Research Letter
National Trends in Pediatric Inpatient Capacity
Kenneth A. Michelson, Anna M. Cushing, Emily M. Bucholz
JAMA Pediatr 2025;179;(2):208-209. doi:10.1001/jamapediatrics.2024.5110
Most pediatric hospitalizations occur in general hospitals, which increasingly transfer rather than hospitalize children, resulting in care concentration at large pediatric centers.1 This shift in pediatric care delivery is partly due to inpatient unit closures, with 19.1% of 1753 closing between 2008 and 2018.2
Whether trends have leveled, persisted, or steepened since the COVID-19 pandemic is unclear. Recent surges in pediatric respiratory illnesses have tested system resilience.3 Continued pediatric capacity losses suggest lower national flexibility to weather future volume surges. We evaluated recent trends and the association of the COVID-19 pandemic with inpatient capacity, comparing child and adult access.
Methods
This cross-sectional study used US medical-surgical hospital data for January 1, 2008, to December 31, 2022, from the American Hospital Association Annual Survey, excluding never-responders and specialty and long-term hospitals. As data are deidentified and publicly available, local ethics review and informed consent were not required in accordance with the Common Rule. We followed the STROBE reporting guideline.
The primary outcome was number of pediatric inpatient units, defined as hospitals with any inpatient beds set up and staffed for pediatric care. Secondary outcomes included counts of pediatric beds, adult units and beds, and closures. Units were considered closed if the latest number of beds was 0. Hospitals were considered closed the first year they were absent from the dataset. We imputed missing bed counts by carrying forward or backward the last reported value. Urban-rural status was determined from census designations.
We used Poisson regression to compare 2022 with 2008 counts. Pediatric and adult trends were compared using a Poisson model with 3 covariates: 2008 or 2022, adult or pediatric, and their interaction (estimated difference between adult and pediatric changes). To assess the pandemic’s influence, we used interrupted time series models to evaluate immediate changes (ie, beyond the preexisting slope) at the 2020 pandemic onset and change in slope postpandemic in units and beds.4 We report closures as proportions. Data were analyzed using R, version 4.4.0 (R Foundation).
Results
Of 4808 hospitals analyzed, 2074 ever reported a pediatric inpatient unit. From 2008 to 2022, pediatric inpatient units decreased from 1749 to 1226, declining 29.9% (95% CI, 24.6%-34.8%), and beds decreased from 31 133 to 25 064 (19.5%; 95% CI, 18.1%-20.8%) (Figure 1). Adult inpatient units decreased from 4519 to 4318, declining 4.4% (95% CI, 0.4%-8.4%), and beds decreased from 405 908 to 393 802 (3.0%; 95% CI, 2.6%-3.4%). Pediatric inpatient units and beds decreased 26.6% (95% CI, 20.2%-32.6%) and 17.0% (95% CI, 15.6%-18.4%) more, respectively, than adult counterparts. Of pediatric inpatient units ever open, 848 (40.9%) closed by 2022 (Figure 2).
Figure 1. Relative Changes in Inpatient Capacity, 2008-2022
Figure 2. Closures by Urban-Rural Status
Closures and bed shifts at all pediatric units open at any time from 2008 to 2022 are stratified by urban-rural status in 2022. Bed shifts were determined based on the earliest reported bed count and the status of the unit in 2022.
With the onset of the pandemic, we observed no significant immediate change in pediatric units but observed an immediate decrease of 3.4% (95% CI, 2.1%-4.6%) for pediatric beds. Among adult units, there was no significant immediate change, but adult beds had an immediate 1.2% increase (95% CI, 0.9%-1.6%). Before the pandemic, pediatric units declined by 2.2% (95% CI, 1.8%-2.6%) per year and beds by 1.4% (95% CI, 1.3%-1.5%) per year, while adult units and beds declined 0.4% (95% CI, 0.1%-0.6%) and 0.3% (95% CI, 0.3%-0.4%) per year, respectively. There were no significant changes in slopes after pandemic onset in adult or pediatric units and beds.
Discussion
From 2008 to 2022, the US lost 29.9% of pediatric inpatient units but only 4.4% of adult units, revealing continued declines in pediatric inpatient capacity, modestly exacerbated by the pandemic. Possible explanations may be that adult beds generate more revenue than pediatric beds,5 pediatric staffing shortages make units difficult to operate, and pediatric hospitalizations are increasingly complex and require specialty resources. Furthermore, pandemic bed conversions may not have been rolled back.6 Study limitations include increased uncertainty through bed count imputation and use of a single dataset. Innovative approaches should be considered to stem future declines in pediatric capacity, which may further decrease access and resilience to surge.
