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Direct hospital admission more cost-effective than ED admission
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Direct hospital admission among children with pneumonia was associated with reduced hospital costs, according to study findings in JAMA Pediatrics.
JoAnna K. Leyenaar, MD, of Tufts University School of Medicine in Boston, and colleagues assessed length of stay, ICU transfers, all-cause readmission within 30 days of hospitalization, high turnover hospitalization, and total costs for children aged 1 to 17 years admitted to hospitals as inpatients between July 2007 and June 2010. Children had a principal diagnosis of pneumonia.
Of 19,736 children admitted to 278 hospitals, 36% were admitted directly (n=7,100) and 64% were first seen in the ED (n=12,636). Direct admission rates varied among hospitals, with a median direct admission rate of 33.3%.
Children admitted directly were more likely to be white and have private health insurance. They were also more likely to receive initial hospital care from a general pediatrician. Children admitted directly were less likely to have asthma, receive steroids and short-acting beta-agonists, and receive initial diagnostic testing than those admitted through the ED.
There was a significantly higher number of children admitted directly at smaller, rural hospitals in the South. About 14% of children directly admitted received care at a children’s hospital, compared with 28.8% of children admitted through the ED.
There were no significant differences regarding ICU transfer or readmission. The average length of stay was somewhat longer among children directly admitted compared with ED admission, but both groups had a median length of stay of 2 days. Children admitted directly were less likely to have a hospital stay less than 2 days’ duration.
An estimated 18% of children admitted directly had high turnover hospitalizations compared with 27.3% of children admitted through the ED.
Despite longer length of stays, total hospital costs were 16% lower among children admitted directly. At 70% of hospitals, direct admission was associated with a longer mean length of stay (P<0.001) and a lower mean hospital cost in relation to admissions through the ED (P<0.001).
When adjusting for clustering within hospitals and controlling for patient and hospital characteristics, children admitted directly were 39% less likely to have high turnover hospitalization compared with those seen through the ED.
In a subanalysis of children with high turnover hospitalizations, adjusted costs were 28% less for children admitted directly than for children admitted through the ED (cost ratio=0.72; 95% CI, 0.71-0.74).
“Although direct admission was associated with decreased costs overall, it is notable that these findings did not apply to all hospitals within our sample… Given the considerable variability in rates and outcomes of direct admission demonstrated in our study, there are undoubtedly cultural, system, and population factors that influence the ability of direct admissions to reduce testing, high turnover hospitalizations, and costs,” the researchers concluded.
Disclosure: The researchers report no relevant financial disclosures.
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