The number of U.S. hospitals capable of delivering higher levels of pediatric care has dropped over the past two decades, according to a study published this week in the journal Pediatrics.
The analysis, which included an average of more than 3,900 acute care hospitals annually from 2003 to 2022, assigned facilities a pediatric capability level from 1 to 4 each year. A level 1 hospital offered a broad range of high-acuity pediatric services (e.g., congenital heart disease hospitalization or organ transplant), whereas a level 4 had few pediatric services beyond their ED or obstetrical unit.
After adjusting for hospital characteristics, the researchers found statistically significant declines in the proportion of level 2 hospitals (54%) and level 3 hospitals (48%) over the study period. There was a much larger jump in the proportion of low-capability, level 4 hospitals, which began at just over a quarter of U.S. hospitals in 2003 but rose 137% to encompass nearly two-thirds of hospitals by 2022.
Level 1 hospitals decreased by a lesser, nonstatistically significant amount (38%).
“Our findings indicate that a small subset of hospitals provides the broadest range of services and that the moderate range of pediatric services decreased most substantially,” the researchers wrote in the journal.
Among the 24 studied pediatric services, the most frequent reductions were among moderate-intensity services like appendectomies (offered by 50.5% fewer hospitals), pneumonia hospitalization (42.3% fewer) and asthma hospitalizations (41.1% fewer).
Despite the shifts in hospitals’ pediatric capabilities, the researchers found that similar to 2003, nearly all pediatric hospitalizations continued to occur in level 1, level 2 and level 3 hospitals in 2022 (98.1% to 99%).
The authors wrote that their findings align with prior evidence suggesting many hospitals are divesting from pediatric inpatient surgical capabilities. Though the reasons for that shift “are not clear and likely vary between hospitals,” they outlined several economic factors that could influence facilities such as lower government reimbursement, staffing difficulties, complex pediatric cases’ increased need for a broad range of services and a general 26% decline in pediatric hospitalizations from 2000 to 2019.
The increased concentration of pediatric hospital services could strain care delivery and access, they wrote, particularly in periods where demand for such care surges such as a respiratory virus epidemic.
To address the trend, the researchers suggested increasing Medicaid reimbursement, deepening investments in safety-net hospitals and expanding teleconsultations. A related commentary also published in the journal emphasized projections of tighter pediatric inpatient bed capacity and geographic disparities and similarly called for Medicaid payment rate changes, care intensity-aligned payment models and minimum standards for pediatric inpatient readiness.