Trends in Admissions to Children’s Hospitals (2024)

Historically, most children hospitalized in the US were treated at general hospitals that cared for both pediatric and adult patients.¹ However, the number of hospitals providing inpatient care to children has decreased during the past decade,² and the viral infection surge in the fall of 2022 highlighted capacity shortages. Because pediatric hospitalizations have concentrated into fewer locations, we explored whether pediatric inpatient care has been redistributed from general hospitals into children’s hospitals (CHs).

We used the Kids’ Inpatient Database (KID) to identify inpatient nonbirth discharges for children younger than 18 years from 2000 to 2019. The KID, aggregated by the Agency for Healthcare Research and Quality, generates national estimates for inpatient pediatric discharges; the 2019 version includes an 80% inpatient sample from 3991 hospitals in 48 states.³ The study was deemed exempt by the University of North Carolina institutional review board because it did not represent human subjects research.

We created 3 categories of hospitals that care for children and reassigned the appropriate category at each analysis year. Freestanding CHs were identified with a specific label available within KID. Nonfreestanding CHs were defined as hospitals that had more than 1500 annual pediatric discharges (excluding healthy newborns) but were not identified as freestanding CHs. This volume cutoff has been used to identify CHs and includes 95% of hospitals in the Children’s Hospital Association Annual Benchmark Survey.⁴ Freestanding CHs and non–freestanding CHs are collectively referred to as CHs. Hospitals that discharge fewer than 1500 children annually were categorized as non-CHs.

We estimated the total number of national pediatric nonbirth discharges per year by hospital type. To further explore redistribution, we also analyzed the percentage of children experiencing interfacility transfer (IFT) during hospitalization, which includes those initially cared for in the emergency department or inpatient unit of one hospital who are then transferred to another hospital for subsequent care; these were counted as 1 hospitalization. We calculated descriptive statistics and used the Cochran-Armitage test for trend to compare hospitalization characteristics by hospital type across years. Analyses, performed with SAS version 9.4, were weighted to produce national estimates; statistical testing was 2-sided, with P < .05 considered statistically significant.

We included 14 758 391 discharges. Annual inpatient discharges decreased by 26.5% from 2000 to 2019 (2 273 225 to 1 671 515, respectively; Table). Simultaneously, the percentage of total national discharges from CHs increased significantly, from 58.9% (95% CI, 56.0%-61.8%) in 2000 to 81.8% (95% CI, 79.8%-83.8%) in 2019: discharges from freestanding CHs increased from 19.3% (95% CI, 16.0%-22.6%) to 34.2% (95% CI, 29.4%-39.1%), those at nonfreestanding CHs increased from 39.6% (95% CI, 36.2%-43.0%) to 47.6% (95% CI, 43.1%-52.1%), and percentage of discharges from non-CHs decreased from 41.1% (95% CI, 38.2%-44.0%) to 18.2% (95% CI, 16.2%-20.2%; P trend <.001 for all; Table and Figure).

An increase in IFT accompanied the changes in the distribution of pediatric discharges. In 2000, 138 939 pediatric patients (6.1% [95% CI, 5.3%-6.8%] of total discharges) were transferred from one facility to another before discharge; in 2019, 314 646 patients (18.8%; 95% CI, 17.3%-20.2%) experienced an IFT (P trend <.001). Of children experiencing an IFT in 2019, 88.0% (95% CI, 85.5%-89.8%) were transferred to a CH.

Between 2000 and 2019, total inpatient pediatric hospitalizations decreased significantly, but with a greater proportion at freestanding CHs and other high-volume hospitals. In 2019, 4 of every 5 pediatric inpatients were discharged from such hospitals, and an increasing percentage of hospitalized children required IFT to receive care. This redistribution is likely related to the trend of national pediatric inpatient unit closures, primarily at smaller non-CHs.²

The effect of concentration of care on access and quality is unknown. In some areas of medicine, regionalization has improved care quality.⁵ However, decreased local inpatient pediatric hospitalization capacity, particularly in rural areas, may create barriers to care and decrease emergency capacity.

Study limitations include that there is no universal definition of a nonfreestanding CH. The definition used was empirically derived. Also, KID captures inpatient but not observation status hospitalizations, so potential shifts of admissions to observation status cannot be determined, and a change in care complexity may have occurred to potentially justify centralization at CHs.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.

Accepted for Publication: September 7, 2023.

Published Online: October 30, 2023. doi:10.1001/jama.2023.19268

Corresponding Author: Michael J. Steiner, MD, MPH, Department of Pediatrics, University of North Carolina at Chapel Hill, MacNider Building, Campus Box 7220, Chapel Hill, NC 27599-7220 (msteiner@med.unc.edu).

Author Contributions: Dr Steiner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Steiner, Hall, Sutton, Chase, McDaniel.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Steiner, Hall.

Critical review of the manuscript for important intellectual content: Sutton, Stephens, Leyenaar, Chase, McDaniel.

Statistical analysis: Hall.

Administrative, technical, or material support: McDaniel.

Supervision: Steiner, McDaniel.

Conflict of Interest Disclosures: Dr Leyenaar reported receiving personal fees from the American Board of Pediatrics Foundation outside the submitted work. No other disclosures were reported.

Funding/Support: Dr McDaniel was supported in this work by the Agency for Healthcare Research and Quality (AHRQ; K08HS028683).

Role of the Funder/Sponsor: AHRQ had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement.

Additional Contributions: We thank Jay Berry, MD, MPH, Boston Children’s Hospital and Harvard School of Medicine; and Mitch Harris, PhD, Children’s Hospital Association, for their thoughtful uncompensated review and feedback on this manuscript.