Elsevier

Injury

Volume 49, Issue 10, October 2018, Pages 1781-1786
Injury

Unwarranted clinical variation in the care of children and young people hospitalised for injury: a population-based cohort study

https://doi.org/10.1016/j.injury.2018.07.009Get rights and content

Abstract

Introduction

Injury is a leading cause of death and disability among children and young people. Recovery may be negatively affected by unwarranted clinical variation such as representation to an emergency department (ED), readmission to a hospital, and mortality. The aim 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).

Materials and Methods

Retrospective population-based cohort study using linked ED, hospital, and mortality data of all children and young people aged ≤25 years who were injured and hospitalised during 1 January 2010–30 June 2014 in NSW. Unwarranted clinical variation across providers was examined using three indicators. That is, for each hospital that treated ≥100 cases per year, risk standardised ratios were calculated with 95% and 99.8% confidence limits using the number of observed and expected events of (1) representations to ED within 72 h, (2) unplanned readmissions to hospital within 28 days, and (3) all-cause mortality within 30 days.

Results

There were 189,990 injury-related hospitalisations of children and young people. Of these, 4.4% represented to an ED, 8.7% were readmitted to hospital, and 0.2% died. Of the 45 public hospitals that treated ≥100 cases per year, higher than expected rates of ED representations, hospital readmissions, and mortality were observed in eleven, six, and two hospitals, respectively.

Conclusion

The rates of ED representations, hospital readmissions, and mortality among children and young people hospitalised for injury in NSW were similar to the rates reported in other countries. However, unwarranted clinical variation across public hospitals was observed for all three indicators. These findings suggest that by improving routine follow-up support services post-discharge for children and young people and their families, it may be possible to reduce unwarranted clinical variation and improve health outcomes.

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

References (39)

  • B.W. Jack et al.

    A reengineered hospital discharge program to decrease rehospitalization: a randomized trial

    Ann Intern Med

    (2009)
  • J. Mainz

    Defining and classifying clinical indicators for quality improvement

    Int J Qual Health Care

    (2003)
  • A.R. Gagliardi et al.

    Establishing components of high-quality injury care: focus groups with patients and patient families

    J Trauma Acute Care Surg

    (2014)
  • Australian Bureau of Statistics

    3101.0 - Australian Demographic Statistics, Jun 2016

    (2016)
  • Centre for Health Record Linkage

    Master linkage key quality assurance

    (2012)
  • World Health Organization

    Programming for adolescent health and development

    Technical report series 886

    (1999)
  • Bureau of Health Information

    Spotlight on measurement: measuring return to acute care following discharge from hospital

    (2017)
  • L.O. Hansen et al.

    Interventions to reduce 30-day rehospitalization: a systematic review

    Ann Intern Med

    (2011)
  • C.M. Miller et al.

    Chronic conditions and outcomes of pediatric trauma patients

    J Trauma Acute Care Surg

    (2013)
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