Caroline Helwick

October 23, 2012

NEW ORLEANS — Infants and young children who have undergone successful enema reduction of intussusceptions can be safely discharged from the hospital, rather than admitted for monitoring. Readmission rates are low and the strategy is cost-effective, according to a 5-year audit of the Pediatric Health Information System database.

"We found that emergency department [ED] discharge is associated with a small but significantly increased risk of readmission and postdischarge intussusceptions, but there was no increase in the need for operative management, and it appears to be cost-effective," said Samuel Rice-Townsend, MD, of Children's Hospital Boston, in Massachusetts.

Dr. Rice-Townsend led the multi-institutional study, which was presented here at the American Academy of Pediatrics (AAP) 2012 National Conference and Exhibition.

"Intussusception is the most common cause of intestinal obstruction in infants and young children. Following enema reduction, patients are often admitted for observation, but some single-institution studies have suggested they can be safely discharged home," Dr. Rice-Townsend said.

To help determine the safety of discharge, Dr. Rice-Townsend and his team conducted what is by far the largest study to date of this issue, involving nearly 4000 patients from 33 hospitals.

The aims were to examine the variation in the practice of discharge from the ED among children's hospitals; to examine the safety of this practice with respect to readmission risk and need for operative reduction; and to determine whether ED discharge is a cost-effective practice.

The cohort included 3880 patients managed with enema reduction between 2007 and 2011, excluding operative cases. The hospital-specific ED discharge rate was defined as the number of discharges directly from the ED after successful treatment, divided by the total number of all patients successfully reduced by enema reduction. The overall rate of discharge among the whole population was determined to be 13%.

Large Variation in Practices

To compare ED discharge with admission after ED treatment, they divided participating hospitals into 2 cohorts: those with a high discharge rate (>13%), labeled the ED-discharge group, whose discharge rate averaged 50% (range, 20% - 90%), and those with a low discharge rate (<13%), labeled the ED-admit group, whose discharge rate averaged 2.6% (range, 0% - 7%) and who formed the majority.

"We found that great variation exists in the practice of ED discharge after successful enema reduction for intussusceptions," he reported.

The readmission rates — within 2 days of discharge — were 10.9% in the ED-discharge group and 8.0% in the ED-admit group, only a 2.9% difference that was nonetheless statistically significant (P = .076), Dr. Rice-Townsend reported.

Among the readmitted patients, the rates of recurrence (reintussusception) were 58.1% and 34.3%, respectively (P < .0001); however, the need for operative reduction was no different: 1.1% vs 4.4% (P = .16).

"In fact, if there was a trend for this, it favored the ED-discharge group," he added.

Use of Hospital Resources

The cumulative length of stay (LOS) — considering both the index visit and readmissions — was significantly lower in the ED-discharge group, who had a mean LOS of 1.8 vs 2.2 days for the ED-admit group (P < .0001).

"Furthermore, patients treated at ED-discharge hospitals had 44% lower median case-related hospital costs, 38% lower median charges, 41% lower median cumulative hospital costs, and 36% lower cumulative charges, after factoring in readmission encounters," Dr. Rice-Townsend said.

The median cumulative costs were $1540 vs $2612, respectively, and median charges were $4133 vs $6405 (P < .001), he said.

Dr. Townsend acknowledged several limitations of the study. "It is a retrospective analysis of administrative data, and thus readmissions to other hospitals and freestanding centers are not captured. We may be underestimating readmission rates," he said. "And we are unable to determine the relative impact of other factors that may be associated with reduced costs."

Finally, he advised, "the decision to admit should be made on a case-by-case basis, based on clinical factors."

Mixed Reactions to Data

Arthur Cooper, MD, professor of surgery and director of Trauma and Pediatric Surgical Services at Columbia University Medical Center, New York, cautioned against overinterpreting the cost-effectiveness of ED discharge.

"Many of us would agree that what's driving earlier discharge is a perceived decrease in overall hospital costs, but we need to be careful when we consider this issue," he suggested.

Dr. Cooper maintained that the costs are "marginal" in a 24-hour admission. "The nursing staff has to be there anyway, the actual cost of IV fluids and so on are relatively insignificant in the overall analysis," he said.

"I would argue that these data clearly show that charges can be minimized, and perhaps the overall costs can be minimized, but the marginal costs probably cannot," he said. "So I caution us to be careful about ascribing significant cost savings to earlier discharge in this situation."

To Sherif G. Emil, MD, director of pediatric general surgery at Montreal Children's Hospital in Canada, the findings were impressive enough to cause a paradigm shift.

"There have been other papers, but this is the largest one, coming from a national database, and they all show the same thing," said Dr. Emil, who moderated the session.

"In other words, you don't have to admit these patients. A few may bounce back to us, but it's not worth admitting all the patients for this 5% or 6%," he said. "We need to give parents clear instructions, because some will have recurrences within a week, but parents already know the symptoms: their child has just had an episode."

Dr. Emil said his center has been discussing moving in this direction, and these data support a change in practice.

Dr. Rice-Townsend, Dr. Cooper, and Dr. Emil have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) National Conference and Exhibition: Abstract 66. Presented October 21, 2012.