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Acad Pediatr. 2018 Jul;18(5):525-534. doi: 10.1016/j.acap.2017.10.002. Epub 2017 Oct 27.

Hospital and Community Characteristics Associated With Pediatric Direct Admission to Hospital.

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Section of Pediatric Hospital Medicine, Department of Pediatrics & The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Graduate Program in Clinical and Translational Science, Sackler School of Graduate Biomedical Sciences, Tufts University, Boston, Mass. Electronic address:
Instititute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School, Springfield, Mass.
Instititute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School, Springfield, Mass; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Mass.
School of Public Health and Health Sciences, University of Massachusetts, Amherst, Mass.



One quarter of pediatric hospitalizations begin as direct admissions, defined as hospitalization without receiving care in the hospital's emergency department (ED). Direct admission rates are highly variable across hospitals, yet previous studies have not examined reasons for this variation. We aimed to determine the relationships between hospital and community factors and pediatric direct admission rates, and to evaluate the degree to which these characteristics explain variation in risk-adjusted direct admission rates.


We conducted a cross-sectional study of the Healthcare Cost and Utilization Project's Kids Inpatient Database, American Hospital Association Database, and Area Health Resource File, including children <18 years of age who were admitted for a medical hospitalization in states contributing data to all data sets. Using hierarchical generalized linear modeling, we generated risk-adjusted direct admission rates and used generalized linear models to assess the association of hospital and community characteristics with these risk-adjusted rates.


We included 211,458 children discharged from 933 hospitals and 26 states; 20.2% were admitted directly. One-fifth of the variance in risk-adjusted direct admission rates was attributed to observed hospital and community factors. The greatest proportion of this explained variance was related to ED volume (37%), volume of pediatric hospitalizations (27%), and size of the pediatrician workforce (12%).


Direct admission rates were associated with several hospital and community characteristics, but the majority of variation in hospitals' direct admission rates was not explained by these factors. These findings suggest opportunities for diverse hospital types to develop the infrastructure and communication systems necessary to support pediatric direct admissions.


care coordination; direct admission; hospitalization; pediatric

[Available on 2019-07-01]

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