Variation in emergency department admission rates in US children's hospitals

Abstract

Objective: To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals.

Methods: We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates.

Results: A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates.

Conclusions: We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.

Keywords: emergency department; hospitalization rates; variation in care.

FIGURE 1

Trends over the study period in median hospital-level severity-adjusted admission rates for select APR-DRG diagnostic groups. There were significant decreases in admission rates among pediatric patients with cellulitis (OR 0.94, 95% CI 0.91–0.98), kidney and urinary tract infections (OR 0.87, 95% CI 0.82–0.92), and concussion (OR 0.86, 95% CI 0.80–0.93). Decreases for the other diagnostic groups were not significant (asthma: OR 0.95; 95% CI 0.90–1.01; bronchiolitis: OR 0.97, 95% CI 0.92–1.03; pneumonia NEC: OR 0.96, 95% CI 0.91–1.02; seizure: 0.99, 95% CI 0.95–1.05).

FIGURE 2

Hospital-level admission rates among pediatric patients assigned the concussion APR-DRG diagnostic grouping. Each letter represents a hospital. Adjusted admission rates are corrected for patient-level severity, as measured by an International Classification of Diseases, Ninth Revision diagnosis-based Severity Classification System. Hospitals are sorted by severity-adjusted admission rates.

FIGURE 3

Hospital-level, severity-adjusted admission rates for select APR-DRG diagnostic groups among pediatric patients treated in the emergency department from 2009 through 2012. For each diagnostic group, hospitals were ranked according to severity-adjusted admission rate and categorized into deciles. Hospitals were assigned an aggregate ranking based on the sum of its 7 decile rankings. Hospitals are ordered in the figure according to their aggregate ranking. Thus, hospital 1 had the lowest aggregate admission rate across the 7 diagnostic groups, and hospital 35 had the highest. UTI, urinary tract infection.