What Are the Reasons for Children's Hospital Stays? (continued)
How Are Hospitalized Infants and Children Affected by Potential Patient Safety Problems Compared With Adults?*
- One measure of the quality of hospital care for children and adolescents is the rate of patient safety events. Potential patient safety problems can be identified using hospital data and the AHRQ Patient Safety Indicators (PSIs).
- The rates of potential patient safety problems for children (excluding newborns and maternal cases) are comparable to rates for adults. Some potential patient safety problems are more common among children, for example, 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 severe obstetrical lacerations and trauma (e.g., lacerations of vagina, rectum and bladder) are seen among girls age 10 to 17, compared with older women giving birth. Compared with women age 25 to 34, adolescents 10 to 17 are about 35 percent more likely to experience severe obstetrical lacerations and trauma.
Select for Figure 11 (5 KB), Rates of Complications of Anesthesia, by Age.
Select for Figure 12 (5 KB), Rates of Iatrogenic Pneumothorax, by Age.
Select for Figure 13 (5 KB), Rates of Postoperative Hemorrhage or Hematoma, by Age.
Select for Figure 14 (5 KB), Rates of Postoperative Pulmonary Embolus or Deep Vein Thrombosis, by Age.
Select for Figure 15 (8 KB), Rates of Severe Obstetric Lacerations and Trauma, by Age.
*The Agency for Healthcare Research and Quality (AHRQ) through the Stanford University-University of California Evidence-base Practice Center has developed a set of Patient Safety Indicators (PSIs) that can be used with the pediatric population. Additional information on current AHRQ PSIs and software can be found at: http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm.
What Are the Most Common Reasons for Pregnancy-Related Hospital Stays, When No Delivery Occurs?
- Some pregnant girls and women are admitted to the hospital for treatment of complications of pregnancy and no delivery occurs during that stay, because the complication has been successfully treated or early labor has been prevented.
- Pregnant adolescents hospitalized without delivery are more likely to be diagnosed with early or threatened labor and urinary tract infection than their older counterparts.
- Conversely, older women who are admitted for pregnancy but do not deliver are more likely to be diagnosed with hypertension, ectopic pregnancy, hemorrhage, and diabetes than are younger women.
- Nearly 24 percent of adolescents admitted for pregnancy without delivery are in the hospital because of early or threatened labor, compared with about 19 percent among women 25 to 34 and 13 percent among women 35 to 44.
- Ectopic pregnancy (in which the fetus grows outside the uterus) occurs in only 2 percent of adolescent hospital stays, compared with 7 percent of pregnancy stays for women 25 to 34 and 9 percent of pregnancy stays for women 35 to 44.
- Similarly, 2 percent of pregnancy admissions for adolescents are for hemorrhage during pregnancy, compared with 4 percent among women 25 to 34 and 5 percent among women 35 to 44.
Select Table 4, Most Common Reasons for Pregnancy-Related Hospital Stays When No Delivery Occurs.
What Are the Most Common Reasons for Pregnancy-Related Hospital Stays During Which a Baby is Delivered?
- Trauma to the perineum and vulva includes damage from tearing the tissue around the vagina during labor and can result from instruments used during labor or a tear during delivery. Roughly equal percentages (approximately 20 percent) of deliveries among women under 34 years experience this condition.
- Compared with older women, adolescent deliveries are more likely to have diagnoses of early or threatened labor, hypertension complicating pregnancy, and excess amniotic fluid.
- Conversely, adolescent deliveries are less likely to be diagnosed with malposition of the fetus, and previous C-section.
Select Table 5, Most Common Reasons for Pregnancy-Related Hospital Stays During Which a Baby Is Delivered.
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What Procedures Do Children Receive in the Hospital?
What Are the Most Common Procedures Received by Neonates?
- Male circumcision is performed on about 30 percent of all births, making this elective procedure the most common one for all neonates. About 59 percent of all male newborns and 86 percent of all male newborns without a complicating diagnosis receive a circumcision.
- Prophylactic vaccinations and inoculations, primarily hepatitis B vaccinations, are the second most common procedure.
- Approximately 6 percent of all newborns are intubated at some point during their neonatal course, 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.
Select Table 6, Most Common Procedures Received by Neonates.
What Are the Most Common Procedures Performed for Pediatric Illness?
Excluding neonates and pregnant adolescents:
- The most common procedures performed on children and adolescents are diagnostic and supportive procedures including spinal taps (used to rule out meningitis) and respiratory therapy treatments (used for conditions such as asthma, pneumonia, and bronchitis).
- Appendectomy is the most common surgical procedure performed on non-neonatal, non-maternal children and adolescents, occurring over 238 times per day in the U.S.
Select Table 7, Most Common Procedures Performed for Pediatric Illness.
How Do Adolescent C-section Rates Compare With Those for Older Women?
- 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 18 to 24, 24 percent of women 25 to 34, and 32 percent of women 35 to 44 deliver their babies in this manner.
Select Figure 16 (7 KB), C-section Rates, by Age.
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How Long Do Children Stay in the Hospital?
How Does Length of Stay for Children Differ From Adults?
- On average, children's stays in the hospital are 29 percent shorter than adult stays.
- Newborns and neonates stayed in the hospital an average of 3.4 days.
- Children admitted for pediatric illness have the longest mean length of stay for all pediatric subgroups at 3.9 days.
- Pregnant adolescents have the shortest mean length of stay at 2.5 days.
Select for Figures 17 and 18 (14 KB).
Which Diagnoses Have the Longest Lengths of Stay for All Children?
- Three of the top 10 diagnoses with the longest lengths of stay are related to mental health: pre-adult mental disorders, anxiety and personality disorders, and affective disorders. (These discharges are from short-term hospitals, excluding long stay, psychiatric, and drug abuse treatment facilities.)
- 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.
Select Table 8, Diagnoses With Longest Lengths of Stay for All Children.
How Long Are Newborn Hospital Stays?
- The average length of stay for a newborn with a complicating diagnosis is nearly 7 days, compared with 2 days for newborns without a complicating diagnosis.
- Newborns who have some type of complicating diagnosis account for about 60 percent of all hospital days for newborns.
Select Figure 19 (7 KB), Length of Newborn Hospitalization.
How Expensive Are Hospital Stays for Children Compared With Adults?
- The average total charge for hospital stays for children is half that of adult stays, due to the shorter length of stay and lower intensity of services for children.
- Average total charges for a neonatal hospitalization are comparable to the average total charges for an adolescent pregnancy hospital stay.
- Average total charges for hospitalization for a pediatric illness are approximately twice the charges for either neonatal or adolescent pregnancy—over $11,000—approaching the average charge of hospital stays for adults.
- The average charge per day for a child's stay in the hospital is about 30 percent of the charge per day for an adult stay. However, the charge per day for pediatric illness ($2,900) is nearly the same as charges for adult stays ($3,100).
Select for Figures 20 and 21 (15 KB).
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How Expensive Are Children's Hospital Stays?
How Expensive Are Hospital Stays for Newborns?
- The average charge for a complicated newborn hospital stay is $13,600, compared with $1,700 for an uncomplicated newborn stay.
- Charges for complicated newborn stays average about $2,000 per day compared to $900 per day for normal newborn stays.
Select Figure 22 (9 KB), Charges for Newborn Hospitalization.
What Are the Most Expensive Diagnoses for Children and Adolescents?
- 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.
Select Table 9, Most Expensive Diagnoses for Children and Adolescents.
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How Does Children's Resource Use Compare With Adults?
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 illness accounts for about 5 percent of all hospital days. Adolescent pregnancy accounts for less than 1 percent of all hospital days.
- Among all children and adolescents, neonatal conditions account for 48.7 percent of hospital charges, pediatric illnesses account for 48.8 percent, and adolescent pregnancies accounts for less than 3 percent.
- In total, children use 10 to 20 percent of all hospital resources compared to the 80 to 90 percent used by adults, as measured by hospital stays, length of hospitalization, and total charges.
Select Figure 23 (15 KB), Total Hospital Resource Use.
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Who Is Billed for Children's Hospital Stays?
Who Is Billed for Children's Hospital Stays? How Does This Compare to Adult Stays?
- About half of both pediatric and adult patients have private health care coverage: 54 percent of children and adolescents in the hospital are privately insured while 47 percent of adults are privately insured.
- About 39 percent of children's hospitalizations are billed to Medicaid—a joint State and Federal Government program.
- Nearly half of adult stays are billed to some type of government program—17 percent of adult stays are billed to Medicaid and 32 percent of adult stays are billed to the Federal Medicare program.
- For both children and adults admitted to the hospital in 2000, nearly 5 percent of hospital stays were uninsured. This is similar to the percent of hospital stays that were uninsured in 1997.*
* Discharge data, such as HCUP, do not provide the details on enrollment in State Children's Health Insurance Programs (SCHIP).
Select for Figures 24 and 25 (8 KB).
Who Is Billed for Neonatal Hospital Stays?
- About 34 percent of uncomplicated newborn hospital stays are billed to Medicaid, while nearly 58 percent are billed to private insurance.
- Nearly 40 percent of complicated newborn stays are billed to Medicaid, while the share billed to private insurance is over 52 percent.
- For neonates readmitted in the first 30 days of life, the share billed to Medicaid is similar to private insurance. About 47 percent of all babies readmitted to the hospital are covered by Medicaid and 46 percent are covered by private insurance. Thus, Medicaid bears a larger burden of complicated newborn and neonatal care than private insurance.
Select Figure 26 (14 KB), Expected Payer for Neonatal Hospital Stays.
Who Is Billed for Pregnancy-Related Hospital Stays for Adolescents, Compared With Older Women?
- Over two-thirds of all adolescent admissions for pregnancy or childbirth are billed to State Medicaid programs. Private insurers are billed for one-fourth of these adolescent pregnancy stays and approximately 6 percent are uninsured.
- Conversely, only one-fourth of hospital stays for pregnant women 25 to 34 are billed to Medicaid and over two-thirds are billed to private health insurance. Four percent of stays for maternal cases in this age group are uninsured.
- Thus, compared with women 25 to 34, Medicaid bears a much larger burden of care for pregnant adolescents than private insurance.
Select Figure 27 (11 KB), Expected Payer for Pregnancy-Related Hospital Stays.
Who Is Billed for Children's Hospital Stays, by Source of Admission?
- Private insurance is billed for the majority of routine hospital admissions for children (56 percent). Medicaid covers over one-third of routine hospital admissions for children (37 percent).
- In contrast, approximately half of admissions that begin in the emergency department or another hospital are billed to private insurers and half are billed to Medicaid.
Select for Figures 28 and 29 (22 KB).
Who Is Billed for Ambulatory Care-Sensitive Conditions?*
Ambulatory care-sensitive (ACS) conditions are conditions for which timely access to quality outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. AHRQ through the Stanford University-University of California Evidence-base Practice Center has developed Prevention Quality Indicators (PQIs)** to identify ambulatory care sensitive conditions, including several pediatric-specific conditions—asthma and gastroenteritis.
- Children and adolescents of all ages were admitted to the hospital for ACS conditions, including asthma and gastroenteritis.
- Asthma is a common reason for children's hospital admission that is potentially preventable. In fact, 4 to 5 out of 1,000 children under age 3 were admitted for asthma in 2000. The hospital admission rate for asthma decreases among older children, but admissions are still high with 1 out of 1,000 6 to 12 year olds being admitted for asthma.
- Gastroenteritis is the most common ACS condition for infants less than 1 year old, being responsible for over 600 admissions per 100,000 children. This suggests that access to good outpatient services and early attention to gastroenteritis could prevent many hospitalizations of infants.
- Children and adolescents enrolled in Medicaid are 3 times more likely to be admitted for asthma and gastroenteritis than privately insured children and adolescents and 5 times more likely to be admitted for these potentially preventable conditions than uninsured children and adolescents. Thus, children and adolescents enrolled in Medicaid disproportionately require inpatient care for conditions that could be treated on an outpatient basis.
* Excludes neonates and pregnant adolescents.
** The AHRQ PQIs were designed to be used with readily available hospital administrative data. While national level statistics are presented in this Fact Book, they can be used to identify unmet health care needs in the community, monitor how well complications from a number of common conditions are being avoided in the outpatient setting, and compare performance of local health care systems across communities. More information on PQIs can be found at http://www.qualityindicators.ahrq.gov/data/hcup/prevqi.htm.
Select for Figures 30 and 31 (16 KB).
Who Is Billed for C-section Deliveries?
- Similar to older women age 18 to 34, pregnant adolescents covered by Medicaid are slightly more likely to deliver their babies by Cesarean section (C-section) than those with private insurance.
- 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.
Select Figure 32 (15 KB), Expected Payer for C-section Deliveries, by Age.
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What Happens When Children Are Discharged From the Hospital?
What Is the Discharge Status of Children Compared With Adults?
- Most discharges for children (94 percent) and adults (73 percent) are routine, that is, they are discharged to their homes without additional special medical care.
- Less than half of 1 percent of children's hospital stays end in death compared to nearly 3 percent of adult hospital stays.
- 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 a long-term care facility, such as a skilled nursing facility or rehabilitation center.
- Nationwide, 47,000 discharges require pediatric long-term care compared to 3.9 million adult long-term care placements. Similarly, 178,000 discharges for children require home health services compared to 2.1 million for adults.
Select for Figures 33 and 34 (15 KB).
What Is the Discharge Status of Neonates?
- About 2 percent of newborns without a complicating diagnosis have home health assistance in the post-partum period compared with about 5 percent of newborns with a complicating diagnosis and 4 percent of readmitted neonates.
- Six percent of newborns with a complicating diagnosis and readmitted neonates are transferred to another hospital.
- 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 and over 2 percent of readmitted neonates died during their stay.
Select Figure 35 (13 KB), Discharge Status of Neonates.
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Source of Data for This Report
The data presented in this report are drawn from the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership to build a multi-state health care data system. This partnership is sponsored by AHRQ and is managed by staff in AHRQ's Center for Delivery, Organization, and Markets.
HCUP is based on data collected by individual State data partners and provided to AHRQ by the State data partners. HCUP would not be possible without State data collection projects and their partnership with AHRQ.
For 2000, 29 State data organizations contributed their data to AHRQ where all data are edited and transformed into a uniform format. The uniform data in HCUP databases make possible comparative studies of health care services and the use and cost of hospital care, including:
- The effects of market forces on hospitals and the care they provide.
- Variations in medical practice.
- The effectiveness of medical technology and treatments.
- Use of services by special populations.
HCUP includes 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 care and psychiatric hospitals are excluded as are substance abuse treatment facilities.
HCUP includes several sets of inpatient databases for health services research. The 2000 State Inpatient Databases (SID) covers inpatient care in community hospitals, as defined by the American Hospital Association (AHA), in 29 States and include nearly 80 percent of all hospital discharges in the U.S. The 2000 Nationwide Inpatient Sample (NIS) includes all discharges from a sample of about 1,000 hospitals drawn from the SID, selected to approximate a national sample. The 2000 Kids' Inpatient Database (KID) is a sample of discharges for children and adolescents, 20 years and younger, drawn from the SID developed from 27 State data organizations.
This report is based on data from the 2000 KID and the 2000 NIS. The KID is a stratified probability sample of pediatric discharges which includes 10 percent of all uncomplicated in-hospital births and 80 percent of other pediatric discharges from all hospitals in the sampling frame. The KID was designed to enable studies of relatively uncommon conditions and procedures among children and adolescents and provides the capacity for weighted national estimates. Sampling weights are based on key hospital characteristics: region, ownership and control, rural or urban location, teaching status, size of the hospital, and whether the hospital is a children's hospital, as defined by the National Association of Children's Hospitals and Related Institutions (NACHRI).
The subset of data from the 2000 KID used in this Fact Book includes 2.0 million discharge records for children 17 years and younger that were weighted to represent all pediatric discharges for children in this age range in the U.S. (6.3 million discharges). The 2000 NIS was used to provide comparisons with the adult population (18 years and older). The NIS approximates a 20-percent sample of U.S. community hospitals. The 2000 NIS includes information from 6.1 million discharges that were weighted to obtain estimates that represent the total number of inpatient hospital discharges in the United States (30 million discharges).
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Methods
The Clinical Classifications Software (CCS), developed by AHRQ, has been used throughout this Fact Book to aggregate diagnosis and procedure codes into a limited number of categories. Diagnoses and procedures recorded on hospital discharge records are coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Fifth Edition. Although ICD-9-CM may be used to provide descriptive statistics, aggregating similar diagnoses or procedures into clinically meaningful categories, such as the CCS, can be more helpful. For some CCS categories, details are provided using individual ICD-9-CM procedure codes.
The groupings for children's hospital stays were based on age, gender, principal (or first-listed) CCS categories, diagnostic related group (DRG) codes, and major diagnostic category (MDC) codes. Hospital records for neonatal conditions were identified as those with DRG codes 385-391, MDC code 15, or age calculated as less than or equal to 30 days. Hospital records for pediatric illness were identified as those with a calculated age greater than or equal to 31 days and a principal diagnosis unrelated to neonatal and maternal conditions. Hospital records for maternal conditions were identified as those with a CCS code between 176-196, MDC code 14, and a recorded gender of female.
Frequencies and rankings of diagnoses are based on the principal diagnosis. Frequencies and rankings of procedures are based on all-listed procedures, that is, all procedures listed on the discharge record. The unit of analysis is the inpatient stay, rather than the patient. All discharges from the KID and the NIS have been weighted to produce national estimates.
Total charges in HCUP data are the amount the hospital charged or billed for the entire hospital stay and do not reflect charges for individual procedures. Charges do not necessarily reflect reimbursements or the costs of actually producing the service (and are generally higher than costs). Hospital charges do not include professional (physician) fees. Charge data were present for 98 percent of all discharges.
Because the 2000 KID is limited to inpatient hospital data, conditions treated in outpatient settings or procedures performed in outpatient or ambulatory care settings are not reflected here.
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For More Information
More information regarding HCUP data is available at www.ahrq.gov/data/hcup, as well as on the HCUP User Support Web site at www.hcup-us.ahrq.gov. More information on the AHRQ Quality Indicators is available at http://www.qualityindicators.ahrq.gov/.
Additional descriptive statistics can be viewed through HCUPnet (http://hcupnet.ahrq.gov/), a Web-based tool providing easy access to information on hospital stays.
KID Data Currently Available Include:
2000
1997
NIS Data Currently Available Include:
2001
2000
1999 (PB 2002-500020)
1998 (PB 2001-500092)
Release 6, 1997 (PB 2000-500006)
Release 5, 1996 (PB 99-500480)
Release 4, 1995 (PB 98-500440)
Release 3, 1994 (PB 97-500433)
Release 2, 1993 (PB 96-501325)
Release 1, 1988-1992 (PB 95-503710)
NIS and KID data can be purchased for research through the HCUP Central Distributor sponsored by AHRQ: Social and Scientific Systems, Inc., telephone: 866-556-4287 (toll-free), fax: 301-628-3201 or E-mail: hcup@s-3.com.
Price of the NIS data is $322 for Release 1; $160 per year for 1993 to
1999; and $200 for 2000 and 2001. Price of the KID data is $220 for
each year. All prices may be higher for customers outside the United
States, Canada, and Mexico.
Previously published HCUP Fact Books in this series are available from the AHRQ Publications Clearinghouse by calling 800-358-9295 (toll free). Order by title and publication number.
Other HCUP Fact Books currently in development include preventable hospitalizations, hospital care of the uninsured, and hospitalizations for mental health and substance abuse conditions. Information on future availability will be posted on the AHRQ Web site.
Impact Case Studies
AHRQ is always looking for ways in which AHRQ-funded research, products, and tools have changed people's lives, influenced clinical practice, improved policies, and affected patient outcomes. Impact case studies describe AHRQ research findings in action. These case studies have been used in testimony, budget documents, and speeches. If you are aware of any impact AHRQ-funded research or products, such as HCUP, have had on health care policy, clinical practice, or patient outcomes, please let us know.
Healthcare Cost and Utilization Project (HCUP)
Agency for Healthcare Research and Quality
Phone: 866-290-HCUP
E-mail: hcup@ahrq.gov
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AHRQ Publication No. 04-0004
Current as of October 2003
Internet Citation:
Care of Children and Adolescents in U.S. Hospitals. HCUP Fact Book No. 4. AHRQ Publication No. 04-0004, October 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/data/hcup/factbk4/factbk4.htm
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