Hospital-based pediatric care occurs in structurally diverse settings, ranging from large freestanding children’s hospitals to small rural community hospitals. Although there has been a recent trend toward increasingly regionalized pediatric care,1 the majority of pediatric patients are still cared for in nonchildren’s hospitals.2 A recent study revealed that less than one-third of all pediatric hospitalizations in the United States occur at freestanding children’s hospitals.2 In contrast, more than half of hospitalizations for children are estimated to occur in community hospitals,2 which we define as general hospitals that are neither freestanding nor nested children’s hospitals that admit children to licensed pediatric beds.

Currently the majority of pediatric research funded by the National Institutes of Health originates at a relatively small number of children’s hospitals,3 and the creators of a national initiative to establish pediatric inpatient research priorities used data that exclusively represented patients cared for at freestanding children’s hospitals.4 The absence of community-hospital representation in the research arena leaves questions that may be the most pertinent to clinical care in these hospitals both unasked and unanswered.

Because of heterogeneity of patient volumes, diverse practice settings, and often limited access to pediatric-specific resources in community hospitals, clinical guidelines and quality improvement (QI) recommendations derived from research conducted at children’s hospitals may not be directly applicable in community settings. Similar to the difference between efficacy and effectiveness trials, the translation of care from a children’s hospital to a community hospital is rarely as simple as taking a pathway from 1 institution and applying it at the next. Because published research is used to inform clinical practice, national guidelines, and quality measures, the misalignment between where research originates and where the majority of children are hospitalized may have important implications for the quality of care we provide to hospitalized children. In this article, we summarize barriers to engaging community hospitals in pediatric research and discuss ways to advance research opportunities in community hospital settings.

A recent study found that the average daily census across a large cohort of community hospitals was 6 children, excluding well newborns.5 In addition to small and variable clinical volumes, community hospitals often have limited access to pediatric-specific resources and research infrastructure.2 Correspondingly, we have identified 3 main barriers to conducting research in community hospitals: small sample sizes, limited available data, and minimal research resources.

Because of relatively low hospitalization rates for children, it is often difficult to adequately power robust studies, even at larger children’s hospitals. For instance, in studies of condition-specific quality measures for common conditions, including asthma and mental health diagnoses, just more than half of children’s hospitals had enough patient volumes to achieve adequate power to differentiate quality of care for pediatric patients.6,7 For less common pediatric conditions, no children’s hospitals met the necessary numbers to detect significant differences in care.7 These sample size issues pose even greater constraints at community hospitals where the average number of patients for a given condition is small. As a result, having adequate statistical power to answer clinically relevant questions at community hospitals is challenging, especially for disease-specific research questions.

Large administrative databases allow researchers to examine variation in pediatric care and to conduct cohort analyses across a large number of patients and settings, but databases that enable identification of community hospitals are limited. Data sources such as Premier Perspective data warehouse, states’ All-Payer Claims Databases, and Medicaid Analytic eXtract include community hospitals, yet aside from Medicaid Analytic eXtract, these data are not highly represented in pediatric research.8 Although the Healthcare Costs and Utilization Project Kids’ Inpatient Database (KID) represents the majority of acute-care hospitals nationally, including community hospitals, the data fields contained are limited, making this data set relevant to a limited number of research questions. For example, the KID precludes examination of resource use beyond clinical volumes, charges, and length of stay by not including pharmacy, laboratory, pathology, or radiology information. Additionally, beginning in 2012, the KID dichotomized hospitals as freestanding children’s hospitals or all other hospitals. As a result, it is difficult to determine what proportion of nonfreestanding children’s hospitals are community hospitals as opposed to children’s hospitals nested within general hospitals. In contrast, the Pediatric Health Information System is a detailed administrative database that contains a record of all billed services at selected children’s hospitals, allowing researchers to characterize clinical practices in more detail, including hospital settings, diagnostic tests performed, and medications administered. As a result, many comparative effectiveness and outcomes research studies in pediatrics have been performed by using the Pediatric Health Information System. Analogous research representing community hospitals is lacking.

The majority of pediatric research funding is allocated to researchers who represent a small number of children’s hospitals.3 Beyond this, community hospitals also have fewer resources necessary for successful pediatric research; pediatric hospitalists pursuing hospital medicine at community hospitals are less likely to report research interests and are less likely to have protected time for scholarly work.9 Additionally, community hospitals often have limited research infrastructure, reduced access to peer-reviewed pediatric journals, and fewer medical trainees who contribute to research. Finally, the higher costs and payments associated with adult medicine, coupled with adult-focused Medicare and Joint Commission quality initiatives, may drive prioritization of already-limited resources for research and QI toward adult care.

As we strive for value-based health care, validating expected outcomes and benchmarks in community hospitals is critical for future national guideline development and quality-of-care metrics. Whether health services, outcomes, educational, or QI implementation research, including children hospitalized at community hospitals increases the ability to provide equitable pediatric care across all settings. To enable evidence-informed decision-making regardless of hospitalization site of care, we must represent children hospitalized at community hospitals in research goals, quality measures, distribution of funding, and journal publications.

Multisite collaborations, such as those successfully modeled within national QI efforts of the Value in Inpatient Pediatrics Network, are an underused opportunity to improve our knowledge about health care delivery and outcomes within community hospitals. Recent examples of effective research collaborations between children’s hospitals and community hospitals include the creation of quality measures to assess quality of transitional care for hospitalized children10 and the validation of the Global Assessment of Pediatric Patient Safety tool.11 Collaboratives such as these provide a valuable and largely unexplored way to generate adequate sample sizes and to expand our understanding of care for hospitalized children across diverse settings. Equitable distribution of research resources that include children in community hospitals should be considered a priority area for federal and foundational funding agencies. This may prompt children’s hospitals to develop new partnerships or leverage existing relationships with community hospitals. Building stand-alone research infrastructure at community hospitals would be costly and may be unnecessary. Instead, formalizing relationships and partnerships between community hospitals and tertiary-care institutions could allow for both mentorship of clinicians at community hospitals and access to research resources and infrastructure.

Lastly, publishers of pediatric journals can explicitly solicit and prioritize research that includes community hospitals. Publishers might consider community-themed issues or develop new report types specific to community hospitals. Prioritizing studies that include children cared for at community hospitals would ultimately serve to improve health care delivery for children regardless of their proximity to a children’s hospital.

Because >50% of pediatric hospitalizations in the United States occur at community hospitals, it is critical to represent children cared for at community hospitals within pediatric research. Although there are barriers to successfully conducting research in community hospitals, we can increase their representation in pediatric research through intentional collaboration and mentorship. This will enable evidence-informed decision-making for all hospitalized children.

Drs McDaniel, Jennings, and Leyenaar conceptualized and drafted the initial manuscript and reviewed and revised the manuscript; Drs Schroeder, Paciorkowski, and Hofmann conceptualized the manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

KID

Kids’ Inpatient Database

QI

quality improvement

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.