PEDIATRICS Vol. 120 No. 4 October 2007, pp. 749-755 (doi:10.1542/peds.2006-3293)
ARTICLE |
Do Adolescent Inpatient Wards Make a Difference? Findings From a National Young Patient Survey
Adolescent Medicine, General and Adolescent Paediatrics Unit, Institute of Child Health, University College London, London, United Kingdom
 |
ABSTRACT |
|---|
 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
OBJECTIVES. There is little evidence to support the effectiveness of adolescent inpatient wards. These analyses test the hypotheses that nursing young people in adolescent wards improves aspects of quality of care and patient satisfaction compared with child or adult wards.
PATIENTS AND METHODS. Secondary analyses of the national English Young Patient Survey 2004 were weighted to take account of variations in hospital size and response rate. Participants included 8855 subjects aged 12 to 17 years. Ward types (adolescent, child, and adult) were compared. Patient-reported quality-of-care indicators included rating by young people of overall care, respect, safety, confidentiality, communication, team-working, noise, and leisure facilities. Logistic regression models were adjusted for gender, disability, and previous hospital admissions.
RESULTS. Ten percent of 12- to 14-year-olds and 18% of 15- to 17-year-olds were nursed in an adolescent ward, 0.4% of 12- to 15-year-olds and 16% of 15- to 17-year-olds in an adult ward, with the remainder in a child ward. Compared with being in an adolescent ward, 15- to 17-year-olds were less likely to report excellent overall care in an adult ward and less likely to report feeling secure, having confidentiality maintained, feeling treated with respect, confidence in staff, appropriate information transmission, appropriate involvement in own care, and appropriate leisure facilities. Compared with being in an adolescent ward, 12- to 14-year-olds were less likely to report excellent overall care in a child ward and less likely to report feeling involved in their own care.
CONCLUSIONS. Dedicated adolescent inpatient wards improve aspects of quality of care for young people compared with child or adult wards, particularly for older adolescents. These data support the continued development of adolescent wards in larger general hospitals and children's hospitals.
Key Words: adolescence • inpatient • hospital • quality of care • health service research
Abbreviations: NHS—National Health Service
The Society for Adolescent Medicine advocates the continuation and establishment of adolescent medicine inpatient units in both general and pediatric hospitals as the "optimal approach to the delivery of developmentally appropriate health care."1 Young people repeatedly report a desire for dedicated adolescent services in hospitals and in primary care.2–5 With changes in pediatric practice, the proportions of adolescent patients within pediatric services are rising.6,7 Indeed, children older than 10 years now constitute nearly 30% of all admissions at one of Australia's leading children's hospitals.8 However, many general and pediatric hospitals in the United States and internationally lack dedicated inpatient wards for adolescents.
The number of adolescent medicine inpatient wards in the United States is unknown. Estimates in 1978 suggested that 
45% of pediatric residency training sites had inpatient adolescent medical services.9 In 1998, although 72% of pediatric residency programs reported providing exposure to inpatient adolescent medicine training, these are likely to have included inpatient services operating in pediatric wards, because only 39% reported providing training in an inpatient adolescent ward.10
In the United Kingdom, a national survey undertaken by the Royal College of Pediatrics and Child Health in 2001 suggested that only 12% of all hospitals had a dedicated adolescent medicine ward.11 This is despite repeated calls for the development of dedicated services for adolescents by the Department of Health12 and the joint medical colleges11 and data showing that the average general hospital serving a regional population of 250000 people has at least 15 beds routinely occupied by 12- to 19-year-olds outside of maternity and mental health services.13
Development of adolescent inpatient services internationally has been hampered by a lack of evidence of benefit.2,11 Existing arguments to support adolescent wards rely on patient satisfaction and professional opinion, with little or no published data on the impact of adolescent medical wards on quality of care. Simple surveys of patient satisfaction have been found to minimally influence health care quality,14 and evidence that adolescent wards improve quantitative health care outcomes remains elusive.
However, modern understandings of patient-centered care have placed patient-reported experiences at the heart of assessment of quality of care. As noted by Cleary, "[p]atients usually cannot assess the technical quality of their care; however, examining a hospitalization through the patients' eyes can reveal important information about the quality of care. Patients are the best source of information about a hospital system's communication, education, and pain-management processes, and they are the only source of information about whether they were treated with dignity and respect."15 In fact, there is increasing evidence that processes of care that are more patient centered lead to improved health outcomes14; thus, the use of patient perceptions of care for systems improvement may lead to better health outcomes.16 Modern survey measures that elicit reports about specific care experiences that reflect the quality of care, not simply the amenities, are appropriate for quality improvement purposes.14
In this study we investigated the impact of dedicated adolescent inpatient wards on quality of care compared with nursing adolescents in child or adult wards and used data from the English National Health Service Young Patients Survey conducted by the Picker Institute in 2004.17
|
METHODS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
The Young Patients Survey 2004 is part of the English National Health Service (NHS) patient survey program. The survey was conducted by the NHS survey advice center at the Picker Institute Europe and conducted in participating NHS acute and specialist hospital trusts in England.18 An NHS hospital trust is a publicly funded management entity that may include 1 or more hospitals in a city or locality providing inpatient care free at the point of contact; this survey included general hospitals, children's hospitals, and specialist medical hospitals and excluded psychiatric and chronic care facilities. All acute and specialist trusts in England were invited to participate, with 150 (87%) of 173 providing data. Five (3%) were stand-alone children's hospital trusts.
Each trust identified a list of 850 eligible patients who had been discharged from the trust from the last date of either November 2003 or January 2004. Four of the trusts identified a list of only 500 eligible patients because they had too few young patients. Patients were eligible to take part if they had been treated as inpatients or day cases in any part of the trust that included adult wards, were aged 0 to 17 years, and were not maternity or psychiatry patients. Patients were sent a postal questionnaire and a cover letter, and up to 2 reminder letters were sent to nonresponders. Questionnaires were sent to 125827 young patients, and 62277 completed questionnaires were returned; 59815 of these patients were within the appropriate age range. This represents a 50% response rate once undelivered questionnaires and deceased patients had been accounted for. Response rates varied between trusts from 32% to 64%, and these rates were equal for boys and girls.19 Subjects aged 12 and older were encouraged to complete the questionnaire themselves or with the assistance of their parents.
The questionnaire drew on previous Picker Institute inpatient surveys of adults and children in the United States16,20 and studies of the domains of care that matter most to hospitalized patients internationally, which include respect for patient preferences, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, and continuity and transition.21,22 The questionnaire was modified to enable assessment of each trust against the English NHS standards for hospital care for children and adolescents12 and also included questions about overall quality of care, safety, and confidentiality and privacy. Analysis of a similar instrument used to survey pediatric inpatient populations in the United States showed high reliability and validity.16,20
Inpatient ward type was defined by the respondents. Young people were asked, "For most of your stay, what type of ward were you in: (1) a child ward; (2) an adult ward; (3) an adolescent or teenager ward; or (4) another type of ward?" In the United Kingdom, adolescent wards include (1) a general ward for adolescents only, encompassing a wide range of conditions and specialties, commonly comprising 12 to 18 beds; (2) a subsection of a general hospital child ward, commonly 4 to 8 beds; or (3) a single-specialty adolescent ward, such as for cancer or cystic fibrosis. Detailed data on the type of adolescent ward were not available from this survey, and their differential impact on quality of care could not be examined. However, data collected by United Kingdom professional bodies in 2004 suggest that the great majority of units were small 4- to 6-bed wards embedded within a general child ward, with only 10 general adolescent wards and 8 to 10 specialty adolescent wards (personal communication, M. de Sousa, MA, written communication, 2006).
For the question on overall rating of care, young people were asked to rate the general quality of hospital care on a 5-point Likert scale (1 = poor, 5 = excellent). For other items, following Co et al's analyses of the Picker Institute's pediatric inpatient survey in the United States,16 responses were dichotomized. For items with >2 response categories, we defined high-quality care as being the most preferable 2 of 4 or 2 or 5 response categories. For example, for questions with response categories of "poor," "fair," "good," "very good," and "excellent," responses of "very good" or "excellent" were considered to indicate high-quality care.
Data were obtained electronically from the United Kingdom Data Archive (www.data-archive.ac.uk). Data were weighted for trust size by using patient population weights19 calculated from the annual total inpatient bed-days for 2003–2004 for each trust, which were obtained from the Information Centre, NHS Hospital Episode Statistics (www.hesonline.nhs.uk). Data were analyzed by using the survey commands in Stata 8 (Stata Corp, College Station, TX) to obtain robust confidence intervals that took into account unequal probabilities of selection attributable to the differences in trust size and response rate. For these analyses, subjects were included if they (1) were aged 12 to 17 years inclusive, (2) were hospitalized overnight or longer, (3) completed the questionnaire themselves or in combination with their parents (responses completed only by parents were excluded), and (4) were not nursed in an "other" type of ward. Data on ethnicity were not available for these analyses; in the overall sample, 89% were white, 5% Asian, 3% black, 3% mixed ethnicity, and 1% of Chinese or other ethnicity.
Proportions that responded positively to each question were examined according to type of ward. Subsequently, logistic regression was used to examine the association of ward type with care variables. Following the methods of Co et al,16 these analyses were adjusted for factors that were considered likely to influence the reporting of care, including gender and presence of a chronic illness. Two variables were used as proxies for chronic illness and previous contact with the health services: (1) whether a young person considered himself or herself as disabled and (2) the number of previous hospital admissions in the past 6 months.
|
RESULTS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
A total of 16707 patients (28% of 59815 respondents) were aged 12 to 17 years. Of these, 13727 had full data on ward type, length of admission, number of admissions, person completing the survey (young person or parent), and the presence of a disability. For these analyses, the following patients were excluded: (1) 3730 who did not stay overnight and (2) 1926 for whom the parents completed the questionnaire without their involvement. Thus, the sample for these analyses was 8071. Patient characteristics for this sample are shown in Table 1. Twelve- to 14-year-[r]olds were predominantly nursed in a child ward (89%), with 361 (10%) nursed in an adolescent ward, and only 18 (0.5%) in an adult ward. Of 15- to 17-year-olds, 811 (18%) were nursed in an adolescent ward, 74 (16%) in an adult ward, and 2960 (66%) in a child ward. When asked about ward preference in the abstract, an adolescent ward was the preferred inpatient option of the majority of respondents; it was the preferred option of 95% of young people who were actually in an adolescent ward, 51% of those in a child ward, and 59% of those in an adult ward.
|
The proportions that responded to each question according to ward type and adjusted odds ratios for the associations between ward type and quality-of-care variables are shown in Table 2. For those aged 12 to 14 years, data are not shown for adult ward type because of the very small sample.
|
Twelve- to 14-Year-Olds
Young people aged 12 to 14 years rated overall care in an adolescent ward significantly superior to that in a child ward (P < .05). This was also the case for the great majority of variables; however, this reached significance only for noise and involvement in own care.
Fifteen- to 17-Year-Olds
Young people aged 15 to 17 years were more likely to rate their overall care as excellent if nursed in an adolescent ward rather than in an adult ward (P < .0001), a pattern that was also seen for each individual variable aside from timing of discharge (all P < .001). Older adolescents nursed in an adolescent ward were also significantly more likely to report satisfactory information-giving by nurses and involvement in own care and less likely to report being bored or bothered by noise than those nursed in a child ward.
|
DISCUSSION |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
These data from a nationally representative sample show that aspects of quality of care, particularly core quality issues such as confidentiality, communication, information-giving, partnership, and respect, were rated significantly higher by young people nursed in inpatient adolescent wards compared with peers nursed in either child wards or adult wards. Although these data relate only to patient-reported aspects of care, such aspects are central to modern understandings of health care quality. Overall care was more likely to be rated as excellent in an adolescent ward for both younger (12- to 14-year-old) and older (15- to 17-year-old) adolescents. Differences in quality of care were particularly striking for those nursed in adult wards, where care was rated significantly more poorly in 14 of the 16 domains studied. Indeed, adolescents in adult wards were approximately half as likely to report that they received excellent overall care, felt safe, received comprehensible information, or felt they were treated with dignity and respect than those who were nursed in an adolescent facility. Although they were rated by young people as providing a higher quality of care than adult wards, child wards were rated as significantly poorer in terms of overall care (younger adolescents only) and in terms of young people in their care, information-giving by nurses, noise, and boredom. It is important to note that there were no areas in this survey in which adolescent wards were rated as performing less well than child or adult wards.
These findings provide an evidence base to support guidelines on the provision of age-appropriate hospital facilities in the United States,1 United Kingdom,11,12 and elsewhere. These findings strongly support the development of adolescent facilities in hospitals where adolescents would otherwise be nursed in adult wards. There were fewer significant differences and smaller effect sizes when adolescent wards were compared with child wards, although there was a consistent pattern for young people to rate adolescent wards as providing a higher quality of care than child wards. This may suggest that child wards go some way toward offering adolescents a developmentally appropriate health care setting if staff members are trained appropriately. However, it is important to note that the adolescent wards in this survey were a heterogenous mix, with the majority being small units embedded within child wards. It is perhaps, therefore, not surprising that mean differences from child wards were not large. Additional research is needed to test the likely conclusion that stand-alone adolescent wards provide greater patient-reported quality of care than child wards, because this could not be studied in the present data set. However, the pattern of differences revealed between child wards and the heterogenous mix of adolescent wards in this study suggest that dedicated adolescent facilities improve quality of care, even if these facilities are restricted in scope.
Comparison With the Literature
These are the first data, to our knowledge, to show a clear benefit for quality of care from adolescent medical inpatient wards. Other studies of pediatric inpatients that used comparable methodology were confined to parents and did not examine outcomes according to ward type.16 The findings presented here are consistent with a large literature, which shows that young people repeatedly report a desire to be treated within dedicated adolescent facilities that respect their rights as young people, maintain confidentiality and privacy, and provide age-appropriate educational and leisure activities.2,3,11 These findings also confirm reports from small specialist studies that young people's satisfaction with many aspects of care is higher when they are nursed in an adolescent specialist ward (eg, adolescent cancer wards compared with pediatric or adult cancer wards).23,24
Overall ratings of quality of care regardless of ward type seem similar to those reported from US surveys of inpatient pediatric care16,25 (eg, in most domains, including safety, information-giving, trust, privacy, and confidentiality, staff team-working, and dignity and respect). Between 60% and 85% of all young people reported a high quality of care regardless of where they were nursed.
Although those who were nursed in adolescent wards were more likely to report a high quality of care in almost every domain, it is disappointing to observe that care in some areas fell short of what is recommended. Providing care in partnership with young people is a core skill in adolescent medicine, yet only 63% of younger adolescents and 59% of older adolescents felt involved in their care as much as they desired. It is unclear whether this particularly relates to the English health care system, because comparative data on partnership working with adolescents from other countries are not available. These findings highlight the work that needs to be performed in the training of health care professionals to ensure that all young patients experience a high quality of care in terms of information-giving, privacy, and confidentiality regardless of setting.
Strengths and Limitations
These findings were drawn from nationally representative data from a recent survey in which subjects were unaware of the hypotheses under study. Survey methodology was designed to be appropriate for quality improvement purposes.14 Analyses were weighted to take into account variations in trust response rates and trust patient populations, and robust confidence intervals were calculated. Questionnaires were completed (with or without their parents) by 72% of those aged 12 to 14 years and 90% of those aged 15 to 17 years.
These data have a number of limitations. Patient report of quality of care is accepted as an important measure of quality in patient-centered systems of care14,15; however, patient rating cannot inform other important aspects of care. Although the overall response rate was 50%, this is unremarkable in postal surveys of this size and, indeed, was highly similar to the 48% response rate obtained in a recent US inpatient pediatric survey.16 Furthermore, we believe it unlikely that response bias influenced the findings concerning ward type reported here. Type of ward was identified by young people, and it is possible, although unlikely, that young people misidentified the type of ward to which they were admitted. However, the finding that 13% of young people reported being nursed in an adolescent ward is consistent with the finding from a national survey in 2001 that 12% of trusts have dedicated adolescent medicine wards.11
Because of limitations in the available data, we could not examine which elements of adolescent care were responsible for improved quality of care (eg, whether benefits related to milieu issues for young patients or, rather, to differences in staff numbers, skills, or training).
Analyses could not be controlled for ethnicity or socioeconomic status, because these data were not available, and it is likely that response rates were higher in those from white subjects and those from higher socioeconomic backgrounds.
|
CONCLUSIONS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Dedicated adolescent medical wards improve aspects of quality of care across a wide range of domains for young people compared with child or adult wards. Young people nursed in adult wards were approximately half as likely to rate their care highly across many domains. Child wards generally performed well in looking after young people, particularly younger adolescents; however, adolescent wards performed significantly better in terms of overall care and in a small number of domains. These data further support the development of adolescent medical inpatient wards in general and children's hospitals, and where this is not possible, the provision of dedicated adolescent facilities in child wards. Additional work is needed to examine the impact of adolescent wards on clinical outcomes and resource use.
|
ACKNOWLEDGMENTS |
|---|
Dr Viner was funded by the English NHS.
|
FOOTNOTES |
|---|
Accepted May 10, 2007.
Address correspondence to Russell M. Viner, MB, PhD, Department of Paediatrics, University College Hospital, 250 Euston Rd, London NW1 2PG, England. E-mail: r.viner{at}ich.ucl.ac.uk
The author has indicated he has no financial relationships relevant to this article to disclose.
|
REFERENCES |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
- Fisher M, Kaufman M. Adolescent inpatient units: a position statement of the Society for Adolescent Medicine. J Adolesc Health. 1996;18 :307 –308[CrossRef][Web of Science][Medline]
- Viner RM, Keane M. Youth Matters: Evidenced-Based Best Practice for the Care of Young People in Hospital. London, United Kingdom: Caring for Children in the Health Services; 1998
- Oppong-Odiseng A, Heycock E. Adolescent health services: through their eyes.
Arch Dis Child. 1997;77
:115
–119
[Abstract/Free Full Text] - Miller NO, Friedman SB, Coupey SM. Adolescent preferences for rooming during hospitalization. J Adolesc Health. 1998;23 :89 –93[CrossRef][Web of Science][Medline]
- Fisher M. Adolescent inpatient units.
Arch Dis Child. 1994;70
:461
–463
[Free Full Text] - Lam PY, Fitzgerald BB, Sawyer SM. Young adults in children's hospitals: why are they there? Med J Aust. 2005;182 :381 –384[Web of Science][Medline]
- Viner RM, Barker M. Young people's health: the need for action.
BMJ. 2005;330
:901
–903
[Free Full Text] - Lam PY, Yeo M, Sawyer SM. Adolescent admissions to a tertiary paediatric hospital: a dynamic pattern. Ann Acad Med Singapore. 2003;32 :58 –63[Web of Science][Medline]
- Comerci GD, Witzke DB, Scire AJ. Adolescent medicine education in pediatric residency programs following the 1978 Task Force on Pediatric Education report. J Adolesc Health Care. 1987;8 :356 –364[CrossRef][Medline]
- Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: are we doing a good job?
Pediatrics. 1998;102
:588
–595
[Abstract/Free Full Text] - Bridging the Gaps: Healthcare for Adolescents. Report of the Joint Working Party on Adolescent Health of the Royal Medical and Nursing Colleges of the UK. London, United Kingdom: Royal College of Paediatrics and Child Health; 2003
- Department of Health, Department for Education and Skills. National Service Framework for Children, Young People and Maternity Services . London, United Kingdom: Department of Health; 2004
- Viner RM. National survey of use of hospital beds by adolescents aged 12 to 19 in the United Kingdom.
BMJ. 2001;322
:957
–958
[Free Full Text] - Cleary PD. The increasing importance of patient surveys: now that sound methods exist, patient surveys can facilitate improvement.
BMJ. 1999;319
:720
–721
[Free Full Text] - Cleary PD. A hospitalization from Hell: a patient's perspective on quality.
Ann Intern Med. 2003;138
:33
–39
[Abstract/Free Full Text] - Co JP, Ferris TG, Marino BL, Homer CJ, Perrin JM. Are hospital characteristics associated with parental views of pediatric inpatient care quality?
Pediatrics. 2003;111
:308
–314
[Abstract/Free Full Text] - Young Patients Survey 2004. London, United Kingdom: Healthcare Commission; 2005
- List of Acute NHS Trusts in England. London, United Kingdom: National Health Service; 2006
- Ramm J, Reeves R, Graham C. Young Patients Survey 2004 Userguide. Oxford, United Kingdom; Picker Institute Europe; 2005
- Reliability and Validity of Picker Questionnaires. Boston, MA: Picker Institute; 1999
- Cleary PD, Edgman-Levitan S, Roberts M, et al. Patients evaluate their hospital care: a national survey. Health Aff (Millwood). 1991;10 :254 –267[Medline]
- Coulter A, Cleary PD. Patients' experiences with hospital care in five countries.
Health Aff (Millwood). 2001;20
:244
–252
[Abstract/Free Full Text] - Reynolds BC, Windebank KP, Leonard RC, Wallace WH. A comparison of self-reported satisfaction between adolescents treated in a "teenage" unit with those treated in adult or paediatric units. Pediatr Blood Cancer. 2005;44 :259 –263[CrossRef][Web of Science][Medline]
- Mulhall A, Kelly D, Pearce S. A qualitative evaluation of an adolescent cancer unit. Eur J Cancer Care (Engl). 2004;13 :16 –22[CrossRef][Medline]
- Homer CJ, Marino B, Cleary PD, et al. Quality of care at a children's hospital: the parent's perspective.
Arch Pediatr Adolesc Med. 1999;153
:1123
–1129
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  D Hardoff, Y Danziger, G Reisler, N Stoffman, and A Ziv Minding the gap: training in adolescent medicine when formal training programmes are not available Arch. Dis. Child. Ed. Pract., October 1, 2009; 94(5): 157 - 160. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
