The Costs and Benefits of Regionalized Care for Children

Regionalization of health care, when purposefully designed, aims to improve the quality and safety of health care delivery by directing patients to facilities with optimal resources and experience for their particular health needs.¹  Although strong evidence supports regionalized care for cardiac arrest and stroke, trauma, and neonatal intensive care, considerably less is known about the regionalization of care for children with common medical conditions.^1,2 

In this issue of Pediatrics, Cushing et al’s³  article, “Trends in Regionalization of Emergency Care for Common Pediatric Conditions,” examines national rates of admission, interhospital transfer, and referral for children with gastroenteritis, asthma, and croup. Analyzing the Nationwide Emergency Department Sample from 2008 to 2016, Cushing et al³  found decreasing rates of admission at the hospitals where children presented for care, a slight increase (0.3%) in transfers for asthma, and unchanged transfer rates for croup and gastroenteritis. However, they identified significant increases in interhospital referral rates, which they defined as the number of children with each condition who were transferred to another hospital divided by the total number of children who were admitted or transferred. The authors use this outcome as an indicator of referral for “definitive care,” including evaluation and discharge at the accepting emergency department or hospital admission. But with a transfer rate that changed minimally over time, the increased referral rate could potentially be driven by fewer admissions and more treat and release at the index hospitals. Cushing et al³  report that referral rates were greatest for emergency departments in the lowest quartile of pediatric volume, the majority of which are located in rural settings, observing an increase in referral rates of 13.6% to 16.4% per year.

This study adds to our knowledge base about the epidemiology of hospital-based care for children, aligning with results of recent studies that show declining rates of pediatric admission nationally (although with the exclusion of observation status stays, it is unknown to what extent hospitalizations are decreasing as opposed to being alternatively classified).^4–7  This study also adds a national perspective to recent state-level studies indicating that definitive pediatric hospital care is declining at community hospitals and increasing at larger academic medical centers.^8,9  In doing so, this work raises important, and almost entirely unanswered, questions about the public health and policy implications of pediatric regionalization of care.

Unlike the regionalized systems of care that have been purposefully developed for trauma and neonatal intensive care, the trends observed by Cushing et al³  more likely reflect the asynchronous results of market forces, variable hospital-level investments in dedicated pediatric services, and increasing need for specialized pediatric care to support the growing population of children with special health care needs. Correspondingly, the costs and benefits of pediatric regionalization are poorly understood. Care at children’s hospitals is costly, and referral may more than double the expenses incurred by families and health care systems relative to care received at a single facility. Although there is a dearth of research, the indirect costs of interhospital referral are undoubtedly also substantial: costs of travel, lost time from work, lost sleep, and emotional stress.^10,11  The benefits of concentrating care for children with common medical conditions at larger hospitals are similarly unknown; a paucity of research has examined the quality of pediatric care at community hospitals relative to larger academic centers.¹²  Understanding the costs and benefits of regionalization for the 11.8 million children in the United States who reside in rural areas is particularly important because national surveys indicate that rural-residing children have higher rates of obesity, disability, and mental, behavioral, and developmental disorders, all of which increase hospitalization risk.^13–16 

Regionalization generally puts specialized hospital care at a greater distance from rural residents, and although several studies in adult populations indicate that distance is associated with poor outcomes, this is understudied in pediatrics.^17,18  Direct attention to the intersection of facility capacity for pediatric care and geographic location is essential; one drawback of the study by Cushing et al³  is that it treated geography as a control variable, leaving unanswered questions about geographic disparities in access to pediatric care. Research is needed to determine the costs and benefits of pediatric regionalization to children, families, and their communities and to inform clinical and policy solutions. From a policy perspective, ensuring that health insurance is portable across facilities and state lines is fundamental to reducing families’ out-of-pocket costs.

Lessons learned from regionalization efforts in the fields of obstetrics and neonatology include the importance of ensuring transparency and clear communication about facilities’ capacities to provide specialized care, providing families and transferring providers with accurate information to make informed decisions. Regionalization also creates an increased need for effective interfacility care coordination, including health information technology that allows patient information to be transferred with the patient, and tools to facilitate effective interfacility handoffs. Wider application of telemedicine, and evaluations of its economic benefits, may reduce referral rates and allow children to remain safely in their communities.^19,20 

A 2007 Institute of Medicine (now National Academy of Medicine) report articulated the importance of taking “a systems approach that considers the full effects of regionalization on a community.”¹  Given current trends in transfer rates for specialized pediatric care, it is time for payers, hospitals, and health care systems to take a step back and develop coordinated systems of care for children, considering both the costs and benefits of pediatric regionalization.