The impact of children with complex chronic conditions on children’s hospitals

I’ve been doing pediatrics since 1978, and over that time have seen a transformation of children’s hospitals. I trained at a then intermediate-sized one (Vanderbilt University Children’s Hospital), that has since grown into quite a big one. When I was a resident we had some children who had complex chronic medical problems, but they were in the minority. Most of the children in the hospital were there for problems that you could call bread-and-butter pediatrics. That situation has now changed, not just at places like Vanderbilt, but at all hospitals that care for children.

Over the past three decades we’ve made huge advances in pediatric care of children with complicated medical needs — premature infants, children with brain and spinal cord problems, those with severe respiratory issues, and many other categories. In the not too distant past, children such as these would not have survived beyond their early years; now many of them are becoming adults. Yet such children are often quite medically fragile, such as being susceptible to what would be minor infections for other children, and many are dependent on advanced technology to live.

These children need hospitalizations more frequently than do their peers who do not have such problems, and their increasing presence has had an impact on the population of America’s children’s hospitals. Two recent studies (here and here) document this evolution of what children’s hospitals do. It only covers a decade — 1997 to 2006. If it were cast back to the 1970s I’m sure the changes would be even more dramatic. The authors found that children with complex chronic conditions now account for 10% of all hospital admissions. However, they use 25% of all hospital days and 40% of hospital costs, numbers which reflect their complicated situations.

I don’t think these findings are unexpected or troubling in any way. Rather, they are a reflection of our success in allowing children who previously would have died to be part of their families, to participate in society. What is clear, however, is that as we plan for what it is that children’s hospitals do, we need to understand that more and more our role will be to care for these children. Young pediatricians completing their training also need to understand that, more and more, they can expect to have several such children at least in their practices. They need to be ready for that. This was also the conclusion of the authors of an excellent accompanying editorial: we need to be ready to give these children the care they need in the best place to receive it.

(Some of the links may only be to an abstract — if anybody wants the complete articles, and can’t obtain them, let me know.)