Shifts in the Hospital Care of Children in the US—A Health Equity Challenge

Mahant, Sanjay; Guttmann, Astrid

doi:10.1001/jamanetworkopen.2023.31763

Cited by 4 publications

(3 citation statements)

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“…Epidemiologic data show that the population-based hospitalization rate for bronchiolitis increased between 2018 and 2024 . Simultaneously, centralization of pediatric care resulted in more children being transferred from community facilities to children’s hospitals and a decrease in locally available pediatric hospital beds . Among children’s hospitals, prior work has shown an increasing proportion of PICU admissions for all conditions, especially for bronchiolitis .…”

Section: Discussionsupporting

confidence: 50%

“…Although influenced by atypical seasonality during the COVID-19 pandemic, PICU admissions for bronchiolitis have continued to rise since 2021 . Findings of previous studies combined with those of the present study suggest that increases in HFNC and NIV use are likely due to multiple factors, including a rising population-based PICU admission rate, increased consolidation of pediatric admissions to children’s hospitals, a rising proportion of children with bronchiolitis being admitted to the PICU, and an increase in the proportion of patients admitted to the PICU receiving noninvasive respiratory support. Thus, solutions aimed at reducing PICU burden need to consider multiple components in the chain of care.…”

Section: Discussionmentioning

confidence: 99%

“…31 Simultaneously, centralization of pediatric care resulted in more children being transferred from community facilities to children’s hospitals and a decrease in locally available pediatric hospital beds. 32 , 33 , 34 , 35 , 36 Among children’s hospitals, prior work has shown an increasing proportion of PICU admissions for all conditions, especially for bronchiolitis. 6 , 7 , 16 Although influenced by atypical seasonality during the COVID-19 pandemic, PICU admissions for bronchiolitis have continued to rise since 2021.…”

Section: Discussionmentioning

confidence: 99%

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Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Pelletier,

Maholtz,

Hanson

et al. 2024

JAMA Netw Open

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ImportanceAdmissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown.ObjectiveTo assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure.Design, Setting, and ParticipantsThis cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV).Main Outcomes and MeasuresThe main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success).ResultsIncluded in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to &lt;2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, −11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P &lt; .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure.Conclusions and RelevanceFindings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

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Section: Discussionsupporting

confidence: 50%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Pelletier,

Maholtz,

Hanson

et al. 2024

JAMA Netw Open

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Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

Leyenaar,

Freyleue,

Arakelyan

et al. 2024

JAMA Netw Open

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ImportanceLimited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC).ObjectivesTo describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes.Design, Setting, and ParticipantsThis retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period.ExposuresRural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children’s hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims.Main Outcomes and MeasuresIn-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications.ResultsAmong 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events.Conclusions and RelevanceIn this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.

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