned (297 to 217 [−26.9%]); small (748 to 570 [−23.8%]); or urban, nonteaching (411 to 276 [−32.8%]), with variability among the Census divisions (Table). Despite the overall decline, proportions within each of the characteristics remained stable, except for the increase in the proportion of urban teaching hospitals from 998 of 2169 hospitals (46.0%) to 941 of 1795 hospitals (52.4%) (P < .001).
Discussion
Decades of consolidating pediatric hospital care have resulted in an increasingly concentrated system reliant on a small number of remaining facilities.3 Hospital consolidation, falling Medicaid reimbursement, and a decrease in volume of pediatric admissions have intensely pressured small and medium-sized hospitals, causing loss of pediatric services.4-6 Our observations suggest that this dynamic accelerated during the COVID-19 pandemic, with an additional loss of one-sixth of the nation’s remaining pediatric inpatient services. In number, this capacity decrease was most pronounced among small, rural, and private hospitals, with declines linearly proportional to Medicaid-insured pediatric admission fractions between 0% and 80%. Proportionally, the decline from 2019 was more pronounced in small, private or investor-owned, and urban nonteaching hospitals.
These findings are limited by NIS sampling methods, which are not stratified by patient characteristics and could miss some pediatric admissions. However, since sensitivity analyses yielded similar results, the observed reductions likely represent conservative estimates within the CIs provided. Second, since the NIS does not include short-stay or observation admissions, some small hospitals serving these could be missed. Third, since COVID-19 spikes continued in 2021, some hospitals may have still been actively prioritizing adults.
Rapid, uncontrolled closure of pediatric hospital services presents a public health challenge. While some closed pediatric inpatient services may reopen, history and system dynamics suggest that most will become permanent casualties of the pandemic. If so, access to care among vulnerable rural and Medicaid populations will be especially affected.
Introduction
Early in the COVID-19 pandemic, many hospital pediatric units were repurposed to expand adult capacity in a restructuring process endorsed by the Children’s Hospital Association.1 During the pandemic, pediatric COVID-19 was mild, while school closures and social distancing reduced regular pediatric admissions, so remaining pediatric facilities were financially strained.2 The impact of this dynamic on access to pediatric hospital care has not been assessed, to our knowledge. In this study, we compare prepandemic with 2021 data to estimate changes in the number of hospitals admitting children.
Methods
This retrospective, cross-sectional study was approved by the Boston Children’s Hospital Committee on Clinical Investigation and informed consent was waived because we used deidentified aggregate data. This study is reported in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
We used 2019 and 2021 National Inpatient Sample (NIS) Databases from the Healthcare Cost and Utilization Project. The NIS draws from all Healthcare Cost and Utilization Project hospitals using a self-weighted, cross-sectional sample design that ensures representation across diverse factors, including hospital, census division, ownership, urban-rural location, teaching status, and bed size. We identified all hospitals with at least 1 pediatric (age <15 years) admission, excluding those caring only for infants younger than 1 year. Bootstrapping with 1000 iterations within each NIS strata set of admissions was used to estimate the medians and 95% CIs for the number of hospitals. Sensitivity analyses were performed by removing hospitals with 1 to 100 sampled admissions. Comparisons between hospital characteristics across years were assessed using the χ2 test. P values were 2-sided, and statistical significance was set at P ≤ .05. Analyses were conducted using Python version 3.10 (Python Software Foundation) from May to July 2024.
Results
In the final dataset, 2169 hospitals had at least 1 pediatric admission in 2019 and 1795 hospitals had at least 1 pediatric admission in 2021, a reduction of 17.2% (P < .001). Almost half of this decline (181 of 374 hospitals [48.4%]) was in hospitals with more than 60% of admissions among Medicaid patients (Figure). These reductions were largest in number for hospitals that were private, nonprofit (206 of 374 [55.1%]); small (178 of 374 [47.6%]); or rural (182 of 374 [48.7%]). Compared with 2019, the largest proportional declines were in hospitals that were private, investor owned (297 to 217 [−26.9%]); small (748 to 570 [−23.8%]); or urban, nonteaching (411 to 276 [−32.8%]), with variability among the Census divisions (Table). Despite the overall decline, proportions within each of the characteristics remained stable, except for the increase in the proportion of urban teaching hospitals from 998 of 2169 hospitals (46.0%) to 941 of 1795 hospitals (52.4%) (P < .001).
Discussion
Decades of consolidating pediatric hospital care have resulted in an increasingly concentrated system reliant on a small number of remaining facilities.3 Hospital consolidation, falling Medicaid reimbursement, and a decrease in volume of pediatric admissions have intensely pressured small and medium-sized hospitals, causing loss of pediatric services.4-6 Our observations suggest that this dynamic accelerated during the COVID-19 pandemic, with an additional loss of one-sixth of the nation’s remaining pediatric inpatient services. In number, this capacity decrease was most pronounced among small, rural, and private hospitals, with declines linearly proportional to Medicaid-insured pediatric admission fractions between 0% and 80%. Proportionally, the decline from 2019 was more pronounced in small, private or investor-owned, and urban nonteaching hospitals.
These findings are limited by NIS sampling methods, which are not stratified by patient characteristics and could miss some pediatric admissions. However, since sensitivity analyses yielded similar results, the observed reductions likely represent conservative estimates within the CIs provided. Second, since the NIS does not include short-stay or observation admissions, some small hospitals serving these could be missed. Third, since COVID-19 spikes continued in 2021, some hospitals may have still been actively prioritizing adults.
Rapid, uncontrolled closure of pediatric hospital services presents a public health challenge. While some closed pediatric inpatient services may reopen, history and system dynamics suggest that most will become permanent casualties of the pandemic. If so, access to care among vulnerable rural and Medicaid populations will be especially affected.