Unwarranted clinical variation in the care of children and young people hospitalised for injury: a population-based cohort study
Introduction
Injury is a leading cause of death and disability among children and young people worldwide [1,2]. The most common mechanisms of injury-related death among young people are road injuries, self-harm, interpersonal violence, and falls [1]. Depending on the type and severity of the injury, a portion of injured children and young people will be hospitalised to receive treatment.
During hospitalised treatment for an injury, a young person’s recovery may be negatively affected by medical complications that could lead to representation to emergency department (ED), unplanned readmission to hospital, and mortality [3,4]. For instance, inadequate transfer of patient data to primary care providers may lead to outpatient clinicians lacking critical information (e.g., test results) and patients not receiving scheduled evaluations and follow-up tests [5]. In some cases, young patients may not be adequately prepared at discharge from hospital (e.g., limited understanding of their principal diagnoses and discharge medications)5.
In a world with limited resources and increasing demands for accountability, evaluating the quality of care has become increasingly important to providers, regulators, and the public [6,7]. There is a need to monitor healthcare quality indicators to identify where unwarranted clinical variation is occurring, design preventive measures and quality improvement strategies, and set priorities for policy or strategic planning [7]. Monitoring indicators also allows for comparing outcomes over time and evaluate the impact of quality improvement efforts [7]. The extent of unwarranted clinical variation across providers of care of children and young people who were injured and hospitalised in Australia has not been identified.
The overall objective of this study was to examine unwarranted clinical variation across providers of care of children and young people who were hospitalised for injury in New South Wales (NSW), Australia, using three indicators: (1) representations to an ED within 72 h after admission; (2) unplanned readmissions to hospital within 28 days after discharge; and (3) all-cause mortality within 30 days after hospital admission.
Section snippets
Study design
This was a retrospective population-based cohort study of children and young people aged ≤25 years who had an injury-related hospital admission in NSW during 1 January 2010–30 June 2014. NSW is the most populous state in Australia, accounting for almost one third of the country’s 24 million residents (7.6 million), including an estimated 2.5 million children and young people aged ≤25 years [8].
Data sources and linkage
This cohort study used linked ED presentation, hospital admission, and mortality data. The ED
Results
From 1 January 2010 to 30 June 2014, there were 189,990 injury-related hospitalisations of children and young people aged ≤25 years in NSW, giving an age-standardised injury hospitalisation rate of 1713 per 100,000 population (95%CI: 1705–1721). Males accounted for approximately two-thirds (66.2%) of injury hospitalisations and those aged 15–25 years accounted for more than half (54.4%) of young people hospitalised (Table 2). Overall, 4.4% of patients represented to an ED within 72 h, 8.7% of
Discussion
This study is amongst the first to use linked health data to document the extent of unwarranted clinical variation across providers of care of children and young people aged ≤25 years. It is important to consider injury-related hospitalisations among children and young people because injury remains a leading cause of long-term disability in this age group [19,20], with significant impact on families and community networks [21]. Overall, 4.4% of young people with an injury-related
Conclusion
The rates of ED representations, hospital admissions, and mortality among children and young people hospitalised for injury in NSW appear to be similar to the rates reported in other countries. However, for each of the three indicators there is noticeable unwarranted clinical variation across public hospitals. It is likely that a substantial portion of unwarranted clinical variation can be prevented by implementing standardised and effective interventions before, during, and after discharge
Conflict of interest
The authors declare that they have no competing interests.
Acknowledgements
The authors wish to thank the NSW Ministry of Health for providing access to the Admitted Patient Data Collection, the NSW Registry of Births, Deaths and Marriages for providing access to mortality data, and the Centre for Health Record Linkage for conducting the record linkage. The authors would also like to thank Dr Marcia Schmertmann for generating the regression models and Hsuen P. Ting at the Australian Institute of Health Innovation for technical assistance with the funnel plots. This
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