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Original Investigation |

Variation and Outcomes Associated With Direct Hospital Admission Among Children With Pneumonia in the United States

JoAnna K. Leyenaar, MD, MPH, MSc1; Meng-Shiou Shieh, PhD2; Tara Lagu, MD, MPH2,3,4; Penelope S. Pekow, PhD2,5; Peter K. Lindenauer, MD, MSc2,3,4
[+] Author Affiliations
1Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
2Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
3Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
4Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts
5School of Public Health and Health Sciences, University of Massachusetts, Amherst
JAMA Pediatr. 2014;168(9):829-836. doi:10.1001/jamapediatrics.2014.339.
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Importance  Although the majority of children with an unplanned admission to the hospital are admitted through the emergency department (ED), direct admissions constitute a significant proportion of hospital admissions nationally. Despite this, past studies of children have not characterized direct admission practices or outcomes. Pneumonia is the leading cause of pediatric hospitalization in the United States, providing an ideal lens to examine variation and outcomes associated with direct admissions.

Objectives  To describe rates and patterns of direct admission in a large sample of US hospitals and to compare resource utilization and outcomes between children with pneumonia admitted directly to a hospital and those admitted from an ED.

Design, Setting, and Participants  Retrospective cohort study of children 1 to 17 years of age with pneumonia who were admitted to hospitals contributing data to Perspective Data Warehouse. We developed hierarchical generalized linear models to examine associations between admission type and outcomes.

Main Outcomes and Measures  Outcome measures included (1) length of stay, (2) high turnover hospitalization, (3) total hospital cost, (4) transfer to the intensive care unit, and (5) readmission within 30 days of hospital discharge.

Results  A total of 19 736 children from 278 hospitals met eligibility criteria, including 7100 (36.0%) who were admitted directly and 12 636 (64.0%) through the ED. Rates of direct admission varied considerably across hospitals, with a median direct admission rate of 33.3% (interquartile range, 11.1%-50.0%). Children admitted directly were more likely to be white, to have private health insurance, and to be admitted to small, general community hospitals. In adjusted models, children admitted directly had a 9% higher length of stay (risk ratio, 1.09 [95% CI, 1.07-1.11]), 39% lower odds of high turnover hospitalization (odds ratio [OR], 0.61 [95% CI, 0.56-0.66]), and 12% lower cost (risk ratio, 0.88 [95% CI, 0.87-0.90]) than those admitted through the ED, with no significant differences in transfers to the intensive care unit (OR, 1.29 [95% CI, 0.83-2.00]) or 30-day readmissions (OR, 0.80 [95% CI, 0.57-1.13]).

Conclusions and Relevance  Increasing rates of direct admission among children with access to outpatient care might be an effective strategy to reduce hospital costs and the volume of patients in the ED. Additional research is needed to establish direct admission policies and procedures that are safe and cost-effective.

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Figure 1.
Adjusted and Unadjusted Rates of Direct Admission for Children With Pneumonia

Adjusted rates were calculated using a hierarchical generalized linear model, adjusting for patient and hospital characteristics, year of admission, and a random effect for hospital.

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Figure 2.
Differences in Mean LOS (A) and Mean Total Hospital Cost (B) Between Children With Pneumonia Admitted From the ED and Those Admitted Directly to the Hospital

Across 172 hospitals with at least 5 admissions via each admission source during the study period (July 1, 2007–June 30, 2010). Hospitals are ordered by rank. The error bars reflect the 95% CIs of the within-hospital differences in length of stay (LOS) and cost. ED indicates emergency department.

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