Care of Children and Adolescents in U.S. Hospitals: HCUP Fact Book No. 4 (continued)

Foreword

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To help fulfill this mission, AHRQ develops a number of databases, including the powerful Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-Industry partnership designed to build a standardized, multi-State health data system; HCUP features databases, software tools, and statistical reports to inform policy makers, health system leaders, and researchers.

For data to be useful, they must be disseminated in a timely, accessible way. To meet this objective, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges (http://hcupnet.ahrq.gov/). Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.

In addition, AHRQ produces the HCUP Fact Books to highlight statistics about hospital care in the United States in an easy-to-use, readily accessible format. Each Fact Book provides national information about specific aspects of hospital care—the single largest component of our health care dollar. The national estimates are benchmarks against which States could compare their own data.

The first Fact Book featured an overview of hospital stays in the United States and types of conditions treated, the second Fact Book described the procedures performed in U.S. hospitals, and the third Fact Book focused on hospital care for women.

This Fact Book examines hospital care for children using one of the newest HCUP databases made publicly available—the Kids' Inpatient Database (KID). The KID is the first database devoted specifically to the study of hospital stays for children. Prior to development of the KID, no research database had sufficient numbers of cases to allow in-depth analysis of children's hospitalizations. The creation of the KID has enabled studies of why children and adolescents are hospitalized, what types of procedures children receive, who is billed for children's hospital stays, disparities in outcomes and use of services, and a host of other topics.

We invite you to tell us how you are using this Fact Book and other HCUP data and tools and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please E-mail us at hcup@ahrq.gov or send a letter to:

Irene Fraser, Ph.D.
Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

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Contributors

Without the following State partners, the Healthcare Cost and Utilization Project (HCUP) and the 2000 Kids' Inpatient Database (KID)* would not be possible:

* Arizona Department of Health Services
* California Office of Statewide Health Planning and Development
* Colorado Health and Hospital Association
* Connecticut Integrated Health Information (Chime, Inc.)
* Florida Agency for Health Care Administration
* Georgia: An Association of Hospitals & Health Systems (GHA)
* Hawaii Health Information Corporation
Illinois Health Care Cost Containment Council
* Iowa Hospital Association
* Kansas Hospital Association
* Kentucky Department for Public Health
* Maine Health Data Organization
* Maryland Health Services Cost Review Commission
* Massachusetts Division of Health Care Finance and Policy
Michigan Health & Hospital Association
* Missouri Hospital Industry Data Institute
* New Jersey Department of Health and Senior Services
* New York State Department of Health
* North Carolina Department of Health and Human Services
* Oregon Association of Hospitals and Health Systems and Office of Oregon Health Policy and Research
* Pennsylvania Health Care Cost Containment Council
* South Carolina State Budget and Control Board
* Tennessee Hospital Association
* Texas Health Care Information Council
* Utah Department of Health
* Virginia Health Information
* Washington State Department of Health
* West Virginia Health Care Authority
* Wisconsin Department of Health and Family Services

Acknowledgments: Thanks to Suzanne Worth at Social and Scientific Systems for her invaluable assistance in statistical programming, to Michael Keane and Minsun Kang for their help in summarizing the findings, and to The Madison Design Group for their work in design and layout of this Fact Book. Special thanks to the National Association of Children's Hospitals and Related Institutions (NACHRI) for their help in creating the Kids' Inpatient Database which forms the basis for this Fact Book and the Stanford University-University of California Evidence-based Practice Center for it's work in developing the AHRQ Quality Indicators.

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Introduction

Americans had 36 million hospital stays in 2000, and about 18 percent of these stays were for children and adolescents 17 years and younger. This Fact Book presents an overview of the care of children and adolescents in U.S. hospitals, providing insight into the types of conditions for which children are hospitalized, the types of procedures they receive, who is billed for the stays, the resource use associated with children's hospital stays, and where children are discharged to when they leave the hospital.

The Fact Book begins with an overview of hospital care for children overall and, to put this care into perspective, compares information about children to information about adults' hospital stays. It then provides more detailed information for three major subgroups of pediatric hospital stays:

1. Neonatal stays—newborns and infants 30 days and younger.
2. Stays for other pediatric illness—admissions for children and adolescents not related to neonatal and maternal conditions.
3. Stays for adolescent pregnancy and delivery—admissions for maternal care.

Data on children come from the 2000 Kids' Inpatient Database (KID), a database maintained and disseminated by the Agency for Healthcare Research and Quality (AHRQ), as part of the Healthcare Cost and Utilization Project (HCUP). The KID—a stratified probability sample of pediatric discharges for all participating hospitals—is the only database specifically developed to allow in-depth studies on children's hospitalizations. Because of its tremendous size (2.5 million records), the 2000 KID can provide information on relatively uncommon diagnoses and procedures, as well as on subpopulations such as specified age groups or diagnostic subgroups.

Information on adult stays in this Fact Book comes from the 2000 Nationwide Inpatient Sample (NIS), a sample of U.S. community hospitals drawn and weighted to provide national estimates. Both databases are uniquely suited to providing a comprehensive picture of hospital care in the U.S. Both databases cover all patients discharged from hospitals, including the uninsured, those covered by public payers such as Medicaid, and those with private insurance. Both provide information on total hospital charges for all patients. Both the KID and the NIS include short-term, non-Federal, community hospitals. General and specialty hospitals such as pediatric, obstetrics-gynecology, short-term rehabilitation, and oncology hospitals are included. Long-term, psychiatric, and substance abuse hospitals are excluded.

This report examines why children and adolescents are hospitalized, what happens to children and adolescents in hospitals, who is billed for children's hospital stays, and what happens when children are discharged.

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Summary

This Fact Book examines hospital care for children age 0 to 17 years old in the United States and divides children's stays into three groups:

• Neonatal conditions: stays for newborns and infants 30 days of age or less.
• Pediatric illness: stays for ill children and adolescents over 30 days of age.
• Adolescent pregnancy: stays during which the patient was pregnant or gave birth.

Why Are Children and Adolescents Hospitalized?

• Almost two-thirds of all childhood hospital stays are for newborns and neonates (babies up to 30 days old). The vast majority of these stays (nearly 95 percent) are for the birth of infants in the hospital.
• About a third of pediatric hospital stays are for pediatric illnesses besides neonatal care and adolescent pregnancy.
• Adolescent pregnancy accounts for 3 percent of all pediatric hospitalizations or nearly 9 percent of non-neonatal hospitalizations.

At What Ages Are Children Most Likely To Be Hospitalized?

• In 2000, children and adolescents accounted for 6.3 million hospital stays or 18 percent of all stays; adults accounted for approximately 30.0 million hospital stays, about 82 percent of all stays.
• Children younger than 1 year comprise only 1 percent of the U.S. population, but they account for nearly 13 percent of all hospital stays. The vast majority of these stays are newborn infants.
• Children and adolescents 1 to 17 years old represent 24 percent of the population, but they account for only 5 percent of hospital stays.
• From age 14 to 16, the number of hospital admissions for pregnancy approximately triples each year, up to 77,100 hospital stays for pregnant 16 year olds. Nearly 2 percent of all adolescent girls age 13 to 17 deliver each year compared to about 10 percent of women 18 to 34 years old.

How Do Children Get Admitted to the Hospital?

• Excluding neonates and adolescent pregnancy, 45 percent of admissions for pediatric illness are routine, non-emergency admissions and 44 percent are through the emergency department (ED). These numbers are very similar to those for adults.
• Compared with children from high income areas, children from low income areas admitted to the hospital are more likely to enter the hospital through the Emergency Department (ED). Excluding neonates and pregnant adolescents, over half of children's admissions from low income areas are through the ED—25 percent more than from higher income areas.

What Are the Reasons for Children's Hospital Stays?

• Over two-thirds of all babies (about 71 percent) are born and discharged from the hospital without any clinical problems or complicating diagnoses.
• Five of the top 10 most common diagnoses for neonates are for either respiratory problems or infections.
• The most common neonatal conditions that require extension of the newborn hospital stay or return to the hospital are conditions associated with bilirubin metabolism (hemolytic jaundice), prematurity (including respiratory distress), respiratory problems, infections, and birth defects.
• Respiratory conditions are the most common reason for non-neonatal, non-maternal hospitalizations among children (pediatric illness). Pneumonia, asthma, and acute bronchitis account for 1 in 5 hospitalizations for pediatric illness. Asthma and pneumonia remain among the top 10 reasons for hospitalizations among all pediatric age groups.
• Infectious disease is another common reason for hospitalizations for pediatric illness throughout childhood. Infections account for 6 of the top 10 diagnoses for infants, 6 of the top 10 diagnoses for 1- to 2-year olds, and 5 of the top 10 diagnoses for 3- to 5-year olds.
• Asthma is the most common reason for hospitalizations among 3- to 5-year olds and 6- to 12-year olds.
• About 7 percent, or 1 in 14 pediatric hospital stays are for mental disorders. Affective disorders (primarily depression) are one of the top 10 reasons for hospitalization among children with illness, accounting for over 74,000 hospital stays in 2000. By age 13 to 17, affective disorders are the most common cause of hospitalization for children for non-neonatal or non-pregnancy related conditions.
• For 13- to 17-year olds, injuries, including leg injuries, medication poisonings and head injuries, are among the top reasons for hospital stays.
• Some potential patient safety problems are more common among children—complications of anesthesia reactions and iatrogenic pneumothorax. Some events are more common among adults—postoperative hemorrhage or hematoma and postoperative thromboembolism—but significant rates are seen among children.
• The highest rates of obstetrical trauma are seen among girls ages 10 to 17, compared with older women giving birth. Compared with women age 25 to 34, adolescents age 10 to 17 are about 35 percent more likely to experience some obstetrical trauma (e.g., perineal lacerations) during deliveries without instrument assistance.
• Pregnant adolescents hospitalized without delivery are more likely to be diagnosed with early or threatened labor or urinary tract infections than older pregnant women.
• Compared with older women, adolescent deliveries are more likely to have diagnoses of early or threatened labor, hypertension complicating pregnancy, and excess amniotic fluid.

What Procedures Do Children Receive In the Hospital?

• Circumcision is performed on about 59 percent of all male newborns and 86 percent of all male newborns without a complicating diagnosis.
• Approximately 6 percent of all neonates are intubated and put on a respirator at some point during their stay, making this the third most common procedure performed on neonates.
• The most common diagnostic procedure among neonates—spinal tap, which is used to rule out neonatal meningitis—is performed on nearly 2 percent of all neonates.
• Appendectomy is the most common surgical procedure performed on children and adolescents in the hospital for non-neonatal or non-pregnancy related conditions, occurring over 238 times per day.
• The likelihood of delivering by Cesarean section (C-section) increases with the age of the mother. About 14 percent of adolescent deliveries are by C-section, while 18 percent of women age 18 to 24, 24 percent of women age 25 to 34, and 32 percent of women age 35 to 44 deliver their babies in this manner.

How Long Do Children Stay in the Hospital?

• On average, children's stays in the hospital are 29 percent shorter than adult stays.
• Three of the top 10 diagnoses with the longest length of stay are conditions originating in the newborn period: prematurity, respiratory distress, and cardiac and circulatory birth defects.
• The average length of stay for a newborn with some type of complication is nearly 7 days. This is nearly 5 days longer than for newborns without complications.

How Expensive Are Children's Hospital Stays?

• The average total charge for children's hospital stays is half that of adult stays. This is due, in part, to the shorter length of stay for children and lower intensity of services. The average charge per day for children's stays in the hospital is about 30 percent of daily charges for adult stays.
• The average total charge for hospitalizations for pediatric illness is about $11,000, approaching the average total charge for adult stays ($15,000).
• Total charges for complicated newborn stays average $13,600, compared to $1,700 for an uncomplicated newborn stay.
• The most expensive condition nationally is also the most common reason for children's stays in the hospital—being born. Nationally, over $17 billion dollars are charged for newborn hospital stays, most of which are uncomplicated.
• Conditions identified in the neonatal period are among the most expensive diagnoses for all children—prematurity, cardiac and circulatory birth defects, birth defects, respiratory distress syndrome and other neonatal respiratory problems, accounting for $4.6 billion in charges or 10 percent of the total dollars spent on hospital stays for children and adolescents.
• Three respiratory problems—pneumonia, acute bronchitis, and asthma—are responsible for nearly $3 billion in charges or nearly 7 percent of the total U.S. health care bill for children and adolescents.

What Percentage of Hospital Resource Use Is Attributable to Children Compared With Adults?

• Care for children and adolescents accounts for about 18 percent of all hospital stays, about 13 percent of all days in the hospital, and about 9 percent of total hospital charges.
• Newborns and neonates account for about 8 percent of all days in the hospital. Pediatric illnesses account for about 5 percent of all hospital days. Adolescent pregnancies account for less than 1 percent of all hospital days.

Who Is Billed for Children's Hospital Stays?

• About 39 percent of children's hospitalizations are billed to Medicaid compared with only 17 percent of adult stays.
• For both children and adults admitted to the hospital in 2000, 5 percent of hospital stays were uninsured. This is similar to the percent of hospital stays that were uninsured in 1997.
• Medicaid is billed for about one-third of uncomplicated newborn stays compared with 58 percent billed to private insurance, but for babies readmitted to the hospital, similar proportions of hospital stays are billed to Medicaid (47 percent) and private insurance (46 percent). Thus, Medicaid bears a larger burden of complicated newborn and neonatal care than private insurance.
• Over two-thirds of all adolescent admissions for pregnancy or childbirth are billed to State Medicaid programs and one-fourth are billed to private insurance. Conversely, only one-fourth of hospital stays for pregnant 25- to 34-year olds are billed to Medicaid and about two-thirds are billed to private health insurance. Medicaid bears a larger burden of care for pregnant adolescents than private insurance.
• Private insurance is billed for 56 percent of routine hospital admissions, while Medicaid is billed for 37 percent. In contrast, nearly equal percentages of hospital admissions through the ED are billed to private insurers as to Medicaid.
• Children and adolescents enrolled in Medicaid are 3 times more likely to be admitted for two ambulatory care sensitive conditions—asthma and gastroenteritis—than are privately insured children. These are conditions for which timely access to quality outpatient care potentially can prevent the need for hospitalization.
• Under age 3, 4 to 5 out of 1,000 children are admitted for asthma. Among children 6 to 12, 1 out of 1,000 children are admitted to the hospital for asthma.
• Pregnant adolescents with no health insurance coverage are the least likely to deliver by C-section, which raises the question about the influence of insurance status on choice of procedures.

What Happens When Children Are Discharged From the Hospital?

• Less than one-half of 1 percent of children's hospital admissions end in death compared to nearly 3 percent of adult hospital admissions.
• Overall, about 17,100 neonates in 2000 died in hospitals within 30 days of birth. While death is extremely rare for newborns without complications, over 1 percent of newborns with a complicating diagnosis die during their newborn hospitalization.
• Compared to children, adults are nearly 3 times more likely to be discharged to home health care and 18 times more likely to be discharged to long-term care. Because the demand for post-hospital specialized care can be relatively infrequent for children, high quality post-hospital pediatric care may be limited in many areas.

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Why Are Children and Adolescents Hospitalized?

• Hospital stays for children and adolescents (0 to 17 years old) can be divided into 3 groups:
  • Neonatal conditions (stays for newborns and infants 30 days of age or less).
  • Pediatric illness (stays for ill children and adolescents over 30 days of age).
  • Adolescent pregnancy (stays during which the patient was pregnant or gave birth).
• Almost two-thirds of all childhood hospitalizations are for neonatal conditions; the vast majority of these stays (approximately 95 percent) are for the birth of infants in the hospital.
• About a third of hospital stays for children are for pediatric illnesses besides neonatal care and adolescent pregnancy.
• Adolescent pregnancy is an important reason for hospitalizations before 18 years of age—adolescent pregnancy accounts for 3 percent of all pediatric hospitalizations or nearly 9 percent of non-neonatal hospitalizations.

Select Figure 1 (4 KB), Children's Hospital Stays, by Type.

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At What Ages Are Children Most Likely to be Hospitalized?

How Old Are Patients in U.S. Hospitals?

• In 2000, children and adolescents accounted for 6.3 million hospital stays (18 percent); adults accounted for approximately 30.0 million hospital stays (82 percent).
• Children younger than 1 year comprise only 1 percent of the U.S. population, but they account for approximately 13 percent of all hospital stays. The vast majority of these stays are newborn infants.
• Children and adolescents 1 to 17 years old represent 24 percent of the population, but they account for only 5 percent of hospital stays.
• People between 18 and 44 years old represent nearly 40 percent of the population in the U.S., yet this group comprises only about one fourth of all hospital stays.
• Adults 65 years and older represent only about 13 percent of the total U.S. population, but they account for well over 1 in 3 of all hospital stays (35 percent).

Select Figure 2 (9 KB), Hospital Stays and U.S. Population, by Age.

At What Ages Are Children Most Likely To Be Hospitalized?

• Of all pediatric discharges from U.S. hospitals, most are for neonates, 30 days of age or younger (72 percent). Discharges for this group alone outnumber discharges for all other pediatric age groups combined by almost 3 to 1.
• Neonates account for 7 times more hospital stays than any other pediatric age group.
• The next closest age group—a distant second—is children 13 to 17 years of age who account for 11 percent of hospital stays for children and adolescents.

Select Figure 3 (4 KB), Percentage of Children's Hospital Stays, by Age Group.

At What Age Are Adolescents Admitted to the Hospital for Pregnancy and Delivery?

• By the teen years, pregnancy becomes a significant reason for hospitalization for adolescent girls. There are approximately 20 hospital stays for pregnancy or childbirth per 1,000 13-to 17-year old girls in the U.S.
• About 2,100 hospital admissions for pregnancy and childbirth were for children 12 years and younger.
• From age 14 to 16, the number of hospital admissions for pregnancy approximately triples with each year of age.

Select Figure 4 (7 KB), Hospital Stays for Pregnant Adolescents, by Age.

How Do Admission Rates for Pregnancy and Delivery Among Females 17 and Younger Compare With Those of Older Women?

• Compared with adolescent hospital stays for pregnancy and delivery, there are about 8 times as many hospital stays for pregnancy and delivery for women age 18 to 24 and about 12 times as many stays for women age 25 to 34.
• Nearly 2 percent of all adolescent girls age 13 to 17 deliver each year compared to about 10 percent of women age 18 to 34. The annual delivery rate for adolescent girls age 13 to 17 is only slightly lower than the annual delivery rate of women age 35 to 44 (about 2.5 percent).

Select Figure 5 (7 KB), Number of Maternal Hospital Stays and Delivery Rates, by Age.

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How Do Children Get Admitted to the Hospital?

How Do Children Get Admitted to the Hospital Compared With Adults?

• More than 2 out of 3 hospital admissions for children are classified as routine, non-emergency admissions compared with less than half of adult admissions. Most children's admissions are babies born in the hospital.
• Excluding neonates and adolescent pregnancy, 45 percent of admissions for pediatric illness are routine and 44 percent are through the emergency department—numbers that are very similar to those for adults.

Select Figure 6 and 7 (23 KB), Hospital Stays by Source of Admission.

What Is the Relationship Between Household Income and Admission to the Hospital Through the Emergency Department?

• Children and adolescents from low income areas admitted to the hospital are more likely to enter the hospital through the emergency department (ED) compared with children and adolescents from higher income areas.
• Nearly one-fourth of all hospital admissions for children and adolescents from low income areas (median household income less than $25,000) are through the ED. As area-level household income increases, admission rates through the ED decrease.
• Excluding neonates and pregnant adolescents, over half of hospital admissions for children and adolescents from low income areas (household income less than $25,000) are through the ED—25 percent higher than children from higher income areas.

Select Figure 8 (10 KB), Household Income and Hospital Admissions Through the Emergency Department.

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What Are the Reasons for Children's Hospital Stays?

What Are the Most Common Reasons for Hospital Stays Among Neonates?

• Neonates are infants 30 days of age or less. The overwhelming majority (95 percent) of hospitalizations in the neonatal period are for newborn infants.
• The most common neonatal conditions that require extension of the newborn hospital stay or return to the hospital are conditions associated with bilirubin metabolism (hemolytic jaundice), prematurity (including respiratory distress), respiratory problems, infections, and congenital anomalies.
• Five of the top 10 most common diagnoses for neonates are for either respiratory problems or infections.

Select Table 1, Most Common Reasons for Hospital Stays Among Neonates.

How Do Newborns Compare With Infants Admitted to the Hospital After Birth?

• A vast majority of hospitalizations for babies 30 days old or younger are newborns, born during that hospital stay. Only 2 percent of all hospitalizations in the first 30 days of life represent infants coming back to the hospital for some complication, such as jaundice and bronchitis.
• Over two-thirds of all babies (about 71 percent) are born and discharged from the hospital without any clinical problems or complicating diagnoses.

Select Figure 9 (9 KB), Hospital Stays for Newborn and Readmitted Neonates.

What Are the Most Common Pediatric Illnesses, by Body System?

Excluding neonates and pregnant adolescents:

• Respiratory conditions, including asthma, pneumonia, and bronchitis, are the most common illnesses associated with pediatric hospitalizations.
• Digestive illnesses, including gastroenteritis, are the second most common pediatric conditions.
• About 7 percent, or 1 in 14 pediatric hospital stays are for mental disorders.

Select Figure 10 (7 KB), Pediatric Illnesses, by Body System.

What Are the Most Common Specific Reasons for Hospitalization Among Children and Adolescents Admitted for Illness?

Excluding neonates and pregnant adolescents:

• Three of the top 10 diagnoses in children and adolescents are respiratory diseases—pneumonia, asthma, and bronchitis.
• Pneumonia accounts for 8 percent and asthma accounts for 7 percent of all stays for pediatric illness.
• Affective disorders (primarily depression) are one of the top 10 reasons for hospitalization among children and adolescents with illness, accounting for 74,000 hospital stays in 2000.

Select Table 2, Most Common Specific Reasons for Hospitalizations Among Children and Adolescents Admitted for Illness.

What Are the Most Common Reasons for Hospitalization for Pediatric Illness by Age Group, Compared With Adults?

The most common reasons for hospitalization for pediatric illness by age group (excluding neonates and pregnant adolescents) compared with adults (excluding women with maternal conditions) follow.

• Infectious disease dominates the most common reasons for hospitalizations for pediatric illness throughout early childhood. Infections account for:
  • 6 of the top 10 diagnoses for infants.
  • 6 of the top 10 diagnoses for 1 to 2 year olds.
  • 5 of the top 10 diagnoses for 3 to 5 year olds.
• Respiratory diseases—asthma and pneumonia—are among the top 10 reasons for hospitalizations among all pediatric age groups in the hospital for illness.
• For children in the 3 to 5 and 6 to 12 age groups, asthma is the most common reason for hospitalization.
• Pneumonia is the most common reason for hospitalization among children 1 to 2 years. It is the second most common reason for hospitalization for children less than 1 year old and children 3 to 5 years old.
• Appendicitis is the second most common reason for hospitalization for children and adolescents 6 to 17 years old.
• In 2000, over 70,000 children's hospitalizations were for affective and other mental disorders. By age 13 to 17, affective disorders are the most common cause of hospitalization.
• For adolescents 13 to 17, injuries, including leg fractures, medication poisonings and head injuries, are among the most common reasons for hospitalization.
• While pneumonia and affective disorders rank in the top 10 for both pediatric and adult hospitalizations, most of the other diagnostic categories do not overlap, demonstrating the unique nature of hospital care for children.

Select Table 3, Most Common Reasons for Hospitalization for Pediatric Illness by Age Group Compared With Adults.

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