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April 1997, Vol 151, No. 4 >
Article | April 1997

Ensuring High-Quality Alternatives While Ending Pediatric Inpatient Care as We Know It FREE

Kenneth M. McConnochie, MD, MPH; Klaus J. Roghmann, PhD; Harriet J. Kitzman, RN, PhD; Gregory S. Liptak, MD, MPH; John T. McBride, MD
Arch Pediatr Adolesc Med. 1997;151(4):341-349. doi:10.1001/archpedi.1997.02170410015002.
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Child advocates recognize pediatric hospitalization as an issue of great concern because of the serious morbidity it reflects and the adverse psychosocial effects of inpatient experience on children and families. Accounting for almost 50% of child health care costs,1 estimated at $49.8 billion in the United States in 1987,2 pediatric hospitalization also represents a substantial financial burden. Studies of the variation in childhood hospitalization rates among geographic areas, however, suggest a large portion of these hospitalizations are avoidable.3-9 In individual level analysis, admitting pediatricians judged 28% of acute, general pediatric hospitalizations to be potentially avoidable had specified alternative services been available.10 Furthermore, evidence supports the safety of care in alternative settings for selected acute illness episodes.11-16 Hospitals share incentives for reducing inpatient services as they join managed care organizations that capitate hospital costs.17 At a time when health care cost reduction has become a

REFERENCES

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Hahn B, Lefkowitz D. Annual Expenses and Sources of Payment for Health Care Services . Rockville, Md: Agency for Health Care Policy and Research; 1992;. US Dept of Health and Human Services publication 93-0007.
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Lewit EM, Monheit AC.  Expenditures on health care for children and pregnant women . Future Child . (Winter) 1992;:95-114.
3 +
Connell FA, Day RW, LoGerfo JP.  Hospitalization of Medicaid children: analysis of small area variations in admission rates . Am J Public Health . 1981;;71:606-613.
4 +
Perrin JM, Homer CJ, Berwick DM, et al.  Variations in rates of hospitalization of children in three urban communities . N Engl J Med . 1989;; 320:1183-1187.
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6 +
McConnochie KM, Roghmann KJ, Liptak GS.  Hospitalization for lower respiratory tract illness in infants: variation in rates among counties in New York State and areas in Monroe County . J Pediatr . 1995;;126:220-229.
7 +
Wennberg J, Kim SYS.  Common uses of hospitals: a look at Vermont . In: Harvard Child Health Project: Vol 2: Developing a Better Health System for Children . Cambridge, Mass: Ballinger Publishing Co;1977;:353-382.
8 +
McConnochie KM, Roghmann KJ, Liptak GS.  Socioeconomic variation in discretionary and mandatory hospitalization of infants: an ecological analysis . Pediatrics . 1997;. In press.
9 +
Goodman DC, Fisher ES, Gittelsohn A, Chang CH, Fleming C.  Why are children hospitalized? the role of non-clinical factors in pediatric hospitalizations . Pediatrics . 1994;;93:896-902.
10 +
Soulen JL, Duggan AK, DeAngelis CD.  Identification of potentially avoidable pediatric hospital use: admitting physician judgment as a complement to utilization review . Pediatrics .1994;; 94:421-424.
11 +
McConnochie KM, Callahan CM, Roghmann KJ, Conners GP.  Adverse outcome in children hospitalized who are candidates for care in alternative settings . Arch Pediatr Adolesc Med . 1996;; 150( (suppl) ):38.
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Strandvic B, Hjelte L, Malmborg AS, Widen B.  Home intravenous antibiotic treatment of patients with cystic fibrosis . Acta Paediatr . 1992;;81:340-344.
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Talcott J, Whalen A, Clark J, Rieker P, Finberg R.  Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule . J Clin Oncol . 1994;;12:107-114.
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Balinsky W, Nesbitt S.  Cost-effectiveness of outpatient patenteral antibiotics: a review of the literature . Am J Nurs . 1989;;87:301-305.
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Graham D, Keldermans M, Klemm L, Semenza N, Shafer M.  Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters . Am J Nurs .1991;;91 ( (suppl 3B) ):3B95-3B100.
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McCarthy CA, Powell KR, Jaskiewicz JA, et al.  Outpatient management of selected infants younger than two months of age evaluated for possible sepsis . Pediatr Infect Dis J . 1990;;9:385-389.
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Rogers MC, Snyderman R, Rogers EL.  Cultural and organizational implications of academic managed-care networks . N Engl J Med . 1994;;331:1374-1377.
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McGlynn EA, Halfon N, Leibowitz A.  Assessing the quality of care for children: prospects under health reform . Arch Pediatr Adolesc Med . 1995;;149:359-368.
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Bass LW, Cohen RL.  Ostensible versus actual reasons for seeking pediatric attention: another look at the parental ticket of admission . Pediatrics . 1982;;70:870-874.
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Levy JC.  Vulnerable children: parents' perspectives and the use of medical care . Pediatrics . 1982;;65:956-963.
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Green M.  The 'vulnerable child': intimations of mortality . Pediatrics . 1980;;65:1042-1043.
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Green M, Solnit AJ.  Reactions to the threatened loss of a child: a vulnerable child syndrome . Pediatrics . 1964;;34:58-66.
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Carey WB.  Psychologic sequelae of early infancy health crises . Clin Pediatr . 1969;;8:459-463.
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McCormick MC, Shapiro S, Starfield B.  Factors associated with maternal opinion of infant development—clues to the vulnerable child syndrome . Pediatrics . 1982;;69:537-543.
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Jeffcoate JA, Humphrey ME, Lloyd JK.  Disturbance in parent-child relationship following preterm delivery . Dev Med Child Neurol . 1979;;21:344-352.
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Thompson RT, Vernon DTA.  Research on children's behavior after hospitalization: a review and synthesis . Dev Behav Pediatr . 1993;;14:28-35.
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Sides J. Emotional Responses of Children to Physical Illness and Hospitalization. Auburn, Ala: Auburn University; 1977. Dissertation.
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Irwin EC, Kovacs A.  Analysis of children's drawings and stories . Assoc Care Child Hosp . 1979;; 8:39-48.
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Astin EW.  Self-reported fears of hospitalized and nonhospitalized children aged ten to twelve . Matern Child Nurs J . 1988;;6:17-24.
35 +
Vernon DTA, Schulman JL, Foley JM.  Changes in children's behavior after hospitalization: some dimensions of responses and their correlates . AJDC . 1966;;111:581-593.
36 +
Craft M, Wyatt N, Sandell B.  Behavior and feeling changes in siblings of hospitalized children . Clin Pediatr . 1985;;24:374-378.
37 +
Craft M, Craft J.  Perceived changes in siblings of hospitalized children: a comparison of sibling and parent report . CHC . 1989;;12:424-448.
38 +
Lynn MR.  Siblings' responses in illness situations . J Pediatr Nurs . 1989;;4:127-129.
39 +
Lovejoy FH, Carper JM, Janeway CA, Kosa J.  Unnecessary and preventable hospitalization: report on an internal audit . J Pediatr . 1971;;79:868-872.
40 +
Duff RS, Cook CD, Wanerka GR, Rowe DS, Dolan TF Jr.  Use of utilization review to assess the quality of pediatric inpatient care . Pediatrics . 1972;;49:169-176.
41 +
Kemper KJ.  Medical inappropriate use in a pediatric population . N Engl J Med . 1988;;318: 1033-1037.
42 +
Gloor JE, Kisoon N, Jouebert G.  Appropriateness of hospitalization in a Canadian pediatric hospital . Pediatrics . 1993;;91:70-74.
43 +
Wennberg JE, McPherson K, Caper P.  Will payment based on diagnosis related groups control hospital costs? N Engl J Med . 1984;;311:295-300.
44 +
Wennberg JE, Barnes BA, Zubkoff M.  Professional uncertainty and the problem of supplier-induced demand . Soc Sci Med . 1982;;15:811-824.
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Eddy DM.  Variations in physician practice: the role of uncertainty . Health Aff . 1984;;3:74-89.
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Wennberg JE.  Factors governing utilization of hospital services . Hosp Pract . 1979;;14:115-117.
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Roos LL.  Supply, workload and utilization: a population-based analysis of surgery . Am J Public Health . 1983;;73:414-421.
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Roos NP, Wennberg JE, McPherson K.  Using diagnosis-related groups for studying variations in hospital admissions . Health Care Financing Rev . 1988;;9:53-62.
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Wennberg JE, Freeman RM, Shelton RM, Bubholz TA.  Hospital use and mortality among Medicare beneficiaries in Boston and New Haven . N Engl J Med . 1989;;321:1168-1173.
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Conway SP, Phillips RR, Panday S.  Admission to hospital with gastroenteritis . AJDC . 1990;; 65:579-584.
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Strandvic B, Hjelte L, Malmborg AS, Widen B.  Home intravenous antibiotic treatment of patients with cystic fibrosis . Acta Paediatr . 1992;; 81:340-344.
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Talcott J, Whalen A, Clark J, Rieker P, Finberg R.  Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule . J Clin Oncol . 1994;;12:107-114.
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Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

References

1 +
Hahn B, Lefkowitz D. Annual Expenses and Sources of Payment for Health Care Services . Rockville, Md: Agency for Health Care Policy and Research; 1992;. US Dept of Health and Human Services publication 93-0007.
2 +
Lewit EM, Monheit AC.  Expenditures on health care for children and pregnant women . Future Child . (Winter) 1992;:95-114.
3 +
Connell FA, Day RW, LoGerfo JP.  Hospitalization of Medicaid children: analysis of small area variations in admission rates . Am J Public Health . 1981;;71:606-613.
4 +
Perrin JM, Homer CJ, Berwick DM, et al.  Variations in rates of hospitalization of children in three urban communities . N Engl J Med . 1989;; 320:1183-1187.
5 +
DeFreese GH, Evans AT, Ricketts TC, Cromartie EP.  Practice variation study of pediatric respiratory illness . In: Final Report: Practice Pattern Variation Committee . Chapel Hill, NC: Health Services Research Center, University of North Carolina; 1989;.
6 +
McConnochie KM, Roghmann KJ, Liptak GS.  Hospitalization for lower respiratory tract illness in infants: variation in rates among counties in New York State and areas in Monroe County . J Pediatr . 1995;;126:220-229.
7 +
Wennberg J, Kim SYS.  Common uses of hospitals: a look at Vermont . In: Harvard Child Health Project: Vol 2: Developing a Better Health System for Children . Cambridge, Mass: Ballinger Publishing Co;1977;:353-382.
8 +
McConnochie KM, Roghmann KJ, Liptak GS.  Socioeconomic variation in discretionary and mandatory hospitalization of infants: an ecological analysis . Pediatrics . 1997;. In press.
9 +
Goodman DC, Fisher ES, Gittelsohn A, Chang CH, Fleming C.  Why are children hospitalized? the role of non-clinical factors in pediatric hospitalizations . Pediatrics . 1994;;93:896-902.
10 +
Soulen JL, Duggan AK, DeAngelis CD.  Identification of potentially avoidable pediatric hospital use: admitting physician judgment as a complement to utilization review . Pediatrics .1994;; 94:421-424.
11 +
McConnochie KM, Callahan CM, Roghmann KJ, Conners GP.  Adverse outcome in children hospitalized who are candidates for care in alternative settings . Arch Pediatr Adolesc Med . 1996;; 150( (suppl) ):38.
12 +
Strandvic B, Hjelte L, Malmborg AS, Widen B.  Home intravenous antibiotic treatment of patients with cystic fibrosis . Acta Paediatr . 1992;;81:340-344.
13 +
Talcott J, Whalen A, Clark J, Rieker P, Finberg R.  Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule . J Clin Oncol . 1994;;12:107-114.
14 +
Balinsky W, Nesbitt S.  Cost-effectiveness of outpatient patenteral antibiotics: a review of the literature . Am J Nurs . 1989;;87:301-305.
15 +
Graham D, Keldermans M, Klemm L, Semenza N, Shafer M.  Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters . Am J Nurs .1991;;91 ( (suppl 3B) ):3B95-3B100.
16 +
McCarthy CA, Powell KR, Jaskiewicz JA, et al.  Outpatient management of selected infants younger than two months of age evaluated for possible sepsis . Pediatr Infect Dis J . 1990;;9:385-389.
17 +
Rogers MC, Snyderman R, Rogers EL.  Cultural and organizational implications of academic managed-care networks . N Engl J Med . 1994;;331:1374-1377.
18 +
McGlynn EA, Halfon N, Leibowitz A.  Assessing the quality of care for children: prospects under health reform . Arch Pediatr Adolesc Med . 1995;;149:359-368.
19 +
Perrin EC, West PD, Culley BS.  Is my child normal yet? correlates of vulnerability . Pediatrics . 1989;;83:355-363.
20 +
Kemper KJ, Forsyth BWC, McCarthy PL.  Jaundice, terminating breast feeding, and the vulnerable child . Pediatrics . 1989;;84:773-778.
21 +
Kemper KJ, Forsyth BWC, McCarthy PL.  Persistent perceptions of vulnerability following neonatal jaundice . AJDC . 1990;;144:238-241.
22 +
Forsyth BWC, McCarthy PL, Leventhal JM.  Problems of early infancy, formula changes and mothers' beliefs about their infants . J Pediatr . 1985;; 106:1012-1017.
23 +
Forsyth BWC.  Mothers' perceptions of their children's vulnerability after hospitalization for infection . AJDC . 1987;;141( (suppl) ):377.
24 +
Bass LW, Cohen RL.  Ostensible versus actual reasons for seeking pediatric attention: another look at the parental ticket of admission . Pediatrics . 1982;;70:870-874.
25 +
Levy JC.  Vulnerable children: parents' perspectives and the use of medical care . Pediatrics . 1982;;65:956-963.
26 +
Green M.  The 'vulnerable child': intimations of mortality . Pediatrics . 1980;;65:1042-1043.
27 +
Green M, Solnit AJ.  Reactions to the threatened loss of a child: a vulnerable child syndrome . Pediatrics . 1964;;34:58-66.
28 +
Carey WB.  Psychologic sequelae of early infancy health crises . Clin Pediatr . 1969;;8:459-463.
29 +
McCormick MC, Shapiro S, Starfield B.  Factors associated with maternal opinion of infant development—clues to the vulnerable child syndrome . Pediatrics . 1982;;69:537-543.
30 +
Jeffcoate JA, Humphrey ME, Lloyd JK.  Disturbance in parent-child relationship following preterm delivery . Dev Med Child Neurol . 1979;;21:344-352.
31 +
Thompson RT, Vernon DTA.  Research on children's behavior after hospitalization: a review and synthesis . Dev Behav Pediatr . 1993;;14:28-35.
32 +
Sides J. Emotional Responses of Children to Physical Illness and Hospitalization. Auburn, Ala: Auburn University; 1977. Dissertation.
33 +
Irwin EC, Kovacs A.  Analysis of children's drawings and stories . Assoc Care Child Hosp . 1979;; 8:39-48.
34 +
Astin EW.  Self-reported fears of hospitalized and nonhospitalized children aged ten to twelve . Matern Child Nurs J . 1988;;6:17-24.
35 +
Vernon DTA, Schulman JL, Foley JM.  Changes in children's behavior after hospitalization: some dimensions of responses and their correlates . AJDC . 1966;;111:581-593.
36 +
Craft M, Wyatt N, Sandell B.  Behavior and feeling changes in siblings of hospitalized children . Clin Pediatr . 1985;;24:374-378.
37 +
Craft M, Craft J.  Perceived changes in siblings of hospitalized children: a comparison of sibling and parent report . CHC . 1989;;12:424-448.
38 +
Lynn MR.  Siblings' responses in illness situations . J Pediatr Nurs . 1989;;4:127-129.
39 +
Lovejoy FH, Carper JM, Janeway CA, Kosa J.  Unnecessary and preventable hospitalization: report on an internal audit . J Pediatr . 1971;;79:868-872.
40 +
Duff RS, Cook CD, Wanerka GR, Rowe DS, Dolan TF Jr.  Use of utilization review to assess the quality of pediatric inpatient care . Pediatrics . 1972;;49:169-176.
41 +
Kemper KJ.  Medical inappropriate use in a pediatric population . N Engl J Med . 1988;;318: 1033-1037.
42 +
Gloor JE, Kisoon N, Jouebert G.  Appropriateness of hospitalization in a Canadian pediatric hospital . Pediatrics . 1993;;91:70-74.
43 +
Wennberg JE, McPherson K, Caper P.  Will payment based on diagnosis related groups control hospital costs? N Engl J Med . 1984;;311:295-300.
44 +
Wennberg JE, Barnes BA, Zubkoff M.  Professional uncertainty and the problem of supplier-induced demand . Soc Sci Med . 1982;;15:811-824.
45 +
Eddy DM.  Variations in physician practice: the role of uncertainty . Health Aff . 1984;;3:74-89.
46 +
Wennberg JE.  Factors governing utilization of hospital services . Hosp Pract . 1979;;14:115-117.
47 +
Wolfe BL, Detmer DE.  The economics of surgical signatures . Hosp Med Staff . 1984;;13:2-9.
48 +
Roos LL.  Supply, workload and utilization: a population-based analysis of surgery . Am J Public Health . 1983;;73:414-421.
49 +
Roos NP, Wennberg JE, McPherson K.  Using diagnosis-related groups for studying variations in hospital admissions . Health Care Financing Rev . 1988;;9:53-62.
50 +
Paul-Shaheen P, Clark JD, Williams D.  Small area analysis: a review and analysis of the North American literature . J Health Polit Policy Law . 1987;;12:741-809.
51 +
Wennberg JE, Freeman RM, Shelton RM, Bubholz TA.  Hospital use and mortality among Medicare beneficiaries in Boston and New Haven . N Engl J Med . 1989;;321:1168-1173.
52 +
Conway SP, Phillips RR, Panday S.  Admission to hospital with gastroenteritis . AJDC . 1990;; 65:579-584.
53 +
Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L.  Impact of socioeconomic status on hospital use in New York City . Health Aff . 1993;;12:162-173.
54 +
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55 +
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