The study findings suggest that a group of children’s hospitals experienced a recent increase in resource use for all types of children. Contrary to past literature,1–3
there was an increase, rather than a decrease, in children hospitalized without a chronic condition (14% increase) and children hospitalized with an episodic chronic condition (18% increase). The cohort size of hospitalized children with significant chronic conditions that affected 2 or more body systems or were complex or progressive increased at the highest rate (32% increase). These children had a high prevalence of primary conditions associated with neurologic impairment and comorbidities such as asthma.
Population growth, rising disease prevalence, and improved patient survival do not fully explain these trends. During the study period, the US population size of all children increased by 1% to 2%.25
The prevalence of asthma, the most common episodic chronic condition in our study, increased by 8%.26
During the past decade, the prevalence of children with special health care needs (ie, children with a chronic condition who require health services beyond that required by children generally) increased by 9%.27
Survival increased for many children with complex chronic conditions but at a much lower rate than the hospitalization growth for these children observed in the present study.5,28,29
The trends could have been influenced by increasing hospital use by children who were socioeconomically disadvantaged. On the basis of their urban location, most children’s hospitals serve an inner-city population of children from low-income families and this population of children increased in size by nearly 20% during the past decade.24
These children are at risk for substandard receipt of preventive care, incomplete vaccinations, and obesity.30–32
They have higher rates of severe asthma than children from higher-income families.33
Hospitalizations for children from low-income families have increased across the United States in the past decade.34
In the present study, children with the greatest hospitalization growth had a high prevalence of diagnoses that result in neurologic impairment with additional comorbidities. This growth is consistent with a reported 46% increase in hospitalization rates between 1991 and 2005 for children with cerebral palsy who had an additional complex chronic condition.35
This trend may be partially explained by an increasing number of surgical operations performed on these children. For example, the number of gastrointestinal operations to improve nutrition and digestion increased by 25% in children with neurologic impairment during the past decade.8
The trend may also be explained by substandard receipt of ambulatory care. It is challenging in the outpatient setting to manage the care of children with neurologic impairment who have additional comorbidities. Ambulatory care has been less effective in preventing hospitalizations for acute respiratory illnesses, such as asthma, in children with neurologic impairment than in healthier children.36
Two-thirds of children with neurologic impairment do not receive comprehensive care within a primary care medical home.37
There could have been a shift in referral patterns and local specialty pediatric inpatient care away from community hospitals and into children’s hospitals during the study period. One study8
reports that children with neurologic impairment experienced this shift. Children’s hospitals are the primary source of care delivered by pediatric specialists. Specialty physician referrals have increased substantially for all patients during the past decade.38
Ashift in inpatient care to children’s hospitals could have occurred to improve patient access to pediatric specialists39
and hospital-based care coordination services for children with medical complexity.40,41
Characterization of hospitalization trends in non–children’s hospitals for patients with and without chronic conditions is needed to further assess this situation.
The growth trends could have been partly influenced by changes in hospital administrative data coding practice (eg, better capture of comorbid diagnoses over time). Although we are unaware of initiatives to alter children’s hospital coding practices during the study period, we minimized the effect of this situation by aggregating each patient’s diagnosis codes for a 3-year period (across multiple hospitalizations) to classify his or her chronic condition complexity. Diagnosis and chronic condition assignment from clinical personnel may be preferable. However, prior research17
found that CRG assignment using administrative data is highly specific (95%) and moderately sensitive (76%) for children with chronic conditions compared with medical record review.
The study has several other limitations. The study cohort did not contain non–children’s hospitals. The results are most likely applicable to children’s hospitals (eTable
). We did not have access to outpatient administrative data that may be helpful when classifying patients with and without chronic illness. For example, outpatient data may provide more diagnostic information for each patient to improve the accuracy of assigning patients to the CRG categories. The data set contained charge but not cost data. Charges may not represent actual expenditures or costs of care. The data set does not contain administrative information on patient referrals. Although we controlled for population changes throughout the United States that may have influenced the hospital resource trends, we were unable to control for these changes in areas specific to the hospitals in the study cohort.
Despite these limitations, the study findings have implications for children’s hospitals represented in this study. If children’s hospitals experience continued growth caring for pediatric patients with complex conditions at a rate that is twice as high or higher than the growth of patients with less complex conditions, then these hospitals may ultimately find themselves structurally and financially stressed to meet the inpatient needs of both types of children. If fewer patients with medical complexity are ultimately diverted to other hospitals, then children’s hospitals may predominately care for a patient population that, by nature, is expensive, has a major risk for experiencing suboptimal health outcomes, and tends to draw inadequate reimbursement from payers to cover inpatient care costs.19,42
We hope the findings from this study may help inform (1) the development of financial strategies to reimburse the costly inpatient needs of children with complex chronic conditions, (2) structural plans to accommodate their inpatient resource growth without jeopardizing the ability to offer continued care to less-complex patients, and (3) the identification of children with complex conditions who may benefit from proactive hospital and community care integration experiments to help meet their health care needs, maximize their health, and minimize their need for inpatient care.