A new national analysis shows that over the past two decades, inpatient care for children with complex chronic conditions (CCCs) has become far more intensive—and is now overwhelmingly concentrated in urban teaching children's hospitals. The authors argue that these shifts necessitate changes in pediatric training, staffing, and Medicaid policy.
Analyzing U.S. hospital discharge data from 2000 to 2022, the study found that children with at least one CCC now account for more than two-fifths of pediatric bed days and nearly three-fifths of hospital charges. Examples include children with cerebral palsy, congenital heart defects, and genetic disorders, and although these children represent a small share of the overall pediatric population, their hospital stays are longer, more complex, and increasingly involve multiple co-occurring conditions and reliance on medical technologies such as feeding and breathing tubes. Children with multiple CCCs drove most of the growth, and discharges for those with three or more CCCs increased more than threefold over the study period.
"Over the last 20 years, the inpatient pediatric caseload has shifted, the children we see in the hospital are far more complex, and almost all children with complex conditions seek care in specialty children's hospitals," said Nathaniel Bayer, MD , associate professor at the University of Rochester's Golisano Children's Hospital and lead author of the study which appears in JAMA Network Open. "That concentration of very sick children has real implications for where care happens, who delivers it, and how it is paid for."
From a small group to a large share of inpatient resources
The study grew out of a national collaboration among pediatric health services researchers from the University of Rochester, Boston Children's Hospital, Johns Hopkins University, the University of Vermont, Children's Mercy Hospital in Kansas City, the University of Toronto, and the Children's Hospital Association. Jay Berry, MD, MPH, with Boston Children's Hospital and Harvard University, is the senior author of the study. The new research builds on a similar analysis conducted 15 years ago.
Using the Kids' Inpatient Database series and national weighting, the research team estimated trends in discharge rates, bed days, and hospital charges for children with and without CCCs. Between 2000 and 2022:
- The rate of hospital discharges for children with at least one CCC rose by more than 24 percent, while the discharge rate for children without CCCs fell by more than 9 percent.
- Children with CCCs increased their share of total pediatric bed days and, despite consisting of 22 percent of all discharges, represent 40 percent of bed days and almost 60 percent of hospital charges.
- The number of children with two CCC diagnoses increased by 60 percent, and the number with three or more increased by 340 percent.
"What jumped out was the rise in hospital resource use by children with multiple, interacting chronic conditions. These are kids who require highly coordinated, intensive inpatient care," said Bayer.
Implications for children's hospitals
The study's findings raise operational and policy concerns. The authors note that most of these complex hospitalizations are covered by Medicaid, and current reimbursement levels frequently do not reflect the true costs of the care provided. "Children's hospitals are providing the majority of this care, but payment rates aren't keeping up. That mismatch contributes to closures of pediatric units in community and rural hospitals and centralizes care in academic centers with unsustainable financial models," said Bayer.
The study also highlighted implications for the workforce and training. "Residency and fellowship programs need to adapt so future pediatricians and subspecialists are prepared to care for these medically complex children. The inpatient experience is changing—residents may care for sicker, more complex patients—and training must address that reality."
Systemic and federal responses are required
The paper calls for a multi-pronged response: hospitals should evaluate team structures and staffing models to ensure safe, coordinated inpatient care; training programs should update curricula and clinical experiences; and policymakers should consider Medicaid policy changes that acknowledge the distinct needs and costs of medically complex children.
"We need pediatric-specific Medicaid policies and payment structures that recognize these children aren't the same as the average adult Medicaid population," said Bayer. "If we want to sustain high-quality pediatric inpatient care, reimbursement and workforce investments have to follow from the public and private payers."
The study contributes to a growing body of evidence documenting the evolution of pediatric inpatient care. The research team hopes their findings will inform hospital planning, training reforms, and policy discussions at the state and federal levels.
