Published in the October 2007 issue of Today’s Hospitalist
In his pediatric practice at the University of Rochester Medical Center in Rochester, N.Y., Ted Sigrest, MD, has long noted the cramped quarters of the three pediatric inpatient floors.
“We’ve had greater than 90% occupancy for the past several years, even with rooms being semi-private,” said Dr. Sigrest, who is currently doing an academic pediatric fellowship. To make matters worse, an adjacent fourth inpatient floor that had been promised to the pediatric department for years was recently scheduled for remodeling “as an adult, not a pediatric, medicine floor.
“Adult inpatient services,” Dr. Sigrest admitted, “are even more overcrowded than we are.”
That inability to expand pediatric bed space may reflect the shape of things to come. That’s because even as more and more outpatient pediatricians want to turn their hospitalized patients over to pediatric hospitalists, fewer hospitals, particularly in smaller markets, may be willing to fund and operate pediatric inpatient services.
At a meeting for pediatric hospitalists held this summer, Dr. Sigrest put a spotlight on the potential future of those services. As a member of the committee on hospital care of the American Academy of Pediatrics (AAP), Dr. Sigrest has been looking into trends, first reported by AAP members, that local pediatric units are shutting down.
“Pediatric inpatient care is changing dramatically,” Dr. Sigrest said, “but the trends have not been documented.” While survey results he presented helped illuminate what is happening with pediatric inpatient units, they also offered insights into the possible future of pediatric hospital medicine.
Falling pediatric census
With about 1,500 physicians in their ranks, pediatric hospitalists make up about 9% of the country’s total hospitalist population. Experts expect that as pediatric hospitalist opportunities grow, particularly in larger, urban markets, more physicians will be drawn to pediatric medicine, in both the inpatient and outpatient arenas.
Yet even as recruiting demands for pediatric hospitalists are on the rise, the landscape of inpatient pediatric care is rapidly changing. The AAP committee that Dr. Sigrest is a member of was charged with investigating a trend first noted by pediatricians in Rhode Island in 2002.
Those physicians claimed that pediatric inpatient units in their region were increasingly being closed or combined with adult hospital services, and that pediatric patients were being transported longer distances for inpatient care. The committee was asked to determine if the trend was a regional or a national phenomenon.
“Their concern,” said Dr. Sigrest, referring to AAP members, “was that the quality of care might suffer because of a lack of local inpatient care.” Committee members also began to worry that the transfer of more patients to academic medical centers might result in overcrowding.
The committee’s initial literature search turned up very little. “As we looked into some of the data sets, pediatric non-newborn admissions account for only 5% of total admissions,” he pointed out. “Our entire world is just a blip on hospital administrators’ radar screens.”
And what committee members heard from hospital administrations wasn’t encouraging. “Pediatric inpatient units in small hospitals are not profitable,” Dr. Sigrest said. “They have a very seasonal population, and they require special training of nurses.”
They also require specialized equipment, leaving many hospital administrators viewing pediatric units as “public relations items” instead of necessary local care. Then there is, Dr. Sigrest pointed out, “a tsunami of elderly patients” on the way.
“After years of decreases through the 1990s,” he explained, “total hospital admissions are expected to grow about 41% over the next 25 years.” Bed requirements for elderly patients are projected to reach 59% of all beds, he said, while bed space requirements for pediatric non-newborns will actually decrease to about 4% of total hospital beds.
“The result,” Dr. Sigrest reported, “will be greatly increased pressure on the inpatient resources that are devoted to pediatric services.”
The survey says
The committee was able to gather some insights from a 2004 AAP periodic survey of pediatricians. According to that survey, 7% of community pediatricians reported local unit closures within the past 10 years, while 14% had experienced unit mergers with adult services.
“That means that one in five had experienced the downsizing of pediatric services,” Dr. Sigrest pointed out. Almost half “47% “had admitted a smaller percentage of their patients locally in the past five years.
The survey found that those losses in smaller markets were offset by more crowding in large urban institutions. Among academic pediatricians, 64% reported rising occupancy rates in the past five years, while 53% reported admission delays because of bed shortages, particularly in medical units and pediatric ICUs.
Another marker of overcrowding: 61% of local pediatricians reported having problems getting information on patients who’d been referred to academic centers.
According to Dr. Sigrest, those survey findings were backed up by bed space data from the annual survey of community hospitals conducted by the American Hospital Association (AHA), covering 1992-2004. The data, which break out pediatric- unit closures according to hospital location, size and teaching status, found that smaller, non-teaching hospitals in rural areas had a 50% decline in pediatric bed space. “That,” Dr. Sigrest noted, “is an incredible decline.”
Factors favoring longevity
When variables such as children’s hospital status and teaching status were taken into account, the picture became clearer.
“The teaching status and the location of the hospital “whether urban or rural “were not significant, and that was surprising for us,” Dr. Sigrest reported. Factors that did bode well for maintaining pediatric inpatient services included hospital size. “The larger you are, the better you’re going to do.”
And the more pediatric, obstetric and emergency room services a hospital offered, the less likely hospitals were to lose pediatric beds. “The presence of a PICU was the most powerful predictor of pediatric inpatient bed survival,” he said.
The committee concluded that there is a clear pattern of inpatient downsizing and outright closure of pediatric units. The prognosis? “Overcrowding in the large, full-service pediatric hospitals can be expected to intensify,” Dr. Sigrest said. Problems related to transferring sick children far from home, including the disruption of family support systems, will also increase.
And “quality of care may be compromised,” he noted, both in smaller, non-teaching hospitals “where one-half of all pediatric inpatients in the U.S. are still being treated “and in increasingly overcrowded large hospitals facing a growing influx of patients.
The impact of pediatric hospitalists?
During a question-and-answer session that followed Dr. Sigrest’s presentation, members of the audience debated how the presence of pediatric hospitalists, in both urban and smaller markets, may affect those bed space trends.
One hospitalist who works at the children’s hospital in Spokane, Wash., said that the hospital is now responsible for close to 90% of the city’s pediatric admissions. Certainly, Dr. Sigrest pointed out, pediatric hospitalists will “encourage the transfer of patients to larger hospitals that can afford to offer a hospitalist service.”
But another member of the audience, who said she works at a community hospital in Annapolis, Md., pointed out that the presence of pediatric hospitalists like herself in smaller hospitals makes preserving pediatric bed space more viable.
She also reported a trend she’s seeing in her region: combining inpatient and emergency services into a pediatric inpatient/ED observation unit.
That model is an excellent way to preserve local pediatric services, Dr. Sigrest replied, because there is such “a huge volume of pediatric outpatient care that’s done in the ED. I’d really like to see that model spread.”
In a telephone interview, however, he pointed out that at a hospital where he once worked in Tuscaloosa, Ala., he proposed just such a model to hospital administrators and emergency physicians.
“The hospital very quickly said, ‘Feel free to go ahead and offer that service,’ ” he recalled, ” ‘but we won’t offer you any money to support it.’ ”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Adult hospitalists get ample reminders that they don’t bring in as much revenue as, say, neurosurgeons, a factor that plays into hospitals’ financial support for hospitalist programs.
But the revenue equation is more dire for pediatric hospitalists. Instead of Medicare reimbursement, they rely in part on Medicaid, a much poorer payer. Pediatric patients don’t use the same level of surgeries or procedures as adult patients, another factor that makes pediatric care less financially attractive to hospitals.
As pediatric hospitalists migrate out from academic centers to community hospitals, says academic pediatrician Ted Sigrest, MD, “there will be a point beyond which hospitalists will not be able to penetrate because of the lack of sufficient revenue.”
According to Jack Percelay, MD, a pediatric hospitalist at Saint Barnabas Medical Center in Livingston, N.J., and the pediatric board member of the Society of Hospital Medicine, pediatric inpatient services can expect to see more consolidation, with smaller hospitals moving to affiliate themselves with tertiary care centers. While the growing demand for adult beds and low pediatric revenue are factors, ensuring the skill sets of nurses who care only occasionally for pediatric patients may be “the hardest nut to crack.”
Plus, public reporting of outcomes and quality data will likewise drive unit consolidation. “It will be hard for marginally-sized units to have the same quality outcomes,” he notes.
Most hospitalized pediatric patients are under age 5, Dr. Percelay points out, so they would never come under the care of adult hospitalists. (Some adult hospitalists are, however, keeping a wary eye on the age threshold where they begin coverage, which in some hospitals has drifted down to 16 from 18.)
But while pediatric unit closings mean that more pediatric patients will be stabilized in emergency departments and referred out, “there may be opportunities in some areas,” says Dr. Percelay, “for med-peds and family medicine hospitalists to care for hospitalized children.”