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Statistical Brief #33: Reasons for Being Admitted to the Hospital through the Emergency Department for Children and Adolescents, 2004

STATISTICAL BRIEF #33


June 2007


Reasons for Being Admitted to the Hospital through the Emergency Department for Children and Adolescents, 2004


Chaya Merrill, M.P.H. and Pamela L. Owens, Ph.D.



Introduction

In 2004, over 1 million children and adolescents entered the hospital through the emergency department (ED), accounting for roughly half of all pediatric hospital stays (excluding births and adolescent pregnancy cases).1 Understanding the reasons why children and adolescents are admitted to the hospital from the ED can help identify conditions for which emergency utilization potentially could be avoided if adequate primary care were available. Examining admissions through the ED is critical to addressing problems of potential overcrowding in the ED, increased costs associated with emergency care, and problems in quality of and access to primary care.

This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on the most common reasons for hospitalizations that began in the ED for patients under 18 years of age and compares these pediatric stays with similar stays for adults. All differences between estimates noted in the text are statistically significant at the 0.05 level or better.

This brief is the second report of a two-part series on pediatric stays that began in the ED. General information on utilization and cost characteristics of pediatric hospital admissions that began in ED is presented in Statistical Brief #32.2
Highlights
  • Among children and adolescents, respiratory disorders were the most frequent reason for admission to the hospital through the ED, accounting for 27.8 percent of all such admissions.


  • Asthma was the single most common reason for hospital stays that began in the ED with over 95,000 hospital admissions (accounting for 8.5 percent of all pediatric admissions through the ED).


  • For the youngest children (age 0 to 4), respiratory conditions —mainly acute bronchitis, pneumonia, and asthma—comprised about 40 percent of stays that began in the ED.


  • Injuries first treated in the ED that resulted in admission to the hospital increased with age among children and adolescents. About 4 percent of children under 1 were admitted through the ED compared with about 30 percent of 15 to 17 year olds.


Findings

In 2004, children and adolescents under 18 years of age accounted for 17.3 percent (6.7 million) of the 38.7 million total hospital stays. Two-thirds of pediatric hospitalizations were related to either births or maternal care. Excluding these cases, nearly half of the remaining pediatric stays (1.1 million hospitalizations) were admitted through the ED. Children and adolescents were often seen in the ED and subsequently admitted to the hospital for acute or preventable conditions, such as asthma or injury.

Reasons for admission to the hospital through the ED for children and adolescents
Figure 1 shows the reasons for child and adolescent hospital admissions from the ED compared with adults, organized by body system. Respiratory disorders accounted for 27.8 percent of all pediatric admissions through the ED. Injuries and digestive disorders were the next most common category of conditions, comprising 16.6 percent and 14.2 percent, respectively, of all pediatric admissions through the ED. Endocrine and nervous system conditions each constituted about 7 percent of admissions. Mental health and substance abuse (MHSA) disorders comprised 5.1 percent of pediatric stays that began in the ED.

Table 1 presents the 20 most frequent specific conditions for which children and adolescents were admitted to the hospital through the ED. These 20 conditions accounted for about two-thirds of all pediatric admissions through the ED. Asthma was the single most common condition with over 95,000 admissions (accounting for 8.5 percent of all pediatric admissions through the ED). This was followed by two conditions also related to the respiratory system—pneumonia and acute bronchitis. These top three conditions accounted for nearly one-quarter of all pediatric admissions through the ED. Appendicitis and fluid/electrolyte disorders ranked 4th and 5th with 64,200 and 53,300, respectively, hospital admissions originating from the ED. Other top 20 conditions included mood disorders (ranked 8th), fractures of the leg and arm (ranked 11th and 12th), and brain injury (ranked 13th).

Reasons for admission to the hospital through the ED, by pediatric age groupings
The reasons why children and adolescents were admitted through the ED varied by age group (figure 2 and table 2). For the youngest children (0 to 4 years), respiratory conditions—mainly acute bronchitis, pneumonia, and asthma—comprised about 40 percent of stays that began in the ED. This percentage dropped to 25.6 percent for 5 to 9 year olds and declined even further for 10 to 14 year olds (12.0 percent) and 15 to 17 year olds (7.9 percent).

For children under one year of age, acute bronchitis was the single most common reason for admission accounting for over 1 in 5 admissions from the ED. For 1 to 4 and 5 to 9 year olds, asthma was the most common reason for admission with about 1 in 7 cases admitted through the ED. Asthma admissions from the ED decreased with age. For 10 to 14 year olds asthma accounted for 1 in 15 admissions and represented only 1 in 35 stays for 15 to 17 year olds (data not shown).

In contrast, admissions for injuries cases through the ED increased with age among children and adolescents—from 4.4 percent in children under 1 (data not shown) to 30.1 percent for 15 to 17 year olds. Stays for MHSA conditions that began in the ED also increased with age accounting for less than 1 percent of stays for children 1 to 4 years of age (data not shown) to over 15 percent for 15 to 17 year olds.

Reasons for admission to the hospital through the ED, pediatric stays versus adult stays
Adults were admitted to the hospital from the ED for different reasons than children and adolescents (table 3). While respiratory conditions were largely responsible for such admissions in the pediatric population, adults were most frequently admitted for circulatory system disorders. Heart-related conditions, such as congestive heart failure, chest pain, hardening of the arteries, heart attack, stroke, and irregular heart beat, accounted for over a quarter (27.2 percent) of all adult stays that began in the ED among adults. This is most likely due to the chronic nature of many circulatory diseases that render them less common in the pediatric population. However, similar to younger patients, conditions of the digestive and respiratory systems, and injuries, accounted for a large portion of stays that originated in the ED among adults. One specific condition that was common in both adult and pediatric stays that began in the ED was pneumonia, which accounted for 5.2 percent of adults stays and 7.4 percent of pediatric stays.

Data Source

The estimates in this Statistical Brief are based on data from the HCUP 2004 Nationwide Inpatient Sample (NIS).

Definitions

Types of hospitals included in HCUP
HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. They exclude long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals, but these types of discharges are included if they are from community hospitals.

Unit of analysis
The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.

Pediatric, neonatal, and maternal cases
Definitions of pediatric, birth, and maternal cases are as follows:
– Pediatric cases: hospital stays for individuals under 18 years of age
– Birth cases: hospital stays during which a child is born (identified via diagnosis codes of V3000 to V3901 with the last 2 digits being "00" or "01" in any diagnosis field)
– Maternal cases: hospital stays for females who are pregnant or gave birth (identified via NEOMAT code of "1" or "3")

Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS)
The principal diagnosis is that condition established after study to be chiefly responsible for the patient’s admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 12,000 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnoses into 260 clinically meaningful categories.3 This "clinical grouper" makes it easier to quickly understand patterns of diagnoses and procedures.

Emergency admission
Admission source indicates where the patient was located prior to admission to the hospital. Emergency admission indicates the patient was admitted to the hospital through the emergency department.

About the NIS

The HCUP Nationwide Inpatient Sample (NIS) is a nationwide database of hospital inpatient stays. The NIS is nationally representative of all community hospitals (i.e., short-term, non-Federal, non-rehabilitation hospitals). The NIS is a sample of hospitals and includes all patients from each hospital, regardless of payer. It is drawn from a sampling frame that contains hospitals comprising 90 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at both the national and regional levels for specific subgroups of patients. In addition, NIS data are standardized across years to facilitate ease of use.

About HCUP

HCUP is a family of powerful health care databases, software tools, and products for advancing research. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP includes the largest all- payer encounter-level collection of longitudinal health care data (inpatient, ambulatory surgery, and emergency department) in the United States, beginning in 1988. HCUP is a Federal-State-Industry Partnership that brings together the data collection efforts of many organizations—such as State data organizations, hospital associations, private data organizations, and the Federal government—to create a national information resource.

For more information about HCUP, visit http://www.hcup-us.ahrq.gov.

HCUP would not be possible without the contributions of the following data collection Partners from across the United States:
Arizona Department of Health Services
Arkansas Department of Health & Human Services
California Office of Statewide Health Planning & Development
Colorado Health & Hospital Association
Connecticut Integrated Health Information (Chime, Inc.)
Florida Agency for Health Care Administration
Georgia GHA: An Association of Hospitals & Health Systems
Hawaii Health Information Corporation
Illinois Health Care Cost Containment Council and Department of Public Health
Indiana Hospital&Health Association
Iowa Hospital Association
Kansas Hospital Association
Kentucky Cabinet for Health and Family Services
Maryland Health Services Cost Review Commission
Massachusetts Division of Health Care Finance and Policy
Michigan Health & Hospital Association
Minnesota Hospital Association
Missouri Hospital Industry Data Institute
Nebraska Hospital Association
Nevada Division of Health Care Financing and Policy, Department of Human Resources
New Hampshire Department of Health & Human Services
New Jersey Department of Health and Senior Services
New York State Department of Health
North Carolina Department of Health and Human Services
Ohio Hospital Association
Oregon Office for Oregon Health Policy and Research and Oregon Association of Hospitals and Health Systems
Rhode Island Department of Health
South Carolina State Budget & Control Board
South Dakota Association of Healthcare Organizations
Tennessee Hospital Association
Texas Department of State Health Services
Utah Department of Health
Vermont Association of Hospitals and Health Systems
Virginia Health Information
Washington State Department of Health
West Virginia Health Care Authority
Wisconsin Department of Health and Family Services

For additional HCUP statistics, visit HCUPnet, our interactive query system at http://hcupnet.ahrq.gov/.

For More Information

For a detailed description of HCUP and more information on the design of the NIS and methods to calculate estimates, please refer to the following publications:

Steiner, C., Elixhauser, A., Schnaier, J. The Healthcare Cost and Utilization Project: An Overview. Effective Clinical Practice 5(3):143–51, 2002.

Design of the HCUP Nationwide Inpatient Sample, 2004. Online. August 8, 2006. U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/db/nation/nis/reports/NIS_2004_Design_Report.pdf

Houchens, R., Elixhauser, A. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances, 2001. HCUP Methods Series Report #2003-2. Online. June 2005 (revised June 6, 2005). U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/methods/2003_02.pdf

Suggested Citation

Merrill, C. T. (Thomson Healthcare) and Owens, P. L. (AHRQ). Reasons for Being Admitted to the Hospital through the Emergency Department for Children and Adolescents, 2004. HCUP Statistical Brief #33. June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb33.pdf.

***

AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of health care in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below:

Irene Fraser, Ph.D., Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850


1Births include hospital stays for a newborn child. Adolescent pregnancy stays include hospitalizations during which the patient was pregnant or gave birth.
2Merrill, C. T. (Thomson Healthcare) and Owens, P. L. (AHRQ). Hospital Admissions That Began in the Emergency Department for Children and Adolescents, 2004. HCUP Statistical Brief #32. June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb32.pdf.
3HCUP Clinical Classifications Software (CCS). Healthcare Cost and Utilization Project (HCUP). August 2006. U.S. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp.





Table 1. Top 20 most common reasons for admission to the ED for children and adolescents, 2004*
Rank Condition (CCS code) Number of admissions through the ED Percentage of all admissions through the ED
1 Asthma 95,400 8.5
2 Pneumonia 83,200 7.4
3 Acute bronchitis 75,900 6.8
4 Appendicitis 64,200 5.7
5 Fluid and electrolyte disorders 53,300 4.8
6 Epilepsy, convulsions 35,100 3.1
7 Urinary tract infections 31,500 2.8
8 Mood disorders (depression and bipolar disorder) 29,000 2.6
9 Intestinal infection 27,200 2.4
10 Skin and subcutaneous tissue infections 27,100 2.4
11 Fracture of leg 24,600 2.2
12 Fracture of arm 24,400 2.2
13 Brain injury 23,600 2.1
14 Other infections of upper respiratory tract (nose, throat, trachea) 23,500 2.1
15 Other conditions occurring around the time of birth 22,600 2.0
16 Viral infections 22,100 2.0
17 Meningitis 20,800 1.8
18 Inflammation of stomach and intestines (noninfectious gastroenteritis) 20,300 1.8
19 Fever of unknown origin 18,400 1.6
20 Diabetes mellitus with complications 15,800 1.4
Top 20 most frequent conditions admitted through the ED 738,000 65.9%
All other conditions admitted through the ED 381,200 34.1%
Total admissions through the ED for children and adolescents 1,119,200 100%
*Includes individuals under 18 years of age and excludes births and maternal cases.
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004.


Table 2. Top five specific conditions that resulted in admission to the hospital from the ED for children and adolescents, by age group, 2004*
Age Groups
Under 1 year 1-4 years 5-9 years 10-14 years 15-17 years
Condition (CCS Code) Number of admissions through the ED (percent) Condition (CCS Code) Number of admissions through the ED (percent) Condition (CCS Code) Number of admissions through the ED (percent) Condition (CCS Code) Number of admissions through the ED (percent) Condition (CCS Code) Number of admissions through the ED (percent)
Acute bronchitis 57,900 (21.4) Asthma 44,000 (15.1%) Asthma 24,800 (13.7%) Appendicitis 27,000 (14.0%) Appendicitis 17,300 (9.4%)
Other conditions occurring around the time of birth 22,500 (8.3) Pneumonia 39,600 (13.6%) Appendicitis 16,800 (9.3%) Asthma 13,100 (6.8%) Mood disorders (depression and bipolar disorder) 15,100 (8.2%)
Pneumonia 21,600 (8.0) Fluid and electrolyte disorders 29,000 (10.0%) Pneumonia 13,800 (7.6%) Mood disorders (depression and bipolar disorder) 11,700 (6.1%) Brain injury 7,900 (4.3%)
Urinary tract infections 14,200 (5.2) Acute bronchitis 16,700 (5.7%) Fracture of arm 9,500 (5.2%) Fracture of leg 8,300 (4.3%) Fracture of leg 7,300 (4.0%)
Fluid and electrolyte disorders 12,600 (4.7) Epilepsy, convulsions 15,400 (5.3%) Fluid and electrolyte disorders 7,100 (3.9%) Diabetes mellitus with complications 6,700 (3.5%) Poisoning by other medi-cations and drugs 7,000 (3.8%)
*Includes individuals under 18 years of age and excludes births and maternal cases.
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004.


Table 3. Top 20 most common reasons for admission to the ED for adults, 2004*
Rank Condition (CCS code) Number of admissions through the ED Percentage of all admissions through the ED
1 Congestive heart failure 787,100 5.2
2 Pneumonia 785,700 5.2
3 Chest pain 685,900 4.5
4 Hardening of the heart arteries and other heart disease 482,900 3.2
5 Heart attack (acute myocardial infarction) 446,000 2.9
6 Stroke (acute cerebrovascular disease) 423,400 2.8
7 Irregular heart beat (cardiac dysrhythmias) 421,700 2.8
8 Chronic obstructive lung disease 391,900 2.6
9 Urinary tract infection 343,700 2.3
10 Septicemia 330,600 2.2
11 Mood disorders (depression and bipolar disorder) 316,600 2.1
12 Diabetes mellitus with complications 315,400 2.1
13 Fluid and electrolyte disorders 310,600 2.1
14 Skin and subcutaneous tissue infections 290,400 1.9
15 Gall bladder disease 268,300 1.8
16 Gastrointestinal hemorrhage 252,100 1.7
17 Hip fracture 240,700 1.6
18 Pancreatic disorders 221,400 1.5
19 Intestinal obstruction without hernia 220,000 1.5
20 Fainting 217,800 1.4
Top 20 most frequent conditions admitted through the ED 7,752,200 51.1%
All other conditions admitted through the ED 7,424,100 48.9%
Total admissions through the ED for adults 15,176,300 100%
*Includes individuals over 17 years of age and excludes maternal cases.
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004.
 

Figure 1. Bar chart showing reasons for hospitalizations admitted through the emergency department, by body system and age group, 2004



Figure 2. Bar chart showing reasons for hospitalizations admitted through the emergency department, by body system and pediatric age group, 2004


Internet Citation: Statistical Brief #33. Healthcare Cost and Utilization Project (HCUP). July 2007. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb33.jsp.
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