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Understanding infant admission rates by comparing administrative data in England and Canada

By Dr Katie Harron, Assistant Professor of Statistics at the London School of Hygiene and Tropical Medicine, for ADRC-England

Edited from the original blog article in The Conversation UK

The number of children admitted to hospital as an emergency in England has risen over the last 15 years. This is not due to a deterioration of childhood health, but to organisational changes such as access to out-of-hours GP services and changes in the behaviour of parents. Clearly, we would expect children with serious conditions to be admitted to hospital and treated appropriately. But minor illnesses are often managed better in the community or even at emergency departments, avoiding the expense of hospital admissions (not to mention the disruption to children and their families).

To try to understand whether infant admission rates are a problem, we used administrative data to compare what happens in England and Canada. Canada has a similar cultural and social background and provision of healthcare services to England: both countries have universal health care systems that patients can access free at the point of care, both countries have GPs that operate similar gatekeeper functions (referring families to hospital when needed), and both populations have similar levels of childhood need (measured, for example, through child poverty or mortality rates). However, there are some differences in healthcare policies and organisation between countries that could shed light on the problem.

We looked at administrative hospital records for infants born between 2010 and 2013, to see how many went to hospital within 1 year of being discharged from hospital after birth in England and Ontario (Canada’s largest province). The data revealed some very interesting patterns. Twice as many infants were admitted to hospital as an emergency in England (20%) than in Ontario (8%), yet the number of infants taken to an emergency department at least once was similar (42% in Ontario and 36% in England). It is unlikely that these differences are due to infants in England being sicker and more in need of being treated on a hospital ward, since we used additional information held in the records to make sure that we were comparing similar infants in both countries (for example, by looking at gestational age at birth).

What we are seeing is an important difference between countries in how likely infants are to be admitted, after having been seen in an emergency department. In Ontario, only 7% of emergency department visits resulted in admission; in England, it was 26%. However, almost half of infants admitted in England were discharged home on the same day compared with only 6% in Ontario. This means that it is unlikely that the excess of admissions in England were for serious conditions.

Taken together, these results suggest that the threshold for admission from emergency departments is much lower in England than in Ontario. At least some of the infants admitted in England could have probably been treated appropriately within emergency departments (or even in the community), without the need for admission to a hospital ward (particularly those admitted and discharged on the same day).

So why do these striking differences between England and Ontario exist? When we discussed the results with clinicians in both countries, they suggested that one of the driving factors is the availability of consultant paediatricians. Whilst consultant paediatricians work in all emergency departments within large community hospitals in Canada, consultant paediatric emergency medicine provision in England varies regionally, and is only recommended for settings seeing more than 16,000 children per year (around half of emergency departments in England).

Another likely explanation is the 4 hour waiting time target for emergency departments, which is stricter in England than Canada. For children, watching and waiting can be important. As the 4 hour target approaches, clinicians may be more inclined to admit to a ward for further observation than risk sending a sick child home. This has been shown in studies demonstrating a sharp peak in admissions just before the 4 hour cut-off. At the same time, shorter waiting times are an incentive for parents to take their child to an emergency department for a minor illness, than wait longer before getting an appointment with their GP.  

Hospital admissions not only increase an infant’s exposure to infection and medical errors, but can also contribute to psychological distress, disruption, or economic loss for children and/or their families. We cannot use these data on their own to say with certainty what impact we would see by increasing the availability of paediatric emergency consultants in English emergency departments, relaxing waiting time targets for children, or more use of short stay observation units. However, we should continue to use administrative data to support hospitals in making decisions about how best to reduce potentially unnecessary short-stay admissions, in order to improve quality of life for children and their families as well as alleviating pressure on hospital resources. 

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Written by Dr Katie Harron for ADRC-England. Published on the ADRN blog under Creative Commons license CC BY-NC-SA 4.0

Published on 2 August 2017

Page last updated: 27/07/2018