Pediatric Hospital Services Within a One-Hour Drive: A National Study

A Survey Study of Motivators for Pediatric Hospitalists to Work in the Community

BACKGROUND AND OBJECTIVE

The loss of pediatric beds in the community has contributed to decreased access to pediatric inpatient and emergency services. Community pediatric hospitalist programs could reduce the overhead of inpatient care, promoting the financial feasibility of caring for hospitalized children closer to home. This study aims to determine which career motivators are the most important for pediatric hospitalists to begin working in, remain in, and leave the community setting.

METHODS

A survey was sent to a convenience sample of 269 community hospitalists from 31 different sites. Sites were invited if the program director was known to the authors. Responses were evaluated and χ-square or Fisher's exact test were used to compare the differences.

RESULTS

One hundred twenty six community pediatric hospitalists completed the survey (response rate 49.1%). The 3 most important motivators for pediatric hospitalists to begin working in the community were work-life integration (80%), geographic location (75%), and flexible hours (71%). Pediatric hospitalists who planned to leave the community setting were more likely to cite mentoring and teaching opportunities (76% vs 32%, P = .0002), opportunities for research and quality improvement (29% vs 10%, P = .021), and paid time for nonclinical interests (52% vs 26%, P = .02) as very important.

CONCLUSIONS

This study demonstrates key motivators for pediatric hospitalists to work in the community and elucidates motivators for transitioning to larger pediatric centers. This knowledge may be used to guide community pediatric hospital medicine recruitment and program development that could lead to improved retention.

Mapping Access to Children's Hospitals in Texas

Vehicle access, travel time, and distance to hospitals and emergency rooms with sufficient patient beds are critical healthcare accessibility measures, especially for children who require specific pediatric services. In a large state like Texas with vast rural areas and limited public transit infrastructure, 75% of the children live over an hour from the closest facility that provides pediatric emergency services or specialty care. In view of this challenge, this study first sought to map the prevailing geographical accessibility to children's hospitals and, second, to model the hospital beds per capita for each hospital's service area within the state of Texas. The results showed disparities in accessing emergency pediatric care, especially in rural areas. However, despite major metro areas recording better geographical accessibility to pediatric healthcare, residents in these areas may experience limited hospital bed availability. The findings indicate an urgent need for more pediatric healthcare services in rural Texas. Given the increasing population growth in metro areas and their surroundings, there is also a need for the expansion of healthcare infrastructure in these areas.

Neighborhood Poverty and Distance to Pediatric Hospital Care

OBJECTIVE

To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care.

METHODS

This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity.

RESULTS

Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001).

CONCLUSIONS

Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.

Quantifying side effects and caregiver burdens of pediatric pulmonary hypertension therapies

BACKGROUND AND OBJECTIVES

Pulmonary hypertension (PH) is a rare, but serious disease among children. However, PH has been primarily evaluated among adults. Consequently, treatment therapies have not been fully evaluated among pediatric populations and are used in an 'off label' manner. The purpose of this study was to estimate the side effect profiles of the most commonly prescribed pediatric PH therapies and to understand the burdens placed upon families caring for children living with PH.

METHODS

Participants were recruited online through the "Families of children with pulmonary hypertension" Facebook group and asked to complete a survey about PH treatments.

RESULTS

A total of 139 parents of a child living with PH completed the survey. Almost all children used ≥ 1 medication to treat PH, with 52% using ≥ 3 medications. The highest average number of side effects was reported by users of Treprostinil, Selexipag and type-5 phosphodiesterase (PDE₅) inhibitors. The most common side effects were skin flushing, headache, nasal congestion, joint/muscle pain, and nausea. In terms of accessing care, 81% travel ≥ 20 miles and 68% travel for ≥ 60 min to receive care.

CONCLUSIONS

We found an array of treatment combinations employed to mitigate symptoms of PH in children, with a wide range of side effects. We also found a large, unseen economic, emotional, and time burden of caring for a child living with PH. Further research is warranted to understand the clinical implications of these side effects to move towards labeled usage of these therapies rather than post-hoc off-label usage.

Availability of Inpatient Pediatric Surgery in the United States

BACKGROUND

In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery.

METHODS

A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth.

RESULTS

Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation.

CONCLUSIONS

Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

EDITOR’S PERSPECTIVE

Availability of Pediatric Inpatient Services in the United States

OBJECTIVES

We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States.

METHODS

We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model.

RESULTS

Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing.

CONCLUSIONS

Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.

From Other Journals: A Review of Recent Articles in Pediatric Cardiology

In this review, we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. Our hope is to provide a summary of the latest articles published recently in other journals in our field. The articles address (1) developing a risk score to predict adverse outcomes in patients with hypoplastic left heart syndrome using the national pediatric cardiology quality improvement collaborative, (2) outcomes of the Ross procedure in patients with a previous aortic valve surgery showing better outcomes in these patients compared to patients with the primary Ross procedure, (3) the initial experience with continuous flow ventricular assist devices in pediatric patients showing low mortality post implantation, (4) lower socioeconomic status is associated with worse long-term neurodevelopmental outcomes in patients with hypoplastic left heart syndrome, (5) QRS fragmentation is associated with higher incidence of appropriate shock after implantable cardioverter defibrillator implantation in repaired tetralogy of Fallot, (6) atrioventricular valve repair may have better outcomes if performed before the Fontan operation compared to after the Fontan operation.