Variations in pediatric pneumonia and bronchitis/asthma admission rates. Is appropriateness a factor?
S. M. Payne, C. Donahue, P. Rappo, J. J. McNamara, J. Bass, L. First, J. Kulig, S. Palfrey, B. Siegel and C. Homer
Boston (Mass) University School of Public Health.
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.
