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Hospital Use (see data for this topic)

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Why This Topic Is Important
All children should have high-quality, accessible, affordable health care, including hospital care when needed. Children with special health care needs, in particular, may require more frequent hospital visits and specialized, intensive medical services. Ensuring that all children have consistent access to affordable, evidence-based, well-coordinated, comprehensive, and family-centered care—all within the context of a medical home—can maximize positive outcomes (1). This type of care also may reduce costly hospitalizations and emergency department visits (1).

While emergency departments (EDs) are critical sources of acute care for children, frequent or non-urgent ED visits may be an indication of unmet health needs and/or difficulty accessing appropriate pediatric care (2). Children from vulnerable groups, especially young children ages 0-5 and those from low-income households, tend to have disproportionately high rates of ED use (3).

Data on hospital use can illuminate trends in health and health care needs, and can inform disease surveillance and public health prevention efforts. For example, data show that ED visits for psychiatric issues have been rising among young people nationwide, with teens and youth of color experiencing the largest increases (4). Additionally, mental illness has become the most common cause of hospitalization among children in California and the U.S. (5, 6). Children admitted to the hospital for mental health reasons also are more likely to have unplanned readmissions than children with other diagnoses (5). These data point to urgent mental health care needs among youth nationwide.
For more information, see kidsdata.org’s Research & Links section.

Sources for this narrative:

1.  National Academies of Sciences, Engineering, and Medicine. (2018). Opportunities for improving programs and services for children with disabilities. National Academies Press. Retrieved from: https://www.nap.edu/catalog/25028/opportunities-for-improving-programs-and-services-for-children-with-disabilities

2.  Taylor, T., & Salyakina, D. (2019). Health care access barriers bring children to emergency rooms more frequently: A representative survey. Population Health Management, 22(3), 262-271. Retrieved from: https://www.liebertpub.com/doi/10.1089/pop.2018.0089

3.  McDermott, K. W., et al. (2018). Overview of pediatric emergency department visits, 2015 (HCUP Statistical Brief No. 242). Agency for Healthcare Research and Quality. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb242-Pediatric-ED-Visits-2015.jsp

4.  Kalb, L. G., et al. (2019). Trends in psychiatric emergency department visits among youth and young adults in the U.S. Pediatrics, 143(4), e20182192. Retrieved from: https://pediatrics.aappublications.org/content/143/4/e20182192

5.  Feng, J. Y., et al. (2017). Readmission after pediatric mental health admissions. Pediatrics, 140(6), e20171571. Retrieved from: https://pediatrics.aappublications.org/content/140/6/e20171571

6.  As cited on kidsdata.org, Hospital discharges, by primary diagnosis. (2020). California Office of Statewide Health Planning and Development.
Policy Implications
Hospital care for children is changing. While hospital admissions are declining, readmissions appear to be rising due to increasing numbers of children with chronic health conditions (1). Admissions, readmissions, and emergency department (ED) visits may be reduced through effective care coordination and discharge planning, especially for children with special health care needs (2, 3). Hospital utilization data can reveal the conditions and populations for which targeted care management and preventive services could have the greatest impact, including children with mental illness and asthma, the leading causes of pediatric hospitalizations statewide (4).

Emergency care for children also has unique challenges. Most children who need emergency care visit community hospital EDs (rather than those at children's hospitals), which may not be well-equipped to care for children with special health care needs, or for pediatric care in general (2, 5). Many EDs face overcrowding, too, as they often function as a safety net for those with unmet health needs or limited access to care (6, 7). Low-income children are more likely to use EDs than higher-income children, and research shows that improving access to appropriate pediatric care may reduce unnecessary ED visits (6, 8).

Policy and practice options that could reduce preventable hospital use and improve pediatric care before, during, and after hospitalizations and ED visits include:
  • Reducing care fragmentation and inefficiency within and across health systems by establishing care coordination services within a patient- and family-centered medical home, including a team-based, strengths-based, comprehensive approach to meeting children's needs while enhancing the caregiving capabilities of families (2, 9)
  • Ensuring that all children have high-quality, accessible, and affordable health care to promote prevention and effective management of chronic conditions (2, 9)
  • Reducing barriers that can prevent families from obtaining timely and appropriate care, such as language/cultural barriers, difficulty finding a doctor or making an appointment, and transportation issues; also, improving family health literacy regarding primary care availability and appropriate use of EDs, which can help reduce non-urgent ED visits (6)
  • Promoting efforts to improve pediatric readiness in all EDs, in accordance with American Academy of Pediatrics guidelines, including identification of a physician and nurse pediatric coordinator and an ongoing commitment that all aspects of EDs, from policies and staff competencies to equipment and medications, are set up to meet the unique needs of children (5)
  • Implementing a standardized, pediatric-specific framework for the transition from hospital to home care that begins at the time of admission, involves the entire care team, engages the child's family, considers family circumstances and social determinants of health, provides clear documentation, and follows up with the family after discharge (3, 10)
  • Continuing to promote community-wide, integrated interventions to decrease the burden of asthma on high-risk populations, such as low-income families and children of color, including strategies to improve insurance coverage among the uninsured and under-insured, provide home visiting and education, and reduce environmental asthma triggers (11)
  • Adopting a comprehensive, evidence-based approach to mental health services for youth that expands and improves prevention, screening, and access to services, while also promoting positive mental health and providing access to wellness supports for all children and families (12)
  • Continuing to support research on strategies to reduce preventable hospital use, particularly for children with special health care needs (1)
For more policy ideas and research on this topic, visit kidsdata.org’s Research & Links section. Also see Policy Implications under Health Care, Children's Emotional Health, Asthma, and topics related to Children with Special Health Care Needs.

Sources for this narrative:

1.  Bucholz, E. M., et al. (2019). Trends in pediatric hospitalizations and readmissions: 2010-2016. Pediatrics, 143(2), e20181958. Retrieved from: https://pediatrics.aappublications.org/content/143/2/e20181958

2.  National Academies of Sciences, Engineering, and Medicine. (2018). Opportunities for improving programs and services for children with disabilities. National Academies Press. Retrieved from: https://www.nap.edu/catalog/25028/opportunities-for-improving-programs-and-services-for-children-with-disabilities

3.  Lax, Y., et al. (2017). Social determinants of health and hospital readmission. Pediatrics, 140(5), e20171427. Retrieved from: https://pediatrics.aappublications.org/content/140/5/e20171427

4.  As cited on kidsdata.org, Hospital discharges, by primary diagnosis. (2020). California Office of Statewide Health Planning and Development.

5.  Remick, K., et al. (2018). Pediatric readiness in the emergency department. Pediatrics, 142(5), e20182459. Retrieved from: https://www.aappublications.org/content/142/5/e20182459

6.  Taylor, T., & Salyakina, D. (2019). Health care access barriers bring children to emergency rooms more frequently: A representative survey. Population Health Management, 22(3), 262-271. Retrieved from: https://www.liebertpub.com/doi/10.1089/pop.2018.0089

7.  Kalb, L. G., et al. (2019). Trends in psychiatric emergency department visits among youth and young adults in the U.S. Pediatrics, 143(4), e20182192. Retrieved from: https://pediatrics.aappublications.org/content/143/4/e20182192

8.  McDermott, K. W., et al. (2018). Overview of pediatric emergency department visits, 2015 (HCUP Statistical Brief No. 242). Agency for Healthcare Research and Quality. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb242-Pediatric-ED-Visits-2015.jsp

9.  American Academy of Pediatrics, Council on Children with Disabilities & Medical Home Implementation Project Advisory Committee. (2018). Patient- and family-centered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics, 133(5), e1451-e1460. Retrieved from: http://pediatrics.aappublications.org/content/133/5/e1451

10.  Berry, J. G., et al. (2014). A framework of pediatric hospital discharge care informed by legislation, research, and practice. JAMA Pediatrics, 168(10), 955-966. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5603147

11.  California Department of Public Health. (2015). Strategic plan for asthma in California: 2015-2019. Retrieved from: https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/EHIB/CPE/CDPH Document Library/SPAC2014_7-28-15APR.pdf

12.  National Academies of Sciences, Engineering, and Medicine. (2019). Fostering healthy mental, emotional, and behavioral development in children and youth: A national agenda. National Academies Press. Retrieved from: https://www.nap.edu/catalog/25201/fostering-healthy-mental-emotional-and-behavioral-development-in-children-and-youth
How Children Are Faring
California children ages 0-17 made more than 2.7 million emergency department (ED) visits in 2018, with children from five Southern California counties—Los Angeles, Riverside, San Bernardino, Orange, and San Diego—accounting for more than half of these. Statewide, traumatic injuries are the most common primary diagnosis among children visiting the ED, representing more than 10% of all visits, followed by viral illnesses or fevers of unknown origin (around 8%) and asthma/bronchitis and fractures (around 4% each). As in previous years, Medi-Cal was the payment source for almost two-thirds (64%) of childhood ED visits in 2018, compared with private insurance at 27%. At the local level, payment sources for ED visits vary widely; e.g., the percentage of visits covered by Medi-Cal in 2018 ranged from 35% in Santa Barbara County to 83% in Merced County.

In 2018, there were 218,946 hospital discharges among California children ages 0-17, a 25% drop compared with 2002. More than one in seven (15%) of these hospital stays were for a primary diagnosis of mental disease or disorder, followed by asthma/bronchitis (8%) and seizures/headaches (4%). Although mental illness has been the most common cause of childhood hospitalization statewide since 2008, wide variation exists across regions. For example, in 2018, the percentage of discharges for mental diseases and disorders among children in San Mateo County was 10 times the percentage for children in Imperial County. Among California children discharged in 2018, Medi-Cal covered the hospitalization expenses for more than half (54%) of these visits, compared with 36% for private insurance. Since 2002, the percentage of visits covered by private insurers has generally decreased, while the percentage covered by Medi-Cal has increased.