Longer Stays but Lower Costs for Direct Pediatric Admissions

Nancy A. Melville

April 04, 2014

LAS VEGAS — For children with pneumonia who are admitted to the hospital directly, rather than through the emergency department (ED), costs are significantly lower, although hospital stays are longer, according to a new study.

"Direct admissions constitute a significant proportion of pediatric hospital admissions in the United States, but no past studies have characterized direct admission patterns or outcomes," said investigator JoAnna Leyenaar, MD, assistant professor at Tufts University School of Medicine in Boston.

"Direct admission may offer several advantages over ED admission, including reduced ED volume, reduced costs, and improved patient satisfaction," she added.

Dr. Leyenaar presented the study results here at Hospital Medicine 2014.

Of the 1 million unplanned hospital admissions each year involving children, approximately half are done through emergency departments.

Because pneumonia is the leading cause of hospitalization in children in the United States, it provided "an ideal lens through which to examine variation and outcomes associated with direct admission," said Dr. Leyenaar.

Dr. Leyenaar and her colleagues compared hospital admissions arranged through a primary care physician or clinic with those arranged through the ED.

The investigators analyzed data from the Perspective Data Warehouse on children 1 to 17 years of age from 278 hospitals. Of the 19,736 children identified, 7100 (36.0%) were admitted to the hospital directly and 12,636 (64%) were admitted through the ED.

Length of hospital stay was 9% longer for children admitted directly than for those admitted through the ED, after adjustment for factors such as patient and hospital characteristics and clustering within hospitals (relative risk [RR], 1.09; 95% confidence interval [CI], 1.06 - 1.11).

Costs were 12% lower for direct admissions than for ED admissions (RR, 0.88, 95% CI, 0.86 - 0.90), although those admitted directly were 39% less likely to have a 1-night hospital stay (odds ratio [OR], 0.63; 95% CI, 0.57 - 0.69).

There was no significant difference between direct and ED admissions for transfers to the ICU (OR, 0.90; 95% CI, 0.63 - 1.29) or 30-day readmission rates (OR, 0.76; 95% CI, 0.57 - 1.01).

Children admitted directly were more likely to be white, to have private health insurance, and to be admitted to small general community hospitals.

Children admitted through the ED were more likely to have asthma. They were also more likely to receive a complete blood count, blood culture, chest x-ray, chest CT, arterial blood gas, urine culture, cerebral spinal fluid culture, and tests for viral pathogens (P < .01 for all).

Although the median rate of direct admission was 33.3%, there was significant variation among hospitals (interquartile range, 11.1% - 50.0%).

At 70% of hospitals, mean hospital stay was longer for those admitted directly than for those admitted through the ED. In contrast, at 70% of hospitals, mean total hospital cost was lower for direct admissions than for ED admissions.

Dr. Leyenaar speculated that cultural and healthcare factors could partially explain the longer stays for patients admitted directly.

"I think some hospitals have well-established direct admission policies and procedures, so staff are better prepared for those admissions. At other institutions, direct admissions are a relative anomaly and take nurses away from other nursing commitments," she explained.

"That might explain some deficiencies and delays in initial management that could possibly lead to adverse outcomes and prolong the length of stay," she added.

Limitations of the study include "a limited ability to assess pneumonia severity or social factors that may have influenced decisions regarding the admission source," Dr. Leyenaar said. In addition, tests and treatments performed in the outpatient setting were not available.

Dr. Daniel Brotman

From center to center, the wide variations in the association between direct admission and length of stay were particularly notable, said Daniel Brotman, MD, director of the hospitalist program at Johns Hopkins Hospital in Baltimore.

"I was most intrigued by the fact that the impact of direct admissions seems to be so different from institution to institution. The differences were well beyond what you would expect with general heterogeneity," he told Medscape Medical News.

The type of admission "can have a very different impact on the length of stay, depending on who your patients are and how you manage the process," he noted. "We need to understand that kind of thing better when addressing quality improvement."

The success of direct admission depends on the accepting physician making sure that bypassing the ED is appropriate for the patient, Dr. Brotman added.

"Anyone involved in direct admissions is aware of the possibility that, if done poorly and cavalierly, you can get burned if the patient is sicker than described," he explained.

The accepting physician must determine whether the patient is sick enough to be hospitalized, and whether the patient is stable and likely to remain stable for the next hour or so, he said.

"You don't want to put yourself in a position of arriving with the patient only to find yourself struggling to get IV access and implementing stat workup and treatment on the floor, with no ED nurses available," he said. "In that kind of situation, the patient is going to suffer."

This research was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences at the National Institutes of Health. Dr. Leyenaar and Dr. Brotman have disclosed no relevant financial relationships.

Hospital Medicine 2014. Presented March 26, 2014.

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