Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Why are so many community hospitals transferring children to larger facilities?

Christopher Johnson, MD
Policy
September 13, 2020
186 Shares
Share
Tweet
Share

A recent edition of Pediatrics has some disturbing research: “Trends in Capability of Hospitals to Provide Definitive Acute Care for Children: 2008 to 2016.” What the paper really does is document what many of us who work in referral hospitals have noted for some time: More and more community hospitals are transferring children who appear in their emergency departments to other, larger facilities instead of admitting them to their own hospital for definitive care. At first glance, one might ask if this could actually be a good thing. After all, isn’t a higher level of capability better for sick children? But it looks to me more as if they just don’t want to provide definitive pediatric care, even for fairly routine things.

We analyzed emergency department (ED) visits by children between 2008 and 2016 using the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability.

The results showed a progressive and steady decrease in children admitted to the original hospital but rather transferred to another facility. This is illustrated in the graphs below, which show EDs stratified by their capability to render definitive care for children.

The panel on the left (A) shows the trend in EDs able to provide definitive care. You can see there was a quite dramatic rise in the number of EDs unable to provide this (orange line — lowest quintile). The blue line shows the highest capability EDs, and there was a drop in those. So overall, there has been a shift in ED capability from higher to lower capability. The panel on the right (B) plots ED visits by children over time. The only real change was that the number of visits to the lowest capability EDs actually increased over time. So more kids are appearing at facilities unable (or unwilling) to care for them. Note that the number of highly capable EDs in panel A actually has gone down, adding more stress to the system.

This graph presents the same trend in a little different but useful way. It simply plots the raw number of EDs that went up in capability or went down over time. Far more went down than up.

So what’s happening? Is this a manifestation of a good regionalization of pediatric care, of providing children better care? I doubt it myself. It would require one to postulate pediatric care a decade ago was not very good, and now it’s much better. One could argue the standard of pediatric care has risen and that smaller hospitals cannot meet this higher standard, so they appropriately transfer children. But that explanation seems doubtful to have developed over such a short time — over my 40 years of practice, probably yes. But not over just ten years. Not surprisingly, this trend hits rural hospitals particularly hard. Transfer distances are long, can take hours, and are expensive and not risk-free. They also can be hard on families. An accompanying editorial, “Emergency and Definitive Care for Children in the United States: The Perfect Storm,” is succinct:

These results portend a “perfect storm” of events for care of children in the United States health care system. Increasing pediatric ED visits, poor access to EDs ready to care for children, reduced inpatient capability of hospitals, and increased transfers create increased risk for poor outcomes. Pediatric inpatient capacity across most general community hospitals is decreasing, shifting the burden of pediatric inpatient care to regional pediatric centers, often freestanding children’s hospitals with a high Medicaid-insured population of patients. These hospitals, which compose 5% of hospitals yet are responsible for more than one-third of pediatric discharges and are relied on to care for children with complex medical conditions, suffer significant financial losses from pediatric inpatient care.

I have my own anecdotal take on this. I spent much of my career at a large tertiary facility 40 miles away from the town I grew up in. My father was a pediatrician in that small town for 50 years, and I myself worked in that hospital during my college years. Occasionally in my capacity as transport director at the tertiary facility, I would get a transfer request from my home town. Several of the older nurses, who knew me and my father well, would often say something like: “Your father never would have transferred this child. How times have changed.”

What we don’t know, of course, is if this trend leads to better outcomes. I do hope the authors will continue their work to answer that key question. But in their discussion, they doubt it. So do I. Me, I think it’s mostly about money, as many things are. It’s hard to make money off children admitted as inpatients, especially if they are on Medicaid. Administrative costs are high because admissions tend to be short, and children typically don’t require all the profit-generating tests and procedures adults do. I think more than a few hospitals are trying to offload this cost under the guise of securing better care for children. This research demonstrates it’s not about patient volume. It’s possible physician unwillingness to admit these children also plays a role. It adds to their already heavy workload. But whatever the cause, or more likely causes, it can’t go on.

Christopher Johnson is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and Illnesses, Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments. He blogs at his self-titled site, Christopher Johnson, MD.

Image credit: Shutterstock.com

Prev

A palliative care physician's brain bleed [PODCAST]

September 12, 2020 Kevin 0
…
Next

Connecting health care, voting, and our communities

September 13, 2020 Kevin 0
…

Tagged as: Pediatrics, Public Health & Policy

Post navigation

< Previous Post
A palliative care physician's brain bleed [PODCAST]
Next Post >
Connecting health care, voting, and our communities

More by Christopher Johnson, MD

  • The success of Australian firearms regulation: What it could mean for children

    Christopher Johnson, MD
  • Do protocols and pathways improve care?

    Christopher Johnson, MD
  • Everyone needs rudimentary statistical training

    Christopher Johnson, MD

Related Posts

  • Detention facilities cannot respond adequately to this pandemic

    Priya Pathak, MD, MPH
  • When celebrities attack children with food allergies

    Lianne Mandelbaum
  • When hospitals are like prisons

    Christopher Blackman
  • Bullying immigrant children in the name of politics

    Linda Girgis, MD
  • A disturbing study about children and guns

    Christopher Johnson, MD
  • How hospitals can impact generic drug companies

    Mark Kelley, MD

More in Policy

  • Healing the damaged nurse-physician dynamic

    Angel J. Mena, MD and Ali Morin, MSN, RN
  • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

    Mohammed Umer Waris, MD
  • Breaking down the barriers to effective bar-code medication administration

    Amy Dang Craft
  • The locums industry has a beef problem

    Aaron Morgenstein, MD
  • Canada’s health workers are sounding the alarm. We must act, now.

    Ivy Lynn Bourgeault, PhD
  • Race categorizations are worsening health inequities for the South West Asian North African (SWANA) communities

    Guleer Shahab, MPH
  • Most Popular

  • Past Week

    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • An unspoken truth about non-compete clauses in medicine

      Harry Severance, MD | Policy
    • Fostering the next (diverse) generation of clinicians

      Imamu Tomlinson, MD, MBA | Physician
    • Healing through love and spirituality

      John T. James, PhD | Conditions
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • Rescuing primary care: the role of health administrators [PODCAST]

      The Podcast by KevinMD | Podcast
    • Breaking down barriers: How technology is improving diabetes management in underserved communities

      Anonymous | Conditions
    • From penicillin to digital health: the impact of social media on medicine

      Homer Moutran, MD, MBA, Caline El-Khoury, PhD, and Danielle Wilson | Social media
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • How to overcome telemedicine’s biggest obstacles

      Harvey Castro, MD, MBA | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Investigational ALS Drug May Have Clinical Benefit, FDA Staff Says
  • Cases of Deadly Fungus Tripled in Past Few Years, CDC Says
  • Small Gains in Cardiorespiratory Fitness Track With Improved Longevity
  • Improved OS With Hyperfractionated RT in Recurrent Nasopharyngeal Carcinoma
  • GPT-4 Is Here. How Can Doctors Use Generative AI Now?

Meeting Coverage

  • Rapid Improvement in Atopic Dermatitis With Topical PDE4 Inhibitor
  • New Approaches in the Bladder-Sparing Paradigm
  • Response Rates in Hidradenitis Suppurativa Continue to Climb With New Therapies
  • Another Win for a JAK Inhibitor in Alopecia Areata
  • Biologic Switch Revs Up Response in Plaque Psoriasis
  • Most Popular

  • Past Week

    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • From physician to patient: one doctor’s journey to finding purpose after a devastating injury

      Stephanie Pearson, MD | Physician
    • An unspoken truth about non-compete clauses in medicine

      Harry Severance, MD | Policy
    • Fostering the next (diverse) generation of clinicians

      Imamu Tomlinson, MD, MBA | Physician
    • Healing through love and spirituality

      John T. James, PhD | Conditions
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • Why are doctors sued and politicians aren’t?

      Kellie Lease Stecher, MD | Physician
  • Recent Posts

    • Rescuing primary care: the role of health administrators [PODCAST]

      The Podcast by KevinMD | Podcast
    • Breaking down barriers: How technology is improving diabetes management in underserved communities

      Anonymous | Conditions
    • From penicillin to digital health: the impact of social media on medicine

      Homer Moutran, MD, MBA, Caline El-Khoury, PhD, and Danielle Wilson | Social media
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • How to overcome telemedicine’s biggest obstacles

      Harvey Castro, MD, MBA | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...