Variation and Outcomes Associated with Direct Admission Among Children with Pneumonia in the United States

1Tufts University School of Medicine, Boston, MA
2Baystate Medical Center, Springfield, MA

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 692


While the majority of children with unplanned admissions are admitted through the emergency department (ED), direct admissions constitute a significant proportion of hospital admissions nationally. Despite this, past studies among 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 admission. The objectives of this study were to describe rates of direct admission in a large sample of US hospitals and to compare resource utilization and outcomes between children with pneumonia admitted directly relative to those admitted from EDs.


We conducted a retrospective cohort study of children 1‐17 years hospitalized with pneumonia at hospitals contributing data to Perspective Data Warehouse. We used multivariable regression to examine associations between admission type (direct admission and admission through the ED) and outcomes, controlling for patient and hospital characteristics and clustering within hospitals. Instrumental variable sensitivity analyses were performed using hospital as the instrument. Outcome measures included (i) length of stay; (ii) transfer to the intensive care unit; (iii) readmission within 30 days of discharge; (iv) high‐turnover hospitalization, and (v) total hospital costs.


A total of 19,736 children from 278 hospitals met eligibility criteria, including 7100 (36.0%) with direct admissions and 12636 (64.0%) with ED admissions. Rates of direct admission varied significantly, with a median direct admission rate of 35.6% (IQR 18.9% ‐52.4%). 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 (RR 1.09, 95% CI 1.06‐1.11), 12% lower costs (CR 0.88, 95%CI 0.86‐0.90), and 37% lower odds of high‐turnover hospitalization relative to those admitted through the ED (OR 0.63,95%CI 0.57‐0.69), with no significant difference in ICU transfer (OR 0.90, 95%CI 0.63‐1.29) or 30‐day readmission (OR 0.76, 95%CI 0.57‐1.01).


Increasing rates of direct admission among children with primary care physicians could be an effective strategy to reduce hospital costs and emergency department patient volumes. Additional research is needed to establish direct admission policies and procedures that are safe and cost‐effective.

To cite this abstract:

Leyenaar J, Shieh M, Lagu T, Pekow P, Lindenauer P. Variation and Outcomes Associated with Direct Admission Among Children with Pneumonia in the United States. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 692. Journal of Hospital Medicine. 2014; 9 (suppl 2). Accessed September 16, 2019.

« Back to Hospital Medicine 2014, March 24-27, Las Vegas, Nev.