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J Pediatr. 2019 Sep 17. pii: S0022-3476(19)30886-8. doi: 10.1016/j.jpeds.2019.07.034. [Epub ahead of print]

Variation in Hospitalization Rates Following Emergency Department Visits in Children with Medical Complexity.

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Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Children's Hospital Association, Lenexa, KS.
Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Division of Research, Rockville, MD.
Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA.
Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Children's Hospital Association, Lenexa, KS; Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO.
Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL.
Department of Pediatrics, University of Texas Medical School, Houston, TX.
Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA. Electronic address:



To evaluate factors associated with admission from emergency department (ED) encounters for children with medical complexity (CMC) and to quantify the hospital admission rate as well as variation in adjusted hospital admission rates across EDs.


Retrospective study of 271 806 visits to 37 EDs in freestanding children's hospitals from January 1, 2014, to June 30, 2017, for patients of all ages with a complex chronic condition. Associations between patient demographic, clinical, and health services characteristics and the likelihood of hospital admission were identified using generalized linear models, which were then used to calculate adjusted hospital admission rates.


Hospital admission occurred with 25.7% of ED visits. Characteristics with the greatest aOR of hospitalization were ≥3 compared with 0 prior hospitalizations in 365 days (4.7; 95% CI, 4.5-4.9), ED arrival overnight compared with during workday 3.2 (95% CI, 3.1-3.3)], and ≥6 vs 0-1 chronic conditions (1.6; 95% CI, 1.5-1.6). Adjusted hospital admission rates varied significantly (P < .001) across EDs (21.1% [10th percentile]) and 30.0% [90th percentile]). Significant variation remained when excluding low-intensity ED visits, excluding hospitalizations requiring surgery and/or intensive care, or restricting the cohort to overnight ED arrival and to children with ≥3 prior hospitalizations.


CMC are frequently admitted from the ED. Substantial variation in CMC hospital admission rates across EDs exists after case-mix adjustment.


children with medical complexity; emergency department; hospitalization

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