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Variations in pediatric pneumonia and bronchitis/asthma admission rates. Is appropriateness a factor?
Insights
This pilot study found that higher pediatric hospital admission rates for pneumonia and bronchitis/asthma were not directly linked to increased inappropriate admissions. However, feedback on utilization review data led to reduced admission rates in one community.
Area of Science:
- Pediatric Healthcare Research
- Health Services Research
- Quality Improvement in Medicine
Background:
- Pediatric hospital admission rates for conditions like pneumonia and bronchitis/asthma exhibit significant geographic variation.
- Understanding the drivers of these variations, such as appropriateness of care, is crucial for optimizing healthcare resource allocation.
Purpose of the Study:
- To investigate the relationship between the appropriateness of pediatric hospital admissions and admission rate variations for pneumonia and bronchitis/asthma.
- To conduct a pilot study in the Boston area to assess medical necessity in pediatric admissions.
Main Methods:
- Identified five communities with varying pediatric admission rates for pneumonia (DRG 91) and bronchitis/asthma (DRG 98).
- Developed and applied criteria-based utilization review instruments to medical records by trained nurse reviewers.
- Calculated age-adjusted admission rates, observed-to-expected ratios, and rates of inappropriate admissions.
Main Results:
- Inappropriate admissions were identified in 9.4% of pneumonia cases and 4.4% of bronchitis/asthma cases.
- No significant association was found between overall admission rates and inappropriateness rates for either condition in this pilot study.
- Targeted feedback to a hospital in a high-rate community led to substantial decreases in subsequent admissions for these conditions.
Conclusions:
- Higher pediatric admission rates may not correlate with higher rates of medical necessity issues.
- Further research with larger sample sizes is recommended to refine understanding of practice variations and patient preferences.
Objective:
To explore through a pilot study the relationship between appropriateness (medical necessity) and variations in pediatric hospital admission rates across several communities in the Boston (Mass) area for two common pediatric conditions with extremely variable admission rates: pneumonia and bronchitis/asthma.
Design:
We identified five communities in the greater Boston area with high, average, and below-average ratios of observed to expected admissions for the study conditions. Diagnosis-specific, criteria-based utilization review instruments were developed by community-based pediatricians and applied by trained nurse reviewers to medical records. ADMISSIONS STUDIED: All admissions for pneumonia (diagnosis related group [DRG] 91) and bronchitis/asthma (DRG 98) of study area residents younger than 18 years to participating hospitals during fiscal year 1986.
Outcome Measures:
For each area, we calculated age-adjusted admission rates, age-adjusted observed to expected ratios, and rates of inappropriate admissions. We tested the hypothesis that admission rates and inappropriateness rates were directly related.
Results:
We deemed 9.4% of pneumonia admissions and 4.4% of bronchitis/asthma admissions inappropriate. Rates of inappropriate admissions were not significantly associated with admission rates in this local pilot study for either study condition at P < .05. However, in one community both rates were high for both conditions. Feedback of findings to the key local hospital there resulted in sharp decreases in admission rates for DRGs 91 and 98 in subsequent years.
Conclusions:
Our results suggest that higher pediatric admission rates may not be associated with higher rates of inappropriateness. Further research is needed, with a larger number of communities, to differentiate practice patterns more precisely and explore patient and family preferences.