Pediatric Capabilities in US Hospitals: 2003–2022

OBJECTIVE: To evaluate how availability of pediatric-capable hospitals has changed over 2 decades. METHODS: We studied US acute care hospitals from 2003 to 2022 using the Healthcare Cost and Utilization Project Kids' Inpatient Database. We determined the annual proportion of hospitals by pediatric capability level from 1 to 4, defined by which of 24 services were provided (level 1: broadest range; level 4: minimal services). We used Poisson models adjusting for hospital characteristics to evaluate changes from 2003 to 2022. We also measured changes in provision of each specific service. RESULTS: We analyzed a mean 3927 hospitals per year, which in 2022 were 67.3% nonprofit, 39.7% urban teaching, 47.0% small, and 37.4% in the South. The number of high-capability hospitals decreased over time. Adjusting for hospital characteristics, level 1 hospitals decreased 38% (95% CI, 27-48), level 2 hospitals decreased 54% (95% CI, 47-60), level 3 hospitals decreased 48% (95% CI, 43-53), and level 4 hospitals increased 137% (95% CI, 119-156). For 17/24 (71%) capabilities, fewer hospitals were capable in 2022 than 2003. The steepest declines of hospital-level specific services were for moderate-intensity services including appendectomy (-50.5%), pneumonia hospitalization (-42.3%), and asthma hospitalization (-41.1%). The smallest changes were for extracorporeal membrane oxygenation (+0.8%), organ transplant (0.0%), and Fontan surgery (-0.1%). CONCLUSIONS: Low-capability hospitals more than doubled over 2 decades, corresponding to substantial losses in hospitals at all higher levels of pediatric capability. This would be expected to limit child access to care across a range of conditions and complexity.