Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019.

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.