Decisions, Defaults, or Disparities: Hospital Locations for Children Assisted by Technology

Decades of regionalization and the concentration of pediatric hospital care availability^1,2  contributed to shortfalls in capacity and infrastructure during the recent respiratory viral surge. These shortfalls captivated national media attention,³  prompting the American Academy of Pediatrics and the Children’s Hospital Association to call on the Department of US Health and Human Services to declare a national emergency to address acute and chronic child health capacity crises.^4,5  Metrics such as the Hospital Capability Index, which reflects the probability of a patient completing care at a given facility, illustrate how challenges extend beyond bed numbers to actual service availability, affecting children more dramatically than adults.^6–9  Children with medical complexity (CMC) are one of the most prevalent populations in hospitals serving children,¹⁰  yet few studies have explored the effects of these trends on CMC.

Offering novel insights within this issue of Pediatrics, Moynihan et al¹¹  expose selective geographic patterns of hospital care for an important subset of CMC, children with tracheostomies, gastrostomies, or ventricular shunts. Using 2017 inpatient and emergency department data from 6 US states, the researchers observed that children assisted by these technologies typically traveled greater distances for care to reach facilities with higher Hospital Capability Indices. The large majority of inpatient or emergency department encounters occurred at just 6% of hospitals, with nearly 90% beyond the child’s nearest facility. When not at the nearest facility, encounters were 4 times farther and typically at higher capability facilities. Disparities were particularly striking, with Black or Hispanic, publicly insured children living in less advantaged neighborhoods having significantly lower likelihood to experience these patterns. These data suggest children from historically marginalized communities do not have the same opportunity to determine where hospital care is received.

Why might these patterns occur? Limited opportunity for choice exists when care location is determined by hospital capacity, specialized service needs, or one’s physical location and severity at illness onset. Therefore, a major part of the answer is whether location represents an explicit decision by someone — patients, families, emergency responders, and/or healthcare providers. But how often hospital location reflects deliberate decision-making to use a specific location when multiple options exist is poorly understood. Consistent with Moynihan et al’s findings, when patients have more complex problems or greater financial resources, they may bypass closer hospitals to attend larger hospitals farther away.¹²  Adult patients’ decisions to seek care at one hospital or another are driven by hospital type, cost, reputation, previous experience with the facility, provider expertise, insurance, and distance, among others.^13–15  If choice is the primary determinant, receiving care past the nearest hospital is not surprising when distances between centers are small. However, at some point, concentration in pediatric hospital services may effectively create barriers that eliminate choice, particularly for specialized care required for children with assistive technologies. Rural communities have experienced the greatest reductions in inpatient capacity and subspecialty access^2,16  and underscore this point.

Most concerning is how equitably the opportunity to decide where care is received may be distributed in the population. Moynihan et al’s study sounds an alarm. Although the difference in distance traveled between those receiving care at the nearest hospital compared with those not receiving care at the nearest hospital was arguably modest (about 7 miles), for families with fewer assets, these differences may be significant enough to eliminate choice, add excessive burden, or force care at “lower capability centers.”

Innovative models to “boost” services for CMC at lower capability centers are necessary in the short term. However, Moynihan et al’s data illustrate that this disproportionately targets underrepresented children from less advantaged neighborhoods, and we must avoid scenarios that perpetuate different models of care being delivered to children based on race and resources. A longer-term equitable solution demands reconfiguration of health infrastructure in a manner that allows children to receive appropriate care at appropriate times regardless of race and resource, whether in children’s hospitals, community hospitals, or through technology and outreach to homes. Direct investment in policies that address social determinants of health may also increase family capacity to receive care at the most appropriate time and location.

How do these hospitalization patterns affect the health of children and families? We know that the specific care CMC receive varies based on where they receive care.^17,18  Receiving care at a higher capability hospital does not guarantee the best outcome, nor does a lower capability center mean that outcomes will be poor. Traveling a short distance to receive care at a preferred center, regardless of its capability index, may or may not be problematic. In fact, even the factors that belong in a risk to benefit calculation for this issue are unknown and presumably highly individualized. Should traditional health services outcomes, such as cost or length of stay, be evaluated against an exposure of discordance between care locale and family preference? Defining the relevant outcomes and exposures is an important next step. Importantly, Colvin et al⁹ demonstrated that a large proportion of CMC hospitalizations would be out-of-network if the Medicare Advantage time and distance standards for network adequacy were applied. Should similar policies be applied to children, financial consequences on families and health systems for managing out-of-network costs could be significant and this should be avoided.

Moynihan et al’s study begs complex, important questions having clear clinical, research, equity, and policy implications. Children with tracheostomies, gastrostomies, and ventricular shunts are a selective group with higher stakes, yet these issues affect all children at risk for serious health emergencies.