Children in rural areas face increasing barriers to pediatric care

Hospital beds for children with asthma, pneumonia, viral infections and other serious illnesses have declined over the past 10 years, especially in rural areas. In a new study published Monday in Pediatrics, researchers found that the percentage of U.S. hospitals with clinical units for pediatric care decreased, as did the number of beds in units that remained open.

The number of hospital wards decreased by 19% and the number of beds decreased by 12%. About 34 pediatric wards were closed each year and an average of 300 beds were removed. The closures and loss of beds were especially steep in rural areas than in urban areas. Nearly 1 in 4 children would now have to travel further to access inpatient hospital care than a decade ago, the researchers found.

This is a situation all too familiar to Sunitha Kaiser, a pediatric hospital physician at the University of California, San Francisco. “I’ve seen all those problems,” she said. “Children become unstable on long journeys, have longer stays and families who have a hard time being far from home while their child is in the hospital.”

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Anna Cushing, the lead author of the study and a pediatric emergency department at Children’s Hospital in Los Angeles, said it’s common to move patients with conditions that would normally be cared for in community hospitals. This could increase health care costs for families, increase infant mortality and worsen other health outcomes by extending the time to receive potentially life-saving care, Kaiser said.

Reducing resources in rural areas can affect hospitals’ ability to handle peaks caused by disasters or pandemics. A record number of rural hospital closures in 2020 reduced access to care for some Covid patients and others, and while children have fared better than adults during this pandemic, “we probably wouldn’t be prepared for anything on a comparable scale to pediatrics.” said Cushing.

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Over the past decade, rural hospitals have cut back on a number of services, including skilled nursing care, obstetrics and home care. Pediatrics is just next to follow that trend, especially as pediatric care has shifted from general community hospitals to more specialized pediatric hospitals and academic centers in large cities, a process called regionalization.

While regionalization may allow for more expert care for children with specialized conditions, it concentrates resources in specific areas, excluding many rural areas, where 1 in 5 children live. “The advantage of regionalized care is that a child can receive care from multiple different specialists under one hospital roof,” said JoAnna Leyenaar, a pediatric hospital and professor of pediatrics at Dartmouth-Hitchcock Medical Center, who was not involved in the study. “But the costs are that this care can often not be provided close to home.”

To better understand these trends in pediatric care, researchers from Harvard Medical School and Boston Children’s Hospital looked at data from 4,720 U.S. hospitals surveyed by the American Hospital Association from 2008 to 2018. One limitation was that the data was self-reported, which could lead to wrong counts or wrong classifications.

The capacity of inpatient pediatric care decreased, especially in rural areas. In contrast, pediatric intensive care units in children’s hospitals have increased, highlighting this process of regionalization.

Experts say this dynamic may be due to reduced demand, as hospital admissions among children have also decreased and stay shorter. But another possible reason to explain the closures is the cost of keeping these units open in under-resourced hospitals. “When you think of an ICU bed for children, that’s expensive to have empty,” said Mark Holmes, a professor at the University of North Carolina who was not involved in the study. For smaller, rural hospitals that receive a significant number of patients covered by Medicaid, which pays less for care than private insurers, the cost of keeping that bed open can be more difficult to manage.

“These smaller units, which are a small cog in the hospital’s bigger wheel, are really hard financially to keep up over time,” said Kaiser, who was not involved in the study. “The most important next steps are figuring out why these units are closing and how best to keep them open.”

In addition to identifying which hospitals are reducing pediatric care, it is also necessary to understand which children and specific communities are affected. Research shows rural hospitals close earlier if they serve non-white populations, putting children and communities of color at greater risk.

In addition to race and ethnicity, it would also be critical to understand the socioeconomic status of the children who lose access to children. “Is there anything about the kind of places that experience this?” said Holmes. These various factors, geography, socio-economic status and race and/or ethnicity, can all together hit the already vulnerable communities the hardest.

The study authors suggested several strategies to address the loss of pediatric beds, such as establishing links between resource-rich general hospitals and children’s hospitals, designating vulnerable pediatric hospital wards as critical access centers, and investing in telecare. .

The researchers said this and future studies will help policymakers understand where to allocate resources. For Cushing, the study lays the foundation for helping children around the world: “We need to make sure we can take care of all the children out there, whether they live down the street or many hours away. ”

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