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Table 1.  Weekly Number of Admissions to Children’s Hospitals Before and During the COVID-19 Pandemic by Patient Characteristics
Weekly Number of Admissions to Children’s Hospitals Before and During the COVID-19 Pandemic by Patient Characteristics
Table 2.  Weekly Number of Admissions for the 20 Most Common Conditions at Children’s Hospitals Before and During the COVID-19 Pandemic
Weekly Number of Admissions for the 20 Most Common Conditions at Children’s Hospitals Before and During the COVID-19 Pandemic
1.
Wilder  JL, Parsons  CR, Growdon  AS, Toomey  SL, Mansbach  JM.  Pediatric hospitalizations during the COVID-19 pandemic.   Pediatrics. 2020;146(6):e2020005983. doi:10.1542/peds.2020-005983PubMedGoogle Scholar
2.
Berry  JG, Hall  M, Cohen  E,  et al.  Hospitals’ diversity of diagnosis groups and associated costs of care.   Pediatrics. 2021;147(3):e2020018101. doi:10.1542/peds.2020-018101PubMedGoogle Scholar
3.
Gill  PJ, Anwar  MR, Thavam  T, Hall  M, Rodean  J, Mahant  S.  Pediatric clinical classification system for use in inpatient settings.   JAMA Pediatr. Published online March 1, 2021. doi:10.1001/jamapediatrics.2020.6007PubMedGoogle Scholar
4.
Coller  RJ, Nelson  BB, Sklansky  DJ,  et al.  Preventing hospitalizations in children with medical complexity: a systematic review.   Pediatrics. 2014;134(6):e1628-e1647. doi:10.1542/peds.2014-1956PubMedGoogle ScholarCrossref
5.
Kamrath  C, Mönkemöller  K, Biester  T,  et al.  Ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the COVID-19 pandemic in Germany.   JAMA. 2020;324(8):801-804. doi:10.1001/jama.2020.13445PubMedGoogle ScholarCrossref
6.
Xie  X, Xue  Q, Zhou  Y,  et al.  Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China.   JAMA Pediatr. 2020;174(9):898-900. doi:10.1001/jamapediatrics.2020.1619PubMedGoogle ScholarCrossref
Research Letter
April 27, 2021

Reasons for Admissions to US Children’s Hospitals During the COVID-19 Pandemic

Author Affiliations
  • 1Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
  • 2Children’s Hospital Association, Lenexa, Kansas
  • 3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
JAMA. 2021;325(16):1676-1679. doi:10.1001/jama.2021.4382

Measures to mitigate the COVID-19 pandemic affected children’s access to health services and their physical and mental health. Reductions in hospitalizations for children occurred in 2020 compared with prior years.1 Little is known about the reasons for the decline and whether it varied by patient characteristics.

Children’s hospitals provide inpatient care for the most diverse, high-severity, and complex illnesses2 and are located in large urban areas, which were particularly affected by COVID-19 outbreaks. Centralization of pediatric inpatient care into children’s hospitals was urged to free beds in non–children’s hospitals for adult COVID-19 patients. We compared hospitalizations in US children’s hospitals before and during the pandemic.

Methods

We conducted a retrospective study of admissions for children aged 0 to 18 years in 42 US freestanding children’s hospitals in the Pediatric Health Information System database. Admissions were categorized by spring (March 15 to May 31) and summer (June 1 to August 31). Using quantile regression, the median weekly volumes of admissions during spring and summer were compared between 2017-2019 and 2020 for all-cause admissions and the most common condition-specific reasons for admission.3 We also assessed patients’ demographic and clinical characteristics. Analyses were performed with SAS version 9.4 (SAS Institute Inc). To account for multiple comparisons, Sidak correction was applied to all P values. The threshold for statistical significance was a 2-sided P < .05. The study was approved by the Boston Children’s Hospital Institutional Review Board with a waiver of consent.

Results

There were 1 699 911 admissions included in the study; 54% were male. Weekly all-cause hospitalizations decreased in the spring from a median of 12 830 (interquartile range [IQR], 12 468-13 095) in 2017-2019 to 7033 (IQR, 6187-8231) in 2020 (48.3% [95% CI, 38.6%-58.0%] decrease) and in the summer from a median of 11 697 (IQR, 11 495-11 947) in 2017-2019 to 9178 (IQR, 8739-9358) in 2020 (23.5% [95% CI, 19.2%-27.8%] decrease) (P < .001 for both). The least percentage change per week was in summer 2020 among adolescents aged 15 to 18 years (−9.6% [95% CI, −17.5% to −1.8%]; P = .47) and the greatest change was in spring 2020 among those with the lowest illness severity (−56.4% [95% CI, −65.1% to −47.7%]; P < .001) (Table 1). Decreases in hospitalizations occurred in all demographic and clinical subgroups.

The largest decrease in weekly condition-specific hospitalizations occurred in spring 2020 with respiratory failure (from a median of 296 [IQR, 253-464] in 2017-2019 to 87 [IQR, 85-134] in 2020; 167.7% [95% CI, 129.6%-205.9%] decrease; P < .001) (Table 2). Decreases also occurred in spring 2020 with nonrespiratory conditions, including cellulitis (from a median of 221 [IQR, 211-239] in 2017-2019 to 120 [IQR, 111-142] in 2020; 45.4% [95% CI, 32.6%-58.1%] decrease; P < .001) and epilepsy (from a median of 585 [IQR, 561-606] in 2017-2019 to 300 [IQR, 239-373] in 2020; 48.0% [95% CI, 31.1%-64.9%] decrease; P < .001). Although not significant, the least percentage change per week was in summer 2020 for diabetic ketoacidosis (from a median of 138 [IQR, 125-146] in 2017-2019 to 150 [IQR, 142-162]; change, −0.7% [95% CI, 12.0% to −13.7%]; P > .99). Suicide/intentional injury was the only hospitalization with a (nonsignificant) percentage increase in summer 2020 (from a median of 93 [IQR, 87-102] to 109 [IQR, 93-128]; change, 11.8% [95% CI, −10.8% to 34.5%]; P > .99).

Discussion

In spring and summer 2020, during the COVID-19 pandemic, all-cause admissions and many condition-specific admissions for acute and chronic health problems decreased in US children’s hospitals. These decreases exceeded those reported with prior initiatives to prevent hospitalizations.4 In addition to social distancing, potential reasons include more watchful waiting for children with symptoms and increased thresholds for emergency department and hospital care, especially for lower-severity illnesses.

Diabetic ketoacidosis and suicide hospitalizations did not significantly change. Increased diabetic ketoacidosis during the COVID-19 pandemic has been reported in Germany.5 Increased depression, anxiety, and suicidal ideation and planning in children have occurred during the COVID-19 pandemic.6

Limitations include the absence of data from non–children’s hospitals. Transfers of pediatric patients from non–children’s hospitals to children’s hospitals did not increase, suggesting that changes in the location of where children received care did not influence the results. Data on the resurgence of COVID-19 in the fall and winter of 2020 were not available.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Correction: This article was corrected on July 13, 2021, for data errors in Table 2.

Accepted for Publication: March 8, 2021.

Corresponding Author: Jay G. Berry, MD, MPH, Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (jay.berry@childrens.harvard.edu).

Author Contributions: Drs Gill and Hall had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Gill, Mahant, Hall.

Drafting of the manuscript: All authors.

Critical revision for important intellectual content: Gill, Mahant, Berry.

Statistical analysis: Hall.

Obtained funding: Berry.

Administrative, technical, or material support: Gill, Mahant, Berry.

Supervision: Berry.

Conflict of Interest Disclosures: Dr Gill reported receipt of grants from the Canadian Institute of Health Research (CIHR) and the Hospital for Sick Children, conference reimbursement from the EBMLive Steering Committee, and advisory board membership and meeting reimbursement from the CIHR Institute of Human Development, Child and Youth Health. Dr Mahant reported receiving grants from the CIHR. No other disclosures were reported.

Funding/Support: Drs Berry and Hall were supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (DHHS) under contract UA6MC31101, Children and Youth With Special Health Care Needs Research Network.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: This information or content and conclusions are those of the author and should not be construed as the official position or policy of nor should any endorsements be inferred by the HRSA, DHHS, or US government.

References
1.
Wilder  JL, Parsons  CR, Growdon  AS, Toomey  SL, Mansbach  JM.  Pediatric hospitalizations during the COVID-19 pandemic.   Pediatrics. 2020;146(6):e2020005983. doi:10.1542/peds.2020-005983PubMedGoogle Scholar
2.
Berry  JG, Hall  M, Cohen  E,  et al.  Hospitals’ diversity of diagnosis groups and associated costs of care.   Pediatrics. 2021;147(3):e2020018101. doi:10.1542/peds.2020-018101PubMedGoogle Scholar
3.
Gill  PJ, Anwar  MR, Thavam  T, Hall  M, Rodean  J, Mahant  S.  Pediatric clinical classification system for use in inpatient settings.   JAMA Pediatr. Published online March 1, 2021. doi:10.1001/jamapediatrics.2020.6007PubMedGoogle Scholar
4.
Coller  RJ, Nelson  BB, Sklansky  DJ,  et al.  Preventing hospitalizations in children with medical complexity: a systematic review.   Pediatrics. 2014;134(6):e1628-e1647. doi:10.1542/peds.2014-1956PubMedGoogle ScholarCrossref
5.
Kamrath  C, Mönkemöller  K, Biester  T,  et al.  Ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the COVID-19 pandemic in Germany.   JAMA. 2020;324(8):801-804. doi:10.1001/jama.2020.13445PubMedGoogle ScholarCrossref
6.
Xie  X, Xue  Q, Zhou  Y,  et al.  Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China.   JAMA Pediatr. 2020;174(9):898-900. doi:10.1001/jamapediatrics.2020.1619PubMedGoogle ScholarCrossref
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