Regional variations in short stay urgent paediatric hospital admissions: a sequential mixed-methods approach exploring differences through data linkage and qualitative interviews

Abstract

Objectives: The aim of this sequential mixed-methods study was to describe and understand how paediatric short stay admission (SSA) rates vary across Health Board regions of Scotland.

Design: Exploratory sequential mixed-methods study. Routinely acquired data for the annual (per capita) SSA to hospital were compared across the 11 regions. Five diverse regions with different SSA per capita formed cases for qualitative interviews with health professionals and parents to explore how care pathways, service features and geography may influence decisions to admit.

Setting: Scotland.

Participants: All children admitted to hospital 2015-2017. Healthcare staff (n=48) and parents (n=15) were interviewed.

Results: Of 171 039 urgent hospital admissions, 92 229 were SSAs, with a fivefold variation between 14 and 69/1000 children/year across regions. SSAs were higher for children in the most deprived compared with the least deprived communities. When expressed as a ratio of highest to lowest SSA/1000 children/year for diagnosed conditions between regions, the ratio was highest (10.1) for upper respiratory tract infection and lowest (2.8) for convulsions. Readmissions varied between 0.80 and 2.52/1000/year, with regions reporting higher SSA rates more likely to report higher readmission rates (r=0.70, p=0.016, n=11). Proximity and ease of access to services, local differences in service structure and configuration, national policy directives and disparities in how an SSA is defined were recognised by interviewees as explaining the observed regional variations in SSAs. Socioeconomic deprivation was seldom spontaneously raised by professionals when reflecting on reasons to refer or admit a child. Instead, greater emphasis was placed on the wider social circumstances and parents' capacity to cope with and manage their child's illness at home.

Conclusion: SSA rates for children vary quantitatively by region, condition and area deprivation and our interviews identify reasons for this. These findings can usefully inform future care pathway interventions.

Keywords: health services accessibility; organisation of health services; paediatric A&E and ambulatory care.

Figure 1

Map of Scottish Health Boards showing the number of all urgent (left panel) and short stay urgent admissions (right panel) of children less than 16 years old to hospital between 2015 and 2017 per 1000 under 16 years. adm/1000 /year=number of admissions per 1000 children (<16 years) per annum.

Figure 2

Bar chart showing the coefficient of variation (expressed as %) for short stay urgent admissions where the diagnosis was one of the ten most common diagnoses. The horizontal dashed line is the coefficient of variation for all short stay admissions (41%). LRTI, lower respiratory tract infection; SoB, shortness of breath; URTI, upper respiratory tract infection.