Appropriateness of Admissions and Days of Stay in Pediatric Wards of Italy
From the Medical School, University "Magna Græcia" of Catanzaro, Catanzaro, Italy
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. The objective of this study was to measure inappropriateness of admission and inpatient days in pediatric hospital wards in Catanzaro, Italy, and the effect of different variables on such inappropriateness.
Design. A retrospective application was made using the Pediatric Appropriateness Evaluation Protocol list of criteria. For each patient, there were recorded data on: sociodemographic characteristics; distance from home to hospital; date, day of the week, ward, and type of admission; overall and pre-index day length of hospital stay; and location within the stay of the day reviewed.
Results. A total of 656 children were reviewed. Overall, 30% of the hospital admissions and 55.5% of days of stay were judged to be inappropriate; for about one third of those admitted inappropriately, the hospital stay was judged to be appropriate. Multiple logistic regression analysis indicated that the inappropriate admission was significantly higher if the admission occurred during the daytime. The inappropriate number of days of hospitalization was significantly higher if the patient was female, if the admission was urgent, in medical wards, for patients who were inappropriately admitted, and for those sampled close to discharge. The main reasons for inappropriate use were hospital organization and an over-cautious physician in the management of a patient.
Conclusions. The high degree of inappropriate admission or days of stay in pediatric wards and the reasons for such unnecessary hospital use suggest the need for a more vigilant interaction between hospital and community-based services to mitigate such inappropriateness and for a continuing education system to define standardized guidelines.
Key Words: appropriateness of admission • appropriateness of stay • hospital utilization • Italy • Pediatric Appropriateness Evaluation Protocol
Abbreviations: PAEP, Pediatric Appropriateness Evaluation Protocol • df, degrees of freedom • OR, odds ratio • CI, confidence interval
In the past decades, health care professionals and policy makers have focused their attention to measuring and assessing the quality of medical care and methods to improve the quality and the efficiency of health care services. Everywhere the costs for providing medical care increases with proportionate increasing deficits in the health care sector. To attempt to solve the imbalances, a number of different strategies have recently been devised. Specifically, these strategies include constant measurements of hospital care processes evaluating, for example, whether hospital resources and facilities are being used to maximum advantage.
In Italy, as in many other developed countries, a patient is able to choose health service providers as well as make outpatient and inpatient appointments and visits. For the new consumer, all visits to and therapies delivered by the public health care setting or even within the private sector (if accredited by the national health system) are free of charge. The nation has accepted this policy, but it has become apparent that many patients request medical treatment even if they do not actually need it. In the context of high costs paid for unnecessary services, administrators of the system are now seeking ways to identify and eliminate inappropriate hospital admission and unnecessary days of stay in an effort to reduce public expenses and preserve access to care for those who truly need it.
The medical literature is rife with ample evidence of the appropriateness of hospital admission and days of stay for the adult population,1–9 but very few studies have evaluated this use in general pediatric inpatient settings.10–15 One of the most widely used instruments for assessing inappropriate hospital use by children is the Pediatric Appropriateness Evaluation Protocol (PAEP), which consists of a set of standards based on objective criteria relating to the condition of the patient or clinical services received. No information exists that pertains directly to pediatric care in Italian hospitals, and data are strongly required by health care professionals and administrators to promote an appropriate use of the pediatric wards because the progressive increase in health care costs is one of the leading economic problems. Therefore, we initiated the present study for the express purpose of measuring inappropriateness of admission and inpatient days in pediatric hospital wards in Italy and the effect of different variables on such inappropriateness.
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METHODS |
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Study Population
We reviewed all medical records for all patients under 18 years of age who were admitted to pediatric wards during the period January to December 2001 on one randomly preselected index day, and who stayed on the ward for at least 24 hours. The records were obtained from 2 hospitals with capacities of 714 and 88 beds, respectively (occupation rates: 75% and 74%), located in the area of Catanzaro, Italy. Children in the intensive care unit, special care nursery, and psychiatric wards were excluded. To determine the appropriateness of hospital admission and hospitalization days, we attempted a retrospective analysis using criteria available in the PAEP. Two physicians not involved in patient care, previously trained and assessed in the use of PAEP, independently collected the information.
The following data were recorded for each patient: sociodemographic characteristics (age, sex, number in the households); distance from home to hospital; date, day of the week, ward, and type of admission; overall and preindex day length of hospital stay; location within stay of day reviewed; PAEP criteria that justified admission; and patient’s hospitalization days of stay. Reviewers based their assessment of admission solely on the medical information relative to the day of admission and the subsequent 24 hours. Assessment of appropriateness of hospital stay was made only for the index day and not for the entire hospitalization. If admission or days of stay were considered unnecessary, a reason was stated. Overrides (extraordinary criteria nullifying PAEP criteria) were used when necessary to classify the admission or a day of care as either appropriate or inappropriate.
Review Instrument
The American version of the PAEP consists of criteria of appropriateness concerning hospital admissions divided into binary subsets related to severity of illness or patient conditions, and health care requirements or clinical services.
Criteria of appropriateness of hospitalization day of care are divided into 3 subsets related to the need for medical services, to nursing/life support services, and to patient condition. In these cases, the presence of only 1 criterion is sufficient to consider the admission or days as appropriate, whereas if none of the criteria are fulfilled, the admission is considered inappropriate. The protocol also provides alternative criteria for repudiating supposedly unnecessary medical care and supplies reasons for doing so. Moreover, it includes override options for the exceptional situation, as discussed above, which allows a reviewer to judge days of stay appropriate even when none of the above criteria were met, or as inappropriate when only a single criterion was met.
The PAEP required minor modifications to facilitate its use in the Italian setting. For instance, hospital admission relating to severity of illness and patient condition was deemed appropriate if the following conditions were present: need for lumbar puncture, persistent fever 
37.8°C orally or 38.3°C rectally for >5 days, pulse in the ranges 100 to 160 beats per minute and 80 to 200 beats per minute, respectively, for children <6 months of age and from 6 months to 2 years; in the intensity of service, intramuscular antibiotic therapy was not included. Adjustment was made for day of care criteria, and the use of intramuscular or subcutaneous drugs was not always considered necessary, especially for chronic conditions (the protocol is available on request from the corresponding author).
Statistical Analysis
Multiple logistic regression with forward elimination analysis was performed. In the models developed, we included variables likely to be associated with the following outcomes of interest: appropriateness of admission (model 1) and appropriateness of hospital days of stay (model 2). In both models, the explanatory variables included were the following: patient’s age (5 categories in years: 1 = 
1, 2 = 2–3, 3 = 4–6, 4 = 7–10, 5 = 11), patient’s sex (1 = male, 2 = female), ward of admission (1 = Pediatric, 2 = Pediatric Surgery), type of admission (1 = elective, 2 = urgent), and day of the week the patient was admitted (1 = weekday, 2 = weekend). In model 1, additional variables were included, namely, distance in kilometers between patient’s home and hospital (1 = 5, 2 = 6–35, 3 = >35) and hour of admission (1 = 8:00 AM to 8:00 PM, 2 = 8:01 PM to 7:59 AM). In model 2, these variables were included: appropriateness of admission (0 = no, 1 = yes), length of stay (continuous), location within stay of the day reviewed (0 = first third, 1 = second third, 2 = third third), and pre-index day length of stay (continuous). The significance level for variables entering the models was set at 0.2 and for removing from the models at 0.4. Adjusted odds ratio (OR) and 95% confidence intervals (CI) were calculated. Data were analyzed using the Stata software program (Stata Corporation, College Station, TX).16
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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No significant differences were found concerning appropriateness of hospital admission and days of stay between the 2 hospitals; therefore, these results are presented in a combined form.
All 656 medical records of eligible children who were admitted to pediatric wards during the study period in the 2 hospitals on one randomly preselected index day were reviewed and the main characteristics are presented in Table 1. Fifty-six percent were male, mean age was 6.2 years, the majority of the admissions were urgent, median length of stay was 5 days (range: 1–56 days), and the majority of patients were from medical wards.
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Overall, 30% of the hospital admissions and 55.5% days of stay were, respectively, judged inappropriate, and for one third of those admitted inappropriately, the hospital stay was judged appropriate. Table 2 presents the distribution of inappropriateness of admission and days of stay according to explanatory variables. The inappropriate admissions are associated with patient’s age (
2 = 2.89, 1 degree of freedom [df], P = .0036) and sex (2 = 4.09, 1 df, P = .043), with hour and admission route, because inappropriateness was significantly higher if the admission occurred during daytime (2 = 10.31, 1 df, P = .001) and if it was urgent (2 = 4.5, 1 df, P = .034). With regard to unnecessary hospitalization, a significant association was found with sex of patient (2 = 7.79, 1 df, P = .005). Inappropriateness of day of stay was also associated with admission ward, with patients in medical wards having the most inappropriate hospital days (2 = 41.67, 1 df, P < .001). Patients who were inappropriately admitted were also more likely to be classified as inappropriate according to hospital stay (2 = 17.9, 1 df, P < .001), and the probability of inappropriate days significantly increased from admission to discharge (2 = 20.3, 2 df, P < .001) and with increasing length of stay (Mann-Whitney U test, z = –3.11, P = .0019).
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The first outcome analyzed was whether or not the hospital admission was appropriate, and the results of the multivariate analysis showed that among all variables tested, only the hour of admission was significantly associated with appropriateness, because the odds of inappropriate admission significantly increased if the admission occurred during daytime (OR = 1.83, 95% CI = 1.19–2.81; model 1 in Table 3).
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12% of the inappropriate admissions, there was insufficient information in the medical records for identifying the reason for admission. However, it was clear from the evidence that for the remaining 162 patients, the overwhelming reasons for considering admission inappropriate were: attitude in managing the patient or over-cautious physician (69.9%), delays in scheduling laboratory tests, diagnostic examinations, or elective surgery procedures (21.1%). In the second model, the dependent variable was whether or not the hospital days of stay were appropriate, and results of the multiple logistic regression analysis indicated that several demographic and hospital variables were significant predictors of the risk for inappropriateness of day of care (model 2 in Table 3). Indeed, if the patient was female (OR = 0.59, 95% CI = 0.41–0.83), if the admission was urgent (OR = 0.54, 95% CI = 0.33–0.86), and, as expected, if the patient was inappropriately admitted, the hospital day of care was more likely classified as inappropriate (OR = 2.00, 95% CI = 1.35–2.96). The odds of a given day being inactive were significantly higher in medical wards (OR = 4.24, 95% CI = 2.76–6.5) compared with surgical wards. A patient sampled nearer to discharge (last third of the hospital stay) was much more likely judged inappropriate than a patient in the first or second phases of the episode regardless of length of stay (OR = 0.52, 95% CI = 0.37–0.74), and inappropriateness of day of stay significantly increased with increased lengths of stay (OR = 1.16, 95% CI = 1.09–1.23).
The reasons cited as causal or contributory factors for inappropriate decisions to retain children in hospital were identified as follows: over-cautious or conservative physician (61.8%); incomplete discharge report (26.1%); or delays in the scheduling of laboratory tests, diagnostic examinations, or elective surgery (7.7%).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Similarities and differences in national health system between Italy and other countries can be seen with our system that provides universal coverage free of charge at the point of service. In the United Kingdom, despite the growth of user charges in some areas, most primary and secondary health care is still provided free of charge; in Canada, the system is publicly financed, but privately delivered; in the United States, the individual is responsible for meeting most health costs. Such differences in health care systems mean that the rates of inappropriate hospital use between countries are not directly comparable, and some evidence already exists that higher levels of primary care services are associated with lower hospitalization of children.17 Bindman et al18 have suggested that there is a relationship between perceived better access to health services and lower hospitalization rates for conditions preventable by adequate ambulatory care. In addition, the pediatrician may play an important role in improving the quality and efficiency of hospital care, because the specialist may be more alert to the circumstances of the children in the home than most general physicians, and this intuition and personal knowledge may influence the decision to hospitalize a patient.
The results of this study show that a substantial proportion of pediatric hospital use is medically inappropriate. Rates of 30% and 55.5% found for inappropriate hospital admission and days of stay, respectively, are higher than the findings of previous studies conducted in other countries. Formby et al19 evaluated the medical records of pediatric patients in Australia and found 24% of admissions and 19% of hospital day of stay were inappropriate. In Canada, Smith et al12 examined admissions to acute wards in a tertiary care pediatric facility and found 29% of the admissions and 22% of the days of stay unnecessary. In a retrospective evaluation of the medical records of 852 patients, Gloor at al11 reported 24% of the hospitalization days as inappropriate. Furthermore, several surveys conducted in the United States reported percentages of nonjustified admissions, which ranged from 2% to 11%, and hospital stay days, which ranged from 12% to 21%.10,20,21
In our survey, in accordance with other studies, hospital utilization was more appropriate for young children,10,11,15 and this may reflect the difference in the complexity of diagnoses between infants and older children. Indeed, infants are most likely to be hospitalized for prematurity, congenital problems, or infectious illnesses, all conditions that would lead to intensive medical services,22 whereas older children present with more chronic diseases rather than acute infectious problems and may be hospitalized for investigations and less intensive therapy. In agreement with Smith et al,12 we found that the higher proportion of inappropriate hospital admissions occurred during the daytime. We can interpret this result by observing that although all children have access to a pediatrician who can provide free primary care during office hours for 32 hours a week, the family tends to use the hospital as their primary health care facility, because it is easier to attend during the daytime. Moreover, there are factors other than the severity of the medical illness that affect physicians’ decision to hospitalize a child, such as the degree of parental anxiety and education, distance from a health care facility, and the physician’s intuition about a child or situation.
We found an association between such inappropriateness of hospital days and admission, because although stays of patients are inappropriate, admissions are also inappropriate in 36.8% of the cases. There is an increase of inappropriate days as well as increase in lengths of stay, and those children sampled close to discharge (last third period of hospital stay) were much more likely judged inappropriate than those patients in the first and second third. Inappropriateness was also associated with the type of hospital wards, and the fact that those children were admitted to surgical wards tends to justify the decision that the hospitalization was likely appropriate. This finding may be attributed to the attitude of physicians and to the modification of our health care payment system with a shift from per diem reimbursement to a system based on diagnosis-related groups, the main purpose of which was to lower costs associated with delays in discharge. Indeed, we may expect in surgical wards a lower postoperative hospitalization with children who are generally discharged no later than 24 to 48 hours after the surgery, whereas in the case of the sickest medical patient, once the acute illness has resolved, the hospitalization nevertheless continues, confirming our hypothesis that professional autonomy remains unchallenged and based more on physicians’ experience. Monitoring these decisions should be continued on well-documented scientific grounds.
With regard to the causes of inappropriate hospital admission, our results showed the important role of the hospital organization and of the physician. Indeed, the reasons most frequently reported for inappropriateness were delays in the scheduling of diagnostic procedures or examinations, incompleteness of discharge reports, and an over-cautiousness of physicians in the medical management of a patient. For example, there is no need to remain in hospital for children admitted for respiratory care, because there is no temperature and no need for medical or nursing services for 48 hours. These results appear to strengthen the data reported by some of us in 2 surveys on appropriateness of hospital utilization.8,9 Furthermore, the over-cautious behavior of physicians in the management of a patient may be explained by the fact that they protect themselves from malpractice litigation. This result finds additional support in a report published by one of us in a survey of preoperative routine investigations.23 Another effect, the evidence of which has not systematically been captured in this study, may be attributable to the behavior and characteristics of the physician, namely the surprising outcome that inappropriateness of day of care was significantly higher in children urgently admitted, whereas inappropriate admission, although not significant in the multivariate analysis, was higher if the admission was programmed.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The high degree of inappropriate admission or days of stay in pediatric wards and the reasons for such unnecessary hospital use suggest the need for a more vigilant interaction between hospital- and community-based services to mitigate such inappropriateness and for a continuing education system to define standardized guidelines.
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FOOTNOTES |
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Received for publication Sep 27, 2002; Accepted Feb 20, 2003.
Reprint requests to (I.F.A.) Medical School, University "Magna Græcia" of Catanzaro, Via Tommaso Campanella, 88100 Catanzaro, Italy. E-mail: angelillo{at}unicz.it
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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