Archives of Disease in Childhood 1994; 70: 488-492

Paediatric inpatient utilisation in a district generalhospital

Y Thakker, T A Sheldon, R Long, R MacFaul

AbstractPaediatric inpatient utilisation in a dis-trict general hospital was studied for 20general practices covering a population of26433 children. The factors influencingthe rate and route of admission (generalpractitioner (GP) or accident and emerg-ency department) were analysed for 894emergency non-traumatic admissionsover a 12 month period.The overall rate of acute, non-

traumatic admission was 33-8 /1000; 35%of these admissions were via the accidentand emergency department. Asthma wasthe most common reason for admission(16.10/o); 56.9% of the admissions resultedfrom respiratory tract illness and 44%were for an infective illness.There was a significant variation in

the route and rate of admission acrosspractices. Admission rates ranged from 10to 70/1000 children under 15 and the pro-portion via the accident and emergencydepartment from 19% to 85%. The pro-portion ofadmissions via the accident andemergency department for each practicewas highly negatively correlated with thenumber of GPs in the practice, thenumber of children under 15 registered,and positively correlated with theunemployment rate attributed to the list.Using multiple logistic regressionanalysis, the risk ofbeing admitted via theaccident and emergency departnent rela-tive to GP admission was shown to behigher for older children (odds ratio foreach year ofage 1.05) and less for childrenregistered with large practices with moreGPs (odds ratio for each extra GP 0.36) orpractices with more children under 15(odds ratio per extra child 0.9991). Accessto hospital as measured by isochrone barsand social characteristics of the ward ofresidence of each child admitted were notassociated with the route of admission.The admission rate for each practice

was positively, but not statistically signifi-cantly, associated with the unemploymentrate attributed to the list, the unemploy-ment rate of the ward where the practicewas located, and the percentage ofadmissions via accident and emergency,and negatively associated with thepercentage ofthe list under 15 years.(Arch Dis Child 1994; 70: 488-492)

explanations have been advanced: theincreased availability of beds because of thedecreasing lengths of stay; changing tech-nology; increased patient expectation6;improved paediatric training for general practi-tioners (GPs)3; and changing patterns ofadmission for childhood asthma.7 8

Admission rates for disorders which havecontributed most to the increase in paediatricadmissions (asthma, upper respiratory tractinfections, and gastrointestinal diseases)' showlarge geographical variations.9 The variationsmay partly result from the referral andadmission process - that is, via the GP or selfreferral to the accident and emergency depart-ment limiting the control over hospital use bythe GP. Between 4%10 and 7%"1 of childrenattending a children's accident and emergencydepartment were referred for outpatient opinionand between 1%10 and 14%11 were admitted.

There is little information on the referralpatterns of paediatric admissions and on thevariation in use of acute paediatric inpatientservices by GPs. This paper reports the resultsof a population based study aimed at identify-ing factors influencing the route of admissionand the rate of admission by GPs.

MethodsData were taken from an extract of theWakefield district information services. Allchildren, aged 0-15 years, admitted as medicalemergencies via GPs and accident and emerg-ency departments between 1 January 1990 and31 December 1990 were identified. For eachchild the diagnosis, route of admission, post-code of residence, and GP were identified.Diagnostic coding analysis showed the range ofdisorders for which children were admitted byeach route. Those with an E code diagnosis -that is, an external cause (such as head injuryand accidental ingestion) - were excluded aspresentation to the accident and emergencydepartment for this reason was clearlyappropriate.Data on children resident in Wakefield but

admitted to neighbouring hospitals were

Table 1 Summary ofstudy population

Population Total No Aged 0-15 years

Wakefield DHA* 145 820 28 520Wakefield DHA practicest 141 048 26 433Catchment population*

All acute specialties 209 000Paediatrics - 46 460

Hospital admissions in childhood have DHA=District Health Authority.*Source: Health Services Indicators.increased over the past 10-15 years. 1 Various tSource: Family Health Services Authority:

Department ofPaediatrics, MiltonKeynes General NHSTrustY Thakker

Centre for HealthEconomics, UniversityofYorkT A Sheldon

Department ofInformation,Pinderfields GeneralHospital, WakefieldR Long

Department ofPaediatrics,Pinderfields GeneralHospital, WakefieldR MacFaul

Correspondence to:Dr Y Thakker, MiltonKeynes General Hospital,Standing Way, Eaglestone,Milton Keynes MK6 5LD.Accepted 23 February 1994

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Paediatric inpatient utilisation in a district general hospital

obtained from the regional informationservices but details of the GP were not avail-able for most of these children and they werenot included in the final analysis. Analysis ofWakefield District Health Authority areageneral practices was carried out. The popula-tion data showed that these practices haveregistered with them 93% of the WakefieldDistrict Health Authority population aged0-15 years (table 1). The Wakefield DistrictHealth Authority practice population wasused because it allowed a population basedanalysis.

For each practice the total number ofadmissions was analysed by route of admissionand proportion of total admissions whichoccurred via the accident and emergencydepartment. Data on practice characteristicswere obtained from the Family Health ServicesAuthority (FHSA).

Social characteristics for each ward werederived from the 1991 census and were linkedvia the postcode to each child admitted. Theunemployment rate and the Jarman under-privileged area score for the electoral ward inwhich each practice was located were alsorecorded. An attributed unemployment ratefor the list of each general practice wasobtained from the FHSA. This was calculatedas a weighted average of the unemploymentrate of each enumeration district weighted bythe number of people registered with eachpractice in each enumeration district.Attributed rates of other social characteristicsfrom the census were not available. The socialcharacteristics of the ward in which thepractice was based were used as proxies forthe socioeconomic profile of the practicepopulation. An average of 52% of all admis-sions were resident in the same electoral wardas the practice (range 30% to 100%), thecentral town practices having the lowerfigures.

Accessibility to the hospital by privatetransport from the different electoral wardswas assessed by the method described by theUniversity of York Health EconomicsConsortium.'2 Areas showing common traveltimes (isochrone bars) were determined. Bysuperimposing the isochrone map onto anelectoral ward map of the Wakefield DistrictHealth Authority and using Office ofPopulation Censuses and Surveys census dataon populations, the proportions of thepopulation in approximate travel time bandswas established. The weighted travel time foreach electoral ward was then calculated.These ranged from five minutes to over 23minutes.

Table 2 Acute medical paediatric (0-15years) admissions to Pinderfields Hospital(1990). Total paediatric admissions 2069, of which 1645 (79-5%) were emergencies

Non-traumatic admissionsNo of Admissions

Route of admission admissions with E code Total Wakefield DHA

Accident and emergency department 845 367 478 318GP 800 16 784 576Total 1645 383 1262 894

DHA=District Health Authority.

ANALYSISConfidence intervals (95%) for the admissionrates and the proportion admitted via accidentand emergency departments were calculatedassuming Poisson and binomial distributionsrespectively, using the software package'Confidence with statistics'. 13The proportion of admissions via accident

and emergency departments for each generalpractice was explored by multiple linear regres-sion on a range of practice characteristics andsocial variables for the practice. Variableswhich were not significant at the 5%/o level wereremoved in a stepwise manner. For childrenadmitted to hospital, the risk ofbeing admittedvia the accident and emergency departmentcompared with GP admission was modelledusing multiple logistic regression. Modellingused a backward manual stepwise approachwhich included all the available individualsocial data based on the ward of residence andpractice characteristics. Variables which werenot significant at the 5%/o level were removed ina stepwise manner. Children admitted by thetwo routes in one year were omitted in this partof the analysis and multiple admissions via oneroute were treated as a single admission as theydo not contain independent information.The variation in practice rates of admission

was analysed by simple correlation and linearregression using the package SPSS. The GPpractice, socioeconomic, and access character-istics were used as explanatory variables. Thepractice characteristics included the number ofGPs, the population and the percentage of thepopulation under 15 years of age registered,the total list size and the attributed unemploy-ment rate, and the unemployment rate andJarman underprivileged score of the ward inwhich the practice was located.

ResultsA total of 2069 paediatric medical admissionsoccurred over the 12 month period. A total of1645 (79-5%) of these were admitted as emer-gencies via the GP or the accident andemergency department. Three hundred andeighty three (23-3%) of all the emergencyadmissions resulted from trauma (head injuryor accidental ingestion) and were excludedfrom the analysis. Three of the remaining 1262children with an acute non-traumatic medicalillness could not be allocated to a practice, onewas not registered with a GP, and the medicalrecords were unobtainable for two. Of theremainder, 894 (71 2%) came from theWakefield District Health Authority practices.Table 2 summarises these data.The 894 admissions analysed occurred in

755 children. Six hundred and forty nine wereadmitted once only; the remaining 106children accounted for 245 admissions with 21children (2-8% of the children admitted)having three or more admissions (accountingfor 8-2% of all admissions). For children underthe age of 2 years such multiple admissionsoccurred in 17%, accounting for 32% of theadmissions in this age group. This pattern hasbeen observed in another study.'4 Forty one

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Table 3 Diagnostic codes and route of admission

Route of admission (%)

No (%o)* Via accident and ViaDiagnosis (ICD codes) (n=894) emergency department GP

Febrile convulsion (780.3) 41 (4-6) 73-2 26-8Otitis media (382) 13 (1-5) 53-8 46-2Constipation (564) 12 (1-3) 50 0 50 0URTI (460-465) 91 (10-2) 38-5 61-5Viral infection (078-079) 78 (8 7) 37-2 62-8Asthma (493) 144 (16-1) 36-1 63-9Gastroenteritis (003-009, 558) 44 (4-9) 31-8 68-2Breathing difficulties (786) 30 (3 3) 30-0 70-0Bronchiolitis (466) 48 (5-4) 29-2 70-8Vomiting (787) 30 (3-4) 20-0 80-0Meningitis (320, 322, 047) 21 (2 3) 14-3 85-7Pneumonia (480-486) 39 (4 4) 15-4 84-6Failure to thrive/feeding problem (783) 26 (2 9) 11-5 88-5Pyloric stenosis (750 5) 11 (1-2) 9 0 91-0UTI(599) 17 (1 9) 0 100-0Others 249 (28-1) 41-4 58-6

URTI=upper respiratory tract infection; UTI=urinary tract infection.*Percentage of all admissions.

children were admitted via both the GP andaccident and emergency routes.Some Wakefield resident children (103)

were admitted to a hospital outside the district.Of these, 98 (95%) went to a hospital for infec-tious diseases. Although these were all referredby a GP, the details of the referring GP werenot available on the data from the regionalinformation services.

Table 3 gives the common diagnoses classi-fied by International Classification of Diseasesgroups and frequency expressed as a percent-age of the total number of admissions. Asthma(144 children (16-1%)) was the most commondiagnosis and 56-9% of the admissionsresulted from respiratory tract illness. Fortyfour per cent of the admissions were forinfective illness.

Febrile convulsion was the only conditionwhere the admission rate via accident andemergency was greater than via the GP routeand reflects the perception of urgency fortreatment. The range of conditions is other-wise similar for the two routes of admission.The overall rate of admission of children

from the Wakefield District Health Authority

Table 4 Variation between practices in admission ratesper 1000 child population and proportion of admissions viathe accident and emergency department

% Via accident andPractice Admission rate/1000 emergency departmentNo (95% CI)* (95% CI)t

1 39 3 (24 to 60) 40-0 (19 to 64)2 18-6(13to25) 20-0(9to36)3 40 3 (30 to 52) 39 7 (27 to 53)4 43-8 (35 to 54) 25-8 (17 to 36)5 44-7 (34 to 57) 40-9 (29 to 54)6 35-6 (28 to 44) 24-4 (16 to 35)7 39 3 (30 to 51) 46-7 (34 to 60)8 33-5 (26 to 47) 30 4 (18 to 46)9 25-7 (20 to 33) 19-4 (10 to 31)10 60-6 (45 to 80) 67-4 (52 to 80)11 43-7 (35 to 54) 24-7 (16 to 35)12 19-4 (14 to 27) 27-0 (14 to 44)13 36 -0 (26 to 49) 48-7 (32 to 61)14 31-0 (24 to 40) 35-6 (24 to 49)15 33-6 (17 to 59) 41-7 (15 to 72)16 16-0 (9 to 25) 33-3 (13 to 59)17 30 5 (19 to 46) 65-2 (43 to 84)18 16-3 (6 to 33) 85-7 (42 to 99)19 35-1 (21 to 54) 70-0 (46 to 88)20 70-0(38to117) 21 3(5to51)

*Calculated assuming Poisson distribution.tCalculated assuming binomial distribution.CI=confidence interval.

Table S Logistic regression model of risk of admission viaaccident and emergency department relative to number ofGPs in the practice

StatisticalCoefficient Standard significance Odds

Variable (/3) error of coefficient ratio

Age on admission 0-0456 0-020 0-025 1-047Number of GPs -1-0342 0-509 0-04 0-3555Practice code 0-0311Constant 3-58 2-11 0-09

practices to Pinderfields Hospital for acutenon-traumatic illness was 33-8/1000. Thirtyfive per cent of these admissions were via theaccident and emergency department. Table 4shows that there was significant variation inthe rates and route of admission among the 20practices. Data on the size and number ofadmissions for each practice are not includedto maintain the anonymity of the practices.The practice child population (0-15 years)ranged from 200 to 2419, with a mean of1322 and a median of 1369. One of thepractices was very small, had unusual charac-teristics with a high proportion of childrenunder 15 years, and was excluded fromfurther analysis.The proportion of admissions which

occurred via the accident and emergencydepartment for each practice was highly nega-tively correlated with the number ofGPs in thepractice (r=-0.72; p<0 001) and the popula-tion under 15 years (r=-0 7; p<0-001), andwas positively correlated with the attributedunemployment rate of the list (r=0.64;p<0-01). Multiple regression analysis resultedin the best model being:% Admitted via accident and emergency= -0-16+0-064

Unemployment- 1 x10-4 Population<15 years (R2=0-59)(p=0 06) (p=0O02)

Using multiple logistic regression, the risk ofbeing admitted via the accident and emergencydepartment relative to GP admission wasshown to be higher for older children (oddsratio for each year of age 1-05; p=0 003) andless for children registered with a practicehaving more GPs (odds ratio for each extra GP0-36; p=0042) (table 5). Independent of thesetwo variables, a further factor for generalpractice was also statistically significant inexplaining the variation in route of admission.This means that one or more unidentifiedcharacteristics that distinguish practices areassociated with the likelihood of admission viaaccident and emergency. Access to hospital, asmeasured by the weighted travel time, was notassociated with the route of admission. Thismodel shows a high sensitivity of the odds ofadmission via accident and emergency to thenumber of GPs. Thus in going from a practiceof three to one of six GPs decreases the odds bya factor of 22. Repeating the analysis, anequally good model replaces 'the number ofGPs' with 'the number of children under 15years of age' with an odds ratio of 0-9991(p<0 000 1), indicating that for every 100 extrachildren in a practice the odds of admission viaaccident and emergency decreases by 0 09(table 6).

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Table 6 Logistic regression model of risk of admission via accident and emergencydepartment relative to number of children aged < 15 years in practice

StatisticalCoefficient Standard significance Odds

Variable (6) error of coefficient ratio

Age on admission 0-048 0-021 0-02 1-049Population under 15 years in practice -0 001 0-0002 0 000 0.999Constant 0-928 0-26 0 000

The rate of admission of children by practicewas positively associated with the attributedunemployment rate of patients registered withthe practice (r=0-24), the unemployment rateof the ward where the practice was located(r=0 39), and the percentage of admissions viaaccident and emergency (r=0-15) and nega-tively associated with the percentage of the listunder 15 years of age (r=-0-3). The latterassociation is in contrast with the review out-patient attendance rate per practice reported ina previous study.'5 None of these was statisti-cally significant at the 5% level, however. Thisis most probably due to the lack of powerbecause of the small number of practices (19)in the analysis. The relation with the Jarman 8underprivileged area score for the ward wherethe practice was based (r=0.27) was less strongthan for unemployment rate. Multiple linearregression of the rate of admission against allthe social and practice characteristic variablesproduced no significant result.

DiscussionThis study provides information on the use ofpaediatric inpatient services in a well definedpopulation which is distributed over a fairlydense urban and surrounding semirural area.

The hospital has 19 paediatric medical bedsand 20 paediatric surgical beds. Referrals foradmission from GPs and the accident andemergency department are received by thesenior house officer on call and are accepted ifthere is an available bed, the threshold foradmission being determined by the source ofreferral. It is departmental policy to admit anychild under the age of 5 years who presents tothe accident and emergency department after 9pm.

The proportion of admissions for eachpractice via the accident and emergencydepartment ranged from 19% to 85%. Thisroute is appropriate for children with traumaticinjuries or serious illnesses needing urgentmedical attention. The former were excludedfrom the analysis and the latter are uncom-

mon. For most children this route of admissionwas inappropriate and in some cases couldhave resulted in an unnecessary admission byvirtue of presenting after 9 pm.

This study shows that the variation in theproportion of children admitted via accidentand emergency is significantly inversely associ-ated with the size of the practice (number ofGPs and children under 15 years). This mayreflect the actual or perceived availability of theGP, which have been identified as importantreasons for self referral to the accident andemergency department. 10 1 16 17 Larger prac-tices may offer greater accessibility through

longer surgery hours, more flexibility in pro-viding urgent appointments and visits, out ofhours (emergency) services, and increasedpromotion/patient education through practiceinformation leaflets.Of interest is the finding that the social

characteristics of the ward of residence ofchildren admitted was not associated with theroute of admission, though the attributedunemployment rate for each practice list ispositively associated with the proportion ofchildren admitted via accident and emergencyin the practice. In other words the individualand the practice based analysis of the factorsinfluencing the route of admission, althoughagreeing on the importance of the size ofthe practice, differed with respect to theimportance of social factors. The social charac-teristics of wards are likely to be poor proxiesfor the characteristics of individual childrenfrom that ward who are admitted to hospital.This is because wards are large and usuallyheterogenous, thus children admitted tohospital are unlikely to be representative of theward (the ecologic problem). The attributedward unemployment rate, being based on thesmaller and less heterogenous enumerationdistricts, is likely to be a more accurate reflec-tion of the average characteristics of the peopleregistered with a GP, but not necessarily offamilies with children registered or childrenadmitted.

Proximity and easy access to the hospitalhave been identified as being important factorscontributing to the inappropriate use of theaccident and emergency departmentl8-20; thiswas not confirmed in this study after adjustingfor other factors.The overall acute, non-traumatic admission

rate per 1000 child practice population was33-8. Reported rates from previous studiesinclude 309/1000 and 21 9/1000. Directcomparison with the previously reportedstudiesl-5 is limited because of the variableinclusion of accidental ingestion and headinjuries. Significant variation was observedbetween general practice admission rates per1000 child population ranging from 10 to 70.The analysis did not successfully explain muchof this variation but suggests that, in additionto chance, the variation may be affected bypractice characteristics (number of childrenunder 15) and socioeconomic factors (such asunemployment rates). Because of the smallnumber of practices, however, there was littlestatistical power to explore these potentialrelations.

Higher rates of admission to hospital inpoorer areas may be due to the increasedprevalence of certain disorders combined witha lowered threshold for admission. The rela-tion between poverty and sickness has beenwell described,21 22 but the actual factorscontributing to it need to be understood. Thefact that the unemployment rate of the ward inwhich the practice was based was morestrongly associated with the rate of admissionthan the attributed rate for the list may have nosignificance, but is of interest. Whether thisreflects some ecologic problems or something

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more interesting about the influence ofpractice location is not possible to explorefurther in this study, but may be worth furtherinvestigation.The extent to which differences in GP

referral behaviour might account for the varia-tion in admission rate for each practice isunclear. Studies of paediatric outpatientreferral patterns suggest that this may varyaccording to the experience/interest of theGP.15 The paediatric experience and trainingof GPs may heighten their awareness of therisks of serious illnesses contributing to alowered threshold for admission.2 3 Theemphasis of both the Court report23 and afollow up report,24 however, has been on theprovision of child health services outside thehospital, with particular emphasis on improve-ment of the primary care of the children. In astudy from the USA 13% of patient days ingeneral paediatrics were judged to be inappro-priate.25 A study on the appropriateness of selfreferrals and referrals for admission from GPshas been undertaken in Wakefield and will bereported elsewhere.

Reduction in some of the variations inadmission rate may be possible with anexperienced paediatric specialist screeningsome admissions, by GPs working in anaccident and emergency department,26 and byencouraging parents into the appropriate useof primary care services. It is likely, however,that further reduction in variations may needto be accompanied by reductions in theinequalities in socioeconomic factors and theirconsequent effect on the health of children.More research is needed to explore thecomplex and interactive effects of socialconditions and practice characteristics andbehaviour on the rate and route of admissions.We acknowledge the useful advice of the two anonymousreferees and the assistance of Alex Watt of the York HealthEconomics Consortium in showing how to construct isochronemeasures.

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2 Forfar JO. Trends in paediatric medical admissions. BMJ1989; 298: 1711.

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4 Thornes R. Where are the children? Report of joint workinggroup of BPA, NAWCH, RCH. London: Caring forChildren in the Health Services, 1987.

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7 Knot A, Bum R, Evans N, Lenney C, Lenney V. Seasonalvariations and time trends in childhood asthma inEngland and Wales 1975-81. BMJ 1984; 289: 235-8.

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10 Bedford HE, Jenkins SM, Shore C, Kenny PA. Use of aneast end children's accident and emergency departmentfor infants: a failure of primary health care? Quality inHealth Care 1992; 1: 29-33.

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12 Watt A. Future role of district health. Assessing needsfor servicesand setting priorities. University of York: York HealthEconomics Consortium Report, Section 6, 1991.

13 Gardner MJ, Altman DG. Statistics with confidence. London:BMJ Publishing Group, 1989.

14 Spencer NJ, Lewis MA. Multiple admissions under 2 yearsof age. Arch Dis Child 1991; 66: 938-40.

15 MacFaul R, Long R. Paediatric outpatient utilisation in adistrict general hospital. Arch Dis Child 1992; 67:1068-72.

16 Horder E. Inappropriate use of casualty departments. Jf RCoil Gen Pract 1988; 38: 372.

17 Singh S. Self referral to accident and emergency depart-ments: patients perceptions. BMJ 1988; 297: 1179-80.

18 McKee CM, Gleadhill DNS, Watson JD. Accident andemergency rates: variations among patients fromdifferent general practices. Jf R Coll Gen Pract 1990; 40:150-3.

19 Roghman KJ, Zastowny TR. Proximity as a factor in theselection of health care provider. Soc Sci Med 1979; 13D:61-9.

20 Ingram DR, Clark DR, Murdie RA. Distant and decision tovisit an emergency department. Soc Sci Med 1978; 12:55-62.

21 MacLure A, Stewart GT. Admission of children to hospitalin Glasgow: relation to unemployment and other depriva-tion variables. Lancet 1984; ii: 682-5.

22 Black D, Morris JN, Townsend P, Smith C. Inequalities inhealth. London: Department of Health and SocialSecurity, 1980.

23 Committee on Child Health Services. Fit for the future.London: HMSO, 1976. (Court report.)

24 Graham P. Investing in the future: child health ten years afterthe Court report. London: Policy and Practice ReviewGroup, National Children's Bureau, 1987.

25 Kemper KJ. Medically inappropriate hospital use in apaediatric population. N Engl J Med 1988; 318: 1033-7.

26 National Audit Office. NHS accident and emergencydepartments in England: National Audit Office report.London: HMSO, 1992. (House of Commons Paper, IAugust 1992.)

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