Children in rural areas face increasing barriers to pediatric care, study finds

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

The number of inpatient units fell 19%, and beds decreased by 12%. Approximately 34 pediatric units were closed and 300 beds were removed each year on average. 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 farther to access inpatient hospital care than they did a decade ago, the researchers found.

This is a situation that’s all too familiar to Sunitha Kaiser, a pediatric hospitalist at the University of California, San Francisco. “I’ve seen all of those issues,” she said. “Children getting unstable during long journeys, having longer stays, and families having the difficulty of being far from their homes while their child is hospitalized.”

Anna Cushing, the study’s lead author and a pediatric emergency fellow at the Children’s Hospital of Los Angeles, said it’s common to receive transfers of patients with conditions that would typically be cared for in community hospitals. This could exacerbate health care costs for families, increase infant mortality, and worsen other health outcomes by prolonging the time to get potentially lifesaving care, Kaiser said.

The reduction of resources in rural areas could affect hospitals’ abilities to deal with surges due to disasters or pandemics. A record number of closures of rural hospitals in 2020 reduced access to care for some Covid patients and others, and though children have fared better than adults during this pandemic, “we would probably not be prepared for something on a similar scale with pediatrics,” said Cushing.

Over the past decade or so, rural hospitals have cut back on a number of services, including skilled nursing care, obstetrics, and home health. Pediatrics is simply the next to follow that trend, especially as care for kids has moved away from general community hospitals towards more specialized children’s hospitals and academic centers in major cities, a process called regionalization.

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

To get a better picture of these trends in pediatric care, researchers at Harvard Medical School and Boston Children’s Hospital looked at data on 4,720 U.S. hospitals surveyed by the American Hospital Association from 2008 to 2018. One limitation was that the data were self-reported, which could lead to miscounts or misclassifications.

Capacity of inpatient pediatric care decreased particularly in rural areas. In contrast, pediatric intensive care units increased in children’s hospitals, highlighting this process of regionalization.

Experts say these dynamics could be due to reduced demand, since pediatric hospitalizations have also declined and stays have become shorter. But another possible reason to explain the closures is the cost of keeping these units open in under-resourced hospitals. “If you think about a pediatric ICU bed, 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 may be harder to manage.

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

Beyond pinpointing which hospitals are decreasing pediatric care, it will also be necessary to understand which children and specific communities are being affected. Research shows that rural hospitals are more likely to close if they are serving non-white populations, putting children and communities of color at higher risk.

In addition to race and ethnicity, understanding the socioeconomic status of the children who are losing pediatric access would also be critical. “Is there something about the kinds of places experiencing this?” said Holmes. These different factors, geography, socioeconomic status, and race and/or ethnicity, could combine to hit already vulnerable communities the hardest.

The authors of the study proposed several strategies to address the loss of pediatric beds, such as establishing affiliations between general hospitals and children’s hospitals that have more resources, designating vulnerable pediatric inpatient units as centers of critical access, and investing in telehealth.

The researchers said this and future studies will help policymakers understand where resources need to be allocated. For Cushing, the study lays the groundwork to help children everywhere: “We need to make sure that we’re able to take care of all of the children that are out there, no matter whether they live down the street or many hours away.”