title: Variation and outcomes associated with direct hospital admission among children with pneumonia in the United States.
abstract: OBJECTIVE
  Although the majority of children with an unplanned admission to the hospital are admitted through the emergency department (ED), direct admissions constitute a significant proportion of hospital admissions nationally. Despite this, past studies of children have not characterized direct admission practices or outcomes. Pneumonia is the leading cause of pediatric hospitalization in the United States, providing an ideal lens to examine variation and outcomes associated with direct admissions.
  
  
  OBJECTIVE
  To describe rates and patterns of direct admission in a large sample of US hospitals and to compare resource utilization and outcomes between children with pneumonia admitted directly to a hospital and those admitted from an ED.
  
  
  METHODS
  Retrospective cohort study of children 1 to 17 years of age with pneumonia who were admitted to hospitals contributing data to Perspective Data Warehouse. We developed hierarchical generalized linear models to examine associations between admission type and outcomes.
  
  
  METHODS
  Outcome measures included (1) length of stay, (2) high turnover hospitalization, (3) total hospital cost, (4) transfer to the intensive care unit, and (5) readmission within 30 days of hospital discharge.
  
  
  RESULTS
  A total of 19,736 children from 278 hospitals met eligibility criteria, including 7100 (36.0%) who were admitted directly and 12,636 (64.0%) through the ED. Rates of direct admission varied considerably across hospitals, with a median direct admission rate of 33.3% (interquartile range, 11.1%-50.0%). Children admitted directly were more likely to be white, to have private health insurance, and to be admitted to small, general community hospitals. In adjusted models, children admitted directly had a 9% higher length of stay (risk ratio, 1.09 [95% CI, 1.07-1.11]), 39% lower odds of high turnover hospitalization (odds ratio [OR], 0.61 [95% CI, 0.56-0.66]), and 12% lower cost (risk ratio, 0.88 [95% CI, 0.87-0.90]) than those admitted through the ED, with no significant differences in transfers to the intensive care unit (OR, 1.29 [95% CI, 0.83-2.00]) or 30-day readmissions (OR, 0.80 [95% CI, 0.57-1.13]).
  
  
  CONCLUSIONS
  Increasing rates of direct admission among children with access to outpatient care might be an effective strategy to reduce hospital costs and the volume of patients in the ED. Additional research is needed to establish direct admission policies and procedures that are safe and cost-effective.
authors.affiliation: Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts.
authors.forename: JoAnna K
authors.initials: JK
authors.lastname: Leyenaar
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.
authors.forename: Meng-Shiou
authors.initials: MS
authors.lastname: Shieh
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts3Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts4Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts.
authors.forename: Tara
authors.initials: T
authors.lastname: Lagu
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts5School of Public Health and Health Sciences, University of Massachusetts, Amherst.
authors.forename: Penelope S
authors.initials: PS
authors.lastname: Pekow
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts3Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts4Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D017063:Outcome Assessment, Health Care; D011014:Pneumonia / Q000453:epidemiology*; D012189:Retrospective Studies; D014481:United States