Fewer U.S. hospitals can care for children

In Massachusetts, a child who winds up in an emergency room - whether for a routine or a serious problem - is likely to be transferred to a second hospital for care, a “potentially concerning” trend that’s being reported by physicians throughout the United States, researchers say.

At the root, they maintain, is the disappearance of pediatric community hospital care.

The number of children transferred from one hospital to another increased by more than 36 percent in Massachusetts from 2004 to 2014, and only about 20 percent of the state’s 66 hospitals completed care for more than half of their pediatric patients without transferring them, the research team reports in JAMA Pediatrics.

“Pediatric hospital care is less available than it used to be, mostly because community hospitals are increasingly transferring children to larger centers,” said senior author Dr. Michael McManus, a pediatrician and professor at Harvard Medical School in Boston.

“Transfer can greatly improve care for some conditions,” he said in an email, “but can delay and potentially worsen care for others.”

The research showed consolidation of care into regional centers for both adults and children over the decade studied. But the move to regional care for children far outpaced that for adults.

The likelihood of a hospital completing a child’s care without a transfer dropped by 65 percent from 2004 to 2014, while the likelihood of a hospital completing an adult’s care without a transfer fell by 11 percent, the study found.

Dr. Nicholas Mohr, a professor at the University of Iowa Carver College of Medicine in Iowa City, said doctors have seen the trend in hospitals throughout the U.S. But the number of children transferred between Massachusetts hospitals surprised him.

“Fewer children are being cared for in community hospitals,” he said in a phone interview. “The big question is whether that’s good or bad.”

“We don’t know what the outcome differences are. That’s the million-dollar question,” said Mohr, who was not involved in the study.

Altogether, the researchers analyzed more than 34 million emergency department as well as inpatient and observation admissions, using data from every acute-care hospital in Massachusetts for 10 years.

Transfer from a hospital generally indicates that it lacked the capability to treat the patient, the authors write.

Although pediatric emergency department visits decreased nearly 3 percent and admissions fell 15 percent, pediatric transfers increased 36 percent over the 10 years, the study found.

The findings could be interpreted to mean that children now get better medical care in more specialized sites. But many of the children moved from one hospital to another were treated for conditions as common as broken limbs, or asthma.

Mohr said the consolidation of hospital care is a well-known factor for both adults and children these days.

“At the same time we have hospitals in some parts of the country closing, tertiary care centers are bursting at the seams,” he said. “It’s striking that both of these things are happening at the same time.”

“If quality of care is no better, then we’re looking at an unsupported practice that’s increasing cost and waste. The big glaring question is whether regionalized care is better,” he said.

The new study can’t answer the question.

A previous study showed that almost a quarter of American children were transferred from one hospital to another for minor conditions and then discharged directly home, while another 17 percent were released in less than 24 hours.

McManus is conducting additional research to explore the myriad of possible reasons for consolidation of pediatric hospital care.

In the meantime, he said, his study’s findings illustrate “how pediatric systems of care are very different from adult systems and need to be considered separately in public health and health policy discussions.”

SOURCE: JAMA Pediatrics, online July 10, 2017.