Some unintended health consequences of the COVID pandemic for children

December 26, 2021  |  General  |  No Comments

There have been some interesting downstream effects of the COVID pandemic on children’s health. For one, our annual influx of kids with RSV (respiratory syncytial virus) and influenza pretty much disappeared. Even the most common reason for young children to visit the doctor — ear infections (otitis media) — also was greatly reduced. My colleagues in primary care told me they went from several a day to one per month. This is quite understandable. Otitis media is essentially a complication of a a viral upper respiratory infection, a cold. With all the kids out of school and daycare closed, the usual ways children get viral infections were shut down. As an aside, now that these things are open again we’re seeing a wave of RSV, as expected. In my own PICU admissions were also down last winter, and this experience was shared by my colleagues. A recent study documented the dramatic drop in PICU admissions around the country.

PICU admissions overall were down by nearly 50% across the country. The most interesting thing was that, as expected during quarantine, admissions for respiratory critical illness were dramatically down. On the other hand, as you might also have expected, PICU admissions for poisoning, drug ingestion, suicide attempt, and endocrine issues, particularly diabetic ketoacidosis, were up. If you coop up all those kids some bad things can happen. This is shown in the graph below. It shows a moving 7-d average of daily PICU admissions during the baseline (averaged over 2017–2019) and 2020 study periods. Stay-at-home orders were initiated at all sites by March 24, 2020.

So maybe that’s good? But also, the pandemic quarantine led to a drop in essential preventative care measures in children. The most recent newsletter of the American Academy of Pediatrics raised the concern for a particular example of this — vision screening. Amblyopia is a disease of vision development affecting 3% of all children. It is highly treatable in the first years of life, but after about age 7 it becomes increasingly difficult to correct. Traditionally, screening for this condition has been part of well child visits, which were dramatically reduced with the quarantine. And it’s something that really needs to be done in person, not remotely or online. There are other examples. Only time will tell if there are other untoward effects of the lapse in well child visits. The authors of the PICU study’s conclusions are kind of glass half full, but do make an important point:

The physical distancing measures put in place to decrease transmission of SARS-CoV-2 were associated with widespread and substantial reductions in PICU admissions, suggesting that a considerable portion of pediatric critical illness may be preventable, particularly those due to respiratory and infectious illnesses. These findings may have important implications for child health and public policy. Further study is warranted to identify which strategies most effectively decrease transmission of childhood infections while avoiding the negative consequences of social isolation.

Poor children have less easy access to pediatric critical care services, and this matters

December 19, 2021  |  General  |  No Comments

It’s long been known poverty among children is highly associated with poorer overall health outcomes. A similar thing occurs in adults, but in children the effects are particularly striking. A recent study in Pediatric Critical Care Medicine highlights a new aspect of this issue — distance from a PICU. The authors examined the relationship between neighborhood socioeconomic status, race, and distance to PICUs throughout the United States. Using a data set with fairly precise neighborhood granularity, they explored this phenomenon nationally and within urban and rural cohorts. The data set they used is called the Area Deprivation Index, which is derived from 17 measures of education, employment, housing, and poverty. In this composite measure, the most advantaged neighborhoods return ADI’s of 1 and the most deprived neighborhoods return ADI’s of 10. The specific question they tried to answer was if children living in areas of higher ADIs were located further away from a PICU than children in more affluent areas. This is important because it’s known transport time matters in outcomes, as does the need to transfer a child from a hospital without a PICU to one with a PICU.

The results are quite interesting — and quite striking to me:

As you can see, there is a consistent linear relationship between ADI and distance to a PICU, from 15 miles in the more affluent places to 40-50 miles in poorer neighborhoods; the distance to pediatric critical care services decreases with affluence throughout the United States. Unlike adult critical care services, where a similar relationship is driven mainly by rural versus urban residential patterns, this was true in pediatrics across urban/suburban and rural regions. This phenomenon is fueled by the physical concentration of pediatric critical care services and by the growing number of suburban poor.

These observations carry implications well beyond the care of pediatric critical illness; it also impacts more ordinary pediatric care. In the United States, pediatric hospital care has become increasingly regionalized, with even very common medical conditions, such as abdominal pain and uncomplicated seizures, now being much more likely to be referred to specialized centers. I have seen this steady development over my own 40 plus years of PICU practice, and have written about it in the past here. Since a reasonable marker of these referral centers is the presence of a PICU, distance to the nearest PICU is also a measure of distance to solutions for a wide range of pediatric medical problems. Distance matters. As the authors conclude:

In summary, we have observed a strongly linear relationship between neighborhood affluence and distance to pediatric critical care services. As a result, children in the least affluent communities need to travel nearly three times as far to reach intensive care as those in the most affluent. This carries important implications for healthcare access and may contribute to income-related disparities in some pediatric health outcomes.

What is the latest on what is best for recurrent acute ear infections (otitis media): frequent antibiotics or ear tubes?

November 29, 2021  |  General  |  No Comments

This has been a controversial topic in pediatrics for many decades. In my forty year experience one of the most common determining factors in whether or not a child gets tympanostomy tubes (ear tubes) is whether or not they’ve been seen by an ENT physician (ear, nose, and throat surgeon). In fairness to my ENT colleagues, of whom I have many excellent ones, I find this not surprising. Any specialist physician is naturally inclined to do what they are trained to do. I suppose it’s also a version of the ancient saying I learned during my surgery rotations: “A chance to cut is a chance to cure.” So generally if your child’s physician refers you to an ENT specialist for recurrent acute ear infections, the recommendation will be for ear tubes. On the other hand, if the referral goes to a pediatric infectious disease specialist, the recommendation may well be for recurrent antibiotics as needed. So what’s the latest on which of these approaches is best? Before we get to that, I should provide some quick background on the cause of acute middle ear infections. If you want a deep dive into that question, you can find more information here.

Ear infections are extremely common in children, particularly toddlers. Estimates are that a quarter of children will have at least one by their first birthday and half will by the age of three. The cause is pretty well known. You can think of an ear infection as a complication of a viral cold, and toddlers get a lot of colds. Inflammation in the back of the nasopharynx blocks drainage from the Eustachian tube that connects the middle ear to the back of the nose. Bacteria normally living in the nose take advantage of this disruption to crawl into the middle ear and multiply, leading to infection. Toddlers are more susceptible because in them this tube is short and straight; as children age it lengthens and develops a kink, making it more inaccessible to bacterial invasion. This process is illustrated in the image below.

Antibiotics are used to kill the bacteria, which generally, but not always, works. But recurrences are common, often leading to multiple rounds of antibiotic treatment. The idea of tympanostomy tubes is to put a plastic ventilation device across the eardrum so that the middle ear has another way to get ventilated if the Eustachian tube gets blocked. After a year or two the tubes usually fall out, but by then the child is often at lower risk owing to age. There are pros and cons to both approaches: antibiotics are cheaper, but recurrent bouts of otitis can add up, and frequent courses of antibiotics carry problems; ear tubes are more expensive up front and they carry the risk of any surgical procedure. So which way is best? We have some useful new information to help parents choose.

The group at the University of Pittsburgh have been doing research on otitis media for a long time — Dr. Jack Paradise has been leading this effort for decades. That group recently published a randomized study in the prestigious New England Journal of Medicine: “Tympanostomy tubes or medical management for recurrent acute otitis media.” Although the study was randomized, meaning assignment of the children to the antibiotic group or the ear tube group was random, of course it couldn’t be blinded, since it’s obvious which group the child is in. Still, it is an excellently designed study. The article is accompanied by a useful editorial on what it all means. If you don’t read the article, I at least recommend the short editorial, even though the editorialist’s final conclusion reads a bit mealy-mouthed to me. So what did they find? The answer is both satisfying and not satisfying, depending upon your perspective, I suppose.

Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management.

To me, that’s kind of an odd way to put it, although I suppose the question they were getting at is if ear tubes are better, which their study shows they aren’t; the two approaches gave equivalent outcomes. Although the two approaches gave the same benefits, there are some differences between them in risks, and that’s where parental choice plays an important role. Recurrent courses of antibiotics carry with them risks of developing allergic reactions to them. There is also the issue of the relatively unclear risks of causing derangements in the normal bacteria living in our gut, since oral antibiotics indiscriminately slaughter masses of “friendly” bacteria. Certainly diarrhea is a common side effect. We are also always concerned about how excessive antibiotic use can lead to development of resistant strains of bacteria. On the other hand, any surgical procedure, even a relatively minor one like ear tubes, carries a slight anesthetic risk. I have also seen complications of ear tubes, such as persistent holes in the eardrum that won’t heal. Tubes can also fall out too soon and need replacement, meaning another surgical procedure.

An important point to understand is that this study is about recurrent bouts of ACUTE ear infections, not CHRONIC, persistent ear problems. Using ear tubes in chronic ear problems is an entirely different issue. If you’re interested in that debate, or if your child has that problem, you can read more about it here. But with recurrent acute ear infections, the editorialist correctly points out:

Thus, management decisions can be made jointly with a high degree of parental satisfaction.

The 25 year success of Australian firearms regulation: What it could mean for children.

April 29, 2021  |  General  |  No Comments

I’ve written several times about the rising plague of firearms deaths among children (here and here). An article in the New England Journal of Medicine in 2018 noted the sad milestone that firearms were causing 15% of all deaths in children and adolescents. Somewhat encouraging, a later study showed states with stricter firearm laws correlated with lower numbers of firearm deaths in children. The relationship was quite linear, as you can see below. The authors had specific criteria for weak vs. strong gun laws: if you’re interested in what they were specifically they’re in the link to the article.

Of course there is a hot debate about what we could do about this sad statistic, specifically if we should pass gun laws aimed at reducing all firearm deaths, not just among children. There are some who insist nothing should be done, that this high death toll is somehow the price of freedom. I disagree. In this regard the experience of Australia is instructive, an experience for which we now have 25 years to evaluate trends. Such an analysis was recently published in another New England Journal of Medicine article.

After a mass shooting in Tasmania in 1996 the state and territorial governments in Australia instituted an aggressive set of regulations. These included implementing or strengthening gun owner licensing, registration, safe-storage policies, and suicide prevention programs. A key part was banning certain classes of weapons, particularly “assault” type semiautomatic rifles with high capacity magazines like the AR 15. For people who already owned these weapons, there was a buy-back program for the government to purchase these weapons from the owners and destroy them. What followed was dramatic. In the 20 years prior to the program, Australia had 11 mass shootings; in the 22 years that followed there were none. There were additional improvements besides a decrease in mass shootings. Overall firearm deaths from suicides and homicides dropped to a third of what they were previously. This is shown in the graph below.

The drop in gun suicides was particularly striking. There was no evidence of replacement of suicide by gun with another method. Research in the USA has long shown the presence of a gun in the house is a strong risk factor for suicide. Globally, total gun ownership correlates highly with firearms deaths. Additionally, intimate partner violence by men against women increases 10-fold if there is a gun available. Of course correlation is not necessarily causation, but I find the data quite convincing.

I can assure you I am not naive about firearms. I grew up in a small Minnesota town and was an avid hunter. I owned two shotguns and two rifles, one a small 0.22 caliber and one a high-powered 7 mm hunting rifle. I even had two pistols — a small 0.22 caliber and a powerful 0.357 magnum. I don’t have them anymore but I am well acquainted with guns. For what it’s worth, I don’t think the AR 15 and similar are game hunting weapons; they are meant to kill people. After all, they were designed as military weapons. For those who insist they are wonderful for target shooting, find something else.

Overall the Australian experience, now spanning 25 years, indicates taking a public health approach to gun violence yields impressive results. I never want to see another child with a gunshot wound.

Rural vs. urban status and state and local expenditures on things not related to healthcare: Effect on infant mortality

December 21, 2020  |  General  |  No Comments

A recent article in Pediatrics, the journal of the American Academy of Pediatrics, studies a particular aspect of a disturbing disparity many of us have known about or suspected for many years: a newborn’s chance of dying varies quite a bit with where it is born and who its mother is. It’s well known infant mortality varies 230% between states, with Mississippi having the highest rate at 8.3 deaths per 1,000 live births. Overall the deep South has the worst rates. It’s also well known infant mortality varies with socioeconomic status, with infants born to poorer mothers suffering a higher risk of death. A previous study identified rural location and low socioeconomic status with a higher infant mortality rate, but those two variables were bound together in that rural mothers tended to be poorer. A key issue is that rural counties have more limited access to healthcare and this would tend to drive up the infant mortality rate irrespective of socioeconomic status of the mother. This study tried to tease out those two factors.

The authors studied an enormous group — all births in the United States between 2014 and 2016 and linked them to infant death records at the county level. They used a somewhat complicated but easily understandable algorithm to adjust death rates independently for access to hospitals and socioeconomic status of the mothers. Their conclusions:

Higher infant mortality rates in rural counties are best explained by their greater socioeconomic disadvantage than more-limited access to health care or the greater prevalence of mothers’ individual health risks.

There is an additional interesting article on a related topic in the same issue of Pediatrics. It studies the effects of overall state and local expenditures on services not related to healthcare, what one might call quality of life things, and the effect on infant mortality. Previous evidence has suggested expenditures on non–healthcare services can reduce infant mortality, but it is unclear what types of spending have the greatest impact among groups at highest risk. Their conclusions:

Increased expenditures in public health, housing, parks and recreation, and solid waste management were associated with the greatest reduction in overall infant mortality rate. Investment in non–health care services was associated with lower infant mortality rates among certain high-risk populations. Continued investments into improved social and environmental services hold promise for further reducing infant mortality disparities.

Each incremental increase in overall state and local spending was associated with what one could call a dose-related improvement in infant mortality. That is a powerful finding. Their conclusion may offer some insight into why the deep South, where spending on these things is notoriously lower than other places in the country, has worse infant mortality rates even beyond the socioeconomic status of the mother. Correlation is not causation, of course, but I think these findings are quite intriguing. If we make life more civil and rewarding, we appear also to increase the chances of an infant living to enjoy it.

Effect of coronavirus on the infants of women delivering while infected

November 13, 2020  |  General  |  No Comments

An important question for pediatricians during our current pandemic is if the novel coronavirus (SARS-CoV-2, Covid-19) has an effect on infants born to mothers who are infected. A recent study in the journal Pediatrics gives some information about this question.

The authors carried out a retrospective, observational study of 149 women who delivered infants while infected with the virus. The patients all delivered during the huge epidemic in New York City last spring. Included in the group were 3 sets of twins and 3 women who had stillbirths. The report is simple; it describes what happened to the mothers and their infants.

Forty percent of the mothers were asymptomatic. Approximately 15% of symptomatic mothers required some form of respiratory support, and 8% required intubation. Eighteen newborns (12%) were admitted to the ICU. Fifteen (10%) were born preterm, and 5 (3%) required mechanical ventilation. Symptomatic mothers had more premature deliveries (16% vs 3%, P = .02), and their newborns were more likely to require intensive care (19% vs 2%, P = .001) than asymptomatic mothers. One newborn tested positive for SARS-CoV-2, which was considered a case of horizontal postnatal transmission rather than vertical transmission from the mother.

We did not observe any distinct case of vertical transmission of SARS-CoV-2 from mothers to their newborns. However, we did observe significant perinatal morbidities among mothers with SARS-CoV-2 and their newborns. We also observed that neonates born to symptomatic mothers with SARS-CoV-2 were more likely to be born prematurely and also be admitted to the NICU than were infants born to asymptomatic mothers diagnosed during universal screening.

The bottom line to me is infants born to mothers symptomatic with Covid-19 have poorer outcomes. This is not particularly surprising, really, but it is good to have these data, which are the first thus far reported about neonatal risk with Covid-19.

Do protocols and pathways improve care? The example of sepsis bundles

September 27, 2020  |  General  |  No Comments

As I’ve written before, I have to confess I’ve never been a huge fan of pathways and protocols. They often struck me as rigid and insensitive to the the nuances of differences between patients. There also are times when they are just absurd, times when physicians, and especially mid-level providers, implement them when analysis of the clinical situation clearly shows them to be inappropriate. I suppose part of me feels rigid protocols and pathways diminish the art of medicine, especially for physicians like me who have been practicing for decades. But more and more evidence is emerging that these things help patient care by ensuring nothing falls through the cracks. I find myself noticing as I enter protocol-driven orders that they can remind me of how to proceed. In the electronic medical record I can always uncheck a pre-filled order box if it is inappropriate for a particular patient.

Now we have more data about the topic. The clinical situation that has been extensively studied with protocols is sepsis, which is a series of life-threatening systemic events that can be provoked by various things, but most commonly a serious infection. A key reason for sepsis being highly appropriate for protocols and pathways is that outcome, odds of survival, is highly influenced by early recognition and treatment. Moreover, the immediate treatment is simple, relatively safe, and available in any hospital. This is why virtually all hospitals now have what are called “sepsis bundles.” These are measures taken for suspected sepsis early in the course, before the diagnosis is confirmed. Because it’s common, researchers have looked at how implementing sepsis bundles has affected outcomes. Bear in mind these comparisons are generally not randomized trials because the ethics of that would be questionable. Historical controls, what happened before implementing the bundle, are often used. This approach carries the possibility of a Hawthorne Effect: the phenomenon that can happen when people know they are being observed and change their behavior.

Of the many investigations reporting an improvement in sepsis outcomes, this one and this one are representative. The latter is part of the Surviving Sepsis program, and initiative of the Society of Critical Care Medicine. The bottom line is that such bundles of strongly recommended actions improve outcomes. Sepsis is a bit of an unusual case, though, because in sepsis early and immediate action is important, something not the case in many other conditions in which we have time to ponder things. New York state offers an interesting test cast of bundle effectiveness since it has a state law that mandates them. The above studies were in adults. There have been several recent studies of sepsis bundles in children, such as here and here, and they also show benefit. New York provided the comparison, before and after the implementation of the mandate (“Rory’s Regulations).

I still believe slavish, unthinking adherence to pathways and protocols is bad because they can get in the way of clear thinking. And we don’t need protocols for everything. Yet with more and more acute care being delivered by mid-level, non-physician providers, people who do not have extensive training in the pathophysiology of disease, these things provide a safety net of care. I’ve become cautiously reconciled to them, especially things like sepsis and stroke, in which early and prompt action matters a great deal.

More data on how fewer and fewer hospitals are able to provide definitive care for children. Why?

April 25, 2020  |  General  |  1 Comment

There are 30 million visits a year to America’s emergency departments by children. Most of these are to community hospitals rather than specialized children’s hospitals. A couple of months ago I wrote about what has been a steady trend in pediatric care — community hospitals are transferring an increasingly number of children who come to their emergency departments to other facilities for definitive care of their problems. 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. It seems highly unlikely that sicker and sicker kids are appearing in emergency departments. Now further data is available from a new study from the same research group that confirms this trend and extends its implications.

The first study looked at the past decade across America and identified those facilities that had moved up in their ability to provide definitive inpatient care to children and compared that to the number that had, for whatever reason, downgraded their capacity to care for hospitalized children. This is well shown in this graph:

The newer study has the advantage of studying three very common conditions that bring children to the emergency department: asthma, croup, and gastroenteritis. Critically ill children were excluded; the authors looked at what are bread-and-butter issues for any emergency department that sees children. They found significant increases in referrals out for all three conditions. Bear and mind these weren’t necessarily children who even needed to be admitted to the hospital. It’s not uncommon at all for them to be sent to another emergency department, evaluated and treated, and then sent home. That’s quite concerning.

For critically ill patients and some specialized conditions, there are clear benefits to transfer, which have informed national recommendations from the American Academy of Pediatrics for implementing regionalized emergency medical services. However, it is uncertain which children with lower-acuity conditions benefit from transfer to pediatric tertiary care hospitals. The majority of pediatric patients transferred between EDs are transferred for common conditions, and as many as one-third of children transferred are discharged from the hospital without requiring further intervention or subspecialty consultation.

The facilities are ranked from those who see less children (lowest) up to pediatric hospitals. Not surprisingly the rate of referral was highest in the facilities that cared for smaller numbers of children, but there were increases in all of them except for specialized children’s hospitals. What’s going on here? Should we be concerned about it? I’m concerned because, although serious and severe cases should not be cared for in facilities with limited pediatric experience, these three common conditions should be within the expertise of emergency department physicians, pediatricians, and family practitioners, particularly since these days it’s easy for physicians in smaller facilities to call larger ones for advice — I get such calls all the time, as do my pediatric hospitalist colleagues.

Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions. . . . These findings provide further evidence of pediatric care regionalization occurring even for common conditions that do not routinely require specialty care.

This can be very hard on families. Being bounced from one facility to another for a common condition, especially if you are then sent home from the second facility, is traumatic and wasteful. I work in a regional facility and my colleagues in the emergency department not uncommonly see a child sent from a facility on hour or more drive away, only to be sent home. I suspect a major reason for this, as usual, is money. Children typically don’t require all the profit-generating tests and procedures adults do. But they do require that emergency department providers be competent in providing care of children. Clearly more and more facilities have decided it’s not worth the cost to provide this. I also think more than a few hospitals are trying to offload this cost under the guise of securing better care for children.

These articles may be behind paywalls except for the abstracts. If anybody is interested, contact me on the contact form on my homepage and I’ll send you the full articles.

Once more with feeling: Don’t let patient care interfere with documentation!

March 12, 2020  |  General  |  No Comments

I’m being sarcastic, of course, but that’s often how it feels some days. And, since I posted on this subject a few years ago, not much has changed. If anything it’s worse, with more and more clicks needed on the screen to find what I want to find. Those are days when I’ve been busy at patients’ bedsides all day and then struggle to get my documentation done later, typically many hours later. I jot notes to myself as I go along, but it can be hard to recall at 5 PM just what I did and why at 8 AM. This is a particular problem in critical care because some of our billing codes are time-based and we’re supposed to remember exactly, to the minute, how much time we spend on each patient.

It used to be very different, and that wasn’t always a good thing either. Years ago I spent months going through patient charts from the era of 1920-1950. They were all paper, of course, and the hospital charts were remarkably thin, even for complicated patients. I recall one chart in particular. It was for a young child who was clearly deathly ill. The physician progress notes for her already prolonged stay in the hospital consisted of maybe 2 sheets of paper. Most of the daily notes were a single line. I could tell from the graphs of the child’s vital signs — temperature, pulse, breathing rates, and blood pressure — that one night in particular was nearly fatal. The note the next morning was written by a very famous and distinguished physician. I knew him in his retirement and he was a very loquacious man in person. His note after the child’s bad night was this: “mustard plaster did not work.” If I were caring for a patient like that today there would be just for that day and night multiple entries probably totaling several pages on the computer screen.

Patient charts are burdened with several purposes that don’t always work together. The modern medical record as we know it was invented by Dr. Henry Plummer of the Mayo Clinic in the first decade of the twentieth century. Up until that time each physician kept his (only rarely her) case notes really as notes to themselves. When the multi-specialty group appeared, and Mayo was among the first, the notion of each physician having separate records for the same patient made no sense; it was far more logical to have a single record that traveled from physician to physician with the patient. That concept meant the medical record was a means for one physician to communicate with another. So progress notes were sort of letters to your colleagues. You needed to explain what you were thinking and why. Even today’s electronic medical records are intended to do this, although they do it less and less well.

Now, however, the record is also the principal way physicians document what they did so they can get paid for it. Patient care is not at all part of that consideration. The record is also the main source for defending what you did, say in court, if you are challenged or sued. The result is that documentation, doctors entering things in the record, has eaten more and more of our time. Patients and families know this well and the chorus of complaints over it is rising. Doctors may only rarely make eye contact these days as they stare at a computer screen and type or click boxes. But we don’t have much choice if we are to get the crucial documentation done. That’s how we (and our hospitals) are paid and payers are demanding more and more complex and arcane documentation. I don’t know what the answer is, but I do think we are approaching a breaking point. We are supposed to see as many patients as we can. But the rate-limiting step is documentation.

To some extent we brought this on ourselves. In our fee-for-service system physicians once more or less said to payers: “We did this — trust us, we did it — now pay us for it.” I can’t think of a formula more guaranteed to cause over-utilization or even rare cases of outright fraud. But there is only so much time in the day. In my world an ever smaller proportion of it is spent actually with the patient.

The demand for ever more detailed documentation is not the fault of the electronic medical record. One thing that helps in pediatric critical care is the notion of bundled care. This applies for all children up to age 5 — there are categories for 0-29 days of age, 29 days to 2 years, and 2 years to 5 years. The patient is charged a flat rate for the initial day of care, then a flat rate for each subsequent day of critical care. For anyone older than 5 you are supposed to keep track of the specific minutes you spend on them. My colleagues in hospital medicine bill according to the complexity of care, called evaluation and management or E&M codes, which on the face of things seems reasonable. What can become unreasonable is that there are all manner of odd and picky criteria, constantly changing, requiring the use of special magic language, to fulfill the requirements of the several different categories. For pediatric critical care (for those under 5) one only really needs to document how the child is critically ill and what you did about it. After that the daily global charge kicks in.

For myself, I only ask for a system in which the time we spend with patients is more than the time we spend with their medical record. Surely such a thing is possible?

Fewer and fewer hospitals are able to provide definitive care for children. Why?

January 20, 2020  |  General  |  No Comments

This month’s 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 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 on 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 10 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.