Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

Clinical Characteristics of Avoidable Patient Transfers for Suspected Pediatric Appendicitis

INTRODUCTION

Pediatric surgical care is becoming increasingly regionalized, often resulting in limited access. Interfacility transfers pose a significant financial and emotional burden to when they are potentially avoidable. Of transferred patients, we sought to identify clinical factors associated with avoidable transfers in pediatric patients with suspected appendicitis.

METHODS

We performed a single-center retrospective study at an academic tertiary referral children's hospital in an urban setting. We included children who underwent interfacility transfer to our center with a transfer diagnosis of appendicitis from July 1, 2021 to June 30, 2023. Encounters were designated as either an appropriate transfer (underwent appendectomy) or an avoidable transfer (did not undergo appendectomy). Encounters treated nonoperatively for complicated appendicitis were excluded. Bivariate analysis was performed using Mann-Whitney test and chi-square tests.

RESULTS

A total of 444 patients were included: 71.2% were classified as appropriate transfers and 28.8% as avoidable transfers. Patients with avoidable transfer were younger compared to those in the appropriate transfer cohort (median age 9 y, interquartile range: 7-13 versus 11 y, interquartile range: 8-14; P < 0.001). Avoidable transfers less frequently presented with the typical symptoms of fever, migratory abdominal pain, anorexia, and nausea/emesis (P = 0.005). Avoidable transfers also reported shorter symptom duration (P = 0.040) with lower median white blood cell count (P < 0.001), neutrophil percentage (P < 0.001), and C-reactive protein levels (P < 0.003). Avoidable transfers more frequently underwent repeat imaging upon arrival (42.9% versus 12.7%, P < 0.001).

CONCLUSIONS

These findings highlight the importance of clinical history in children with suspected appendicitis. Younger patients without typical symptoms of appendicitis, those with a shorter duration of symptoms, and lower serum inflammatory markers may benefit from close observation without transfer.

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BACKGROUND

Acute pediatric respiratory illness is one of the most common reasons for emergency department(ED) transfer however few studies have examined predictors of potentially avoidable ED transfer(PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness.

METHODS

Cross-sectional analysis of 8,402,577 visits for patients <17 years from 2018-2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a three-level generalized linear mixed model with adjustment for patient and hospital covariates.

RESULTS

Among 4,409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits(n=472, 42.0%). In the multivariable model, likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09 -3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes(OR 0.48 95% CI 0.26-0.88).

CONCLUSIONS

Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower three quartiles of pediatric volume.

Outcome of interhospital pediatric foreign body transfers

BACKGROUND

Children with foreign bodies are often transferred from general emergency departments (EDs) to children's hospitals for optimal management. Our objective was to describe the outcomes of interhospital pediatric foreign body transfers and examine factors associated with potentially avoidable transfers (PATs) in this cohort.

METHODS

We conducted a retrospective cohort study of children aged <18 years transferred to our hospital for the primary complaint of foreign body from January 1, 2020, to September 30, 2022. Data collected included demographics, diagnostic studies and interventions performed, and disposition. A transfer was considered a PAT if the patient was either discharged from the pediatric emergency department (PED), or from inpatient care within 24 h, did not require procedural sedation and any procedural intervention by a pediatric sub-specialist (other than a pediatric ED physician). Logistic regression analysis was performed to evaluate factors associated with PATs.

RESULTS

A total of 213 patients were analyzed based on eligibility criteria. The majority of patients were male (51.2%), pre-school age (59.2%), symptomatic (55.8%), and transferred from academic EDs (61%). Coins were the most common foreign bodies (30%), with the gastrointestinal tract (63.8%) being the most common location. Half of the non-respiratory and non-gastrointestinal foreign bodies were successfully removed in the PED. Over half (57.3%) of the patients were discharged from PED. Operative intervention was required in 82 (38.5%) patients, most commonly for coins (50%). 41.8% of transfers were deemed PATs. Presence of foreign body in the esophagus or respiratory tract (OR: 0.071, 95% CI: 0.025-0.200), symptoms at presentation (OR: 0.265, 95% CI: 0.130-0.542), magnet ingestions (OR: 0.208, 95% CI: 0.049-0.886) and transfers from community EDs (OR: 0.415, 95% CI: 0.194-0.885) were less likely associated with PATs. Button battery-related transfers were more likely associated with an avoidable transfer (OR: 6.681, 95% CI: 1.15-39.91).

CONCLUSIONS

PATs are relatively common among children transferred to a children's hospital for foreign bodies. Factors associated with PATs have been identified and may represent targets for interventions to avoid low value pediatric foreign body transfers.

False Positive Rate Among Pediatric Appendicitis Patients Transferred to a Tertiary Children's Hospital

BACKGROUND

Many patients with suspected appendicitis are initially evaluated at outlying hospitals and then transferred to a tertiary care pediatric hospital for surgical management. We sought to evaluate whether diagnosis prior to transfer provides a reliable basis for direct admission to a pediatric surgery service.

METHODS

Patients transferred during calendar year 2018 with the principal diagnosis of acute appendicitis were compared based on the service accepting the patient: Emergency Department (ED) or Pediatric Surgery (PS). Data were evaluated using Student's t-tests.

RESULTS

Overall patient characteristics were consistent among ED and PS transfers. The number of patients accepted directly to PS underwent significantly more computed tomography (80.2% vs 54.1%, P = .0002). Despite diagnostic "confirmation" with cross-sectional imaging, 14.7% of patients admitted directly to PS were found to be false positives.

CONCLUSION

A significant proportion of patients referred to pediatric hospitals for appendicitis do not require admission or operation. A protocol which encourages cross-sectional imaging before PS evaluation may subject children to unnecessary radiation and still result in non-surgical admissions. Routine ED transfer allows PS evaluation, targeted imaging, and discharge for non-surgical patients. This approach decreases costs for the families whose children received a false positive diagnosis at a referring facility, while preserving inpatient bed availability.

Pediatric Patient Insurance Status and Regionalization of Admissions

BACKGROUND

Pediatric hospital care is becoming increasingly regionalized, and previous data have suggested that insurance may be associated with transfer. The aims of the study are to describe regionalization of pediatric care and density of the interhospital transfer network and to determine whether these varied by insurance status.

METHODS

Using the New York State ED Database and State Inpatient Database from 2016, we identified all pediatric patients and calculated regionalization indices (RI) and network density, overall and stratified by insurance. Regionalization indices are based on the likelihood of a patient completing care at the initial hospital. Network density is the proportion of actual transfers compared with the number of potential hospital transfer connections. Both were calculated using the standard State ED Database/State Inpatient Database transfer definition and in a sensitivity analysis, excluding the disposition code requirement.

RESULTS

We identified 1,595,566 pediatric visits (emergency department [ED] or inpatient) in New York in 2016; 7548 (0.5%) were transferred and 7374 transferred visits had eligible insurance status (Medicaid, private, uninsured). Of the transfers, 24% were from ED to ED with discharge, 28% from ED to ED with admission, 31% from ED to inpatient, 16% from inpatient to inpatient, and 1.2% from inpatient to ED. The overall RI was 0.25 (95% confidence interval [95% CI], 0.20-0.31). The overall weighted RI was 0.09 (95% CI, 0.06-0.12) and was 0.09 (95% CI, 0.06-0.13) for Medicaid-insured patients, 0.08 (95% CI, 0.05-0.11) for privately insured patients, and 0.08 (95% CI, 0.05-0.11) for patients without insurance. The overall network density was 0.018 (95% CI, 0.017-0.020). Network density was higher, and transfer rates were lower, for patients with Medicaid insurance as compared with private insurance.

CONCLUSIONS

We found significant regionalization of pediatric emergency care. Although there was not material variation by insurance in regionalization, there was variation in network density and transfer rates. Additional work is needed to understand factors affecting transfer decisions and how these patterns might vary by state.

Neighborhood Poverty and Distance to Pediatric Hospital Care

OBJECTIVE

To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care.

METHODS

This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity.

RESULTS

Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001).

CONCLUSIONS

Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.

Air ambulance retrievals of patients with suspected appendicitis and acute abdominal pain: The patients' journeys, referral pathways and appendectomy outcomes using linked data in Central Queensland, Australia

INTRODUCTION

Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer.

AIMS

describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity).

METHODS

Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy.

RESULTS

There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes.

CONCLUSIONS

Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy.

Pediatric Appendicitis Transfers From Adult Centers: Can Alvarado Scores Help Determine Which Patients Need a CT?

BACKGROUND

Acute appendicitis is possible for any pediatric patient with abdominal pain. At our tertiary care center, patients are transferred for surgical management with unnecessary or excessive imaging. We hypothesize that using the Alvarado score (AS) to clinically stage patients will identify patient groups that could be transferred prior to imaging.

METHODS

Retrospective review of pediatric patients transferred to our hospital for suspected appendicitis between 11/2020 and 3/2022 was performed. Variables collected included AS, imaging, and pathology. Alvarado score was calculated for each patient, and patients were grouped into low score, intermediate score, and high score groups. Positive predictive values (PPVs) were calculated for patients who underwent CT.

RESULTS

196 patients (age 2-17, 58% male) were transferred with suspected appendicitis. CT was obtained in 67% of patients and was not significantly different between groups. The low-score group (n=35) had a rate of appendicitis of 14% and the PPV of CT was 33%. The intermediate-score group (n = 74) had a rate of appendicitis of 62% and the PPV of CT was 88%. In the high-score group (n = 87), the rate of appendicitis was 92% and PPV of CT was 98%.

DISCUSSION

Our data show that patients with low, intermediate, and high AS undergo CT at similar rates. We suggest that patients in the low score and high score groups may not benefit from reflexive CT given the likelihood of appendicitis based on the Alvarado score. We propose that CT in these groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.

Socioeconomic Disadvantage and Distance to Pediatric Critical Care

OBJECTIVES

To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States.

DESIGN

Retrospective, cross-sectional study.

SETTING

Contiguous United States.

PATIENTS

Children less than 18 years as represented in the 2016 American Community Survey.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas.

CONCLUSIONS

In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.

Interfacility Transfers Among Patients With Complex Chronic Conditions

OBJECTIVES

To describe interfacility transfers among children with complex chronic conditions (CCCs) and determine if interfacility transfer was associated with health outcomes. We hypothesized that interfacility transfer would be associated with length of stay (LOS), receipt of critical care services, and in-hospital mortality.

METHODS

In this retrospective cohort study, we used data from the 2012 Kids' Inpatient Database. CCC hospitalizations were identified by International Classification of Diseases, Ninth Revision codes. Receipt of critical care services was inferred by using International Classification of Diseases, Ninth Revision diagnosis and procedure codes. We performed a descriptive analysis of CCC hospitalizations then determined if transfer was associated with LOS, mortality, or receipt of critical care services using survey-adapted quasi-Poisson or logistic regression models, controlling for hospital and patient demographics.

RESULTS

There were 551 974 non-birth hospitalizations with at least 1 CCC diagnosis code. Of these, 13% involved an interfacility transfer. Compared with patients with CCCs who were not transferred, patients with CCCs who were transferred in and ultimately discharged from the receiving hospital had an adjusted LOS rate ratio of 1.6 (95% confidence interval [CI]: 1.5-1.7; P < .001), were more likely to have received critical care services (adjusted odds ratio 3.0; 95% CI: 2.7-3.2; P < .001), and had higher in-hospital mortality (adjusted odds ratio 3.6; 95% CI: 3.2-3.9; P < .001) (controlling for patient and hospital characteristics).

CONCLUSIONS

Many hospitalizations for children with CCCs involve interfacility transfer. Compared with in-house admissions, hospitalizations of patients who are transferred in and ultimately discharged from the receiving hospital involve longer LOS, greater odds of receipt of critical care services, and in-hospital mortality. Further evaluation of the role of clinical and transfer logistic factors is needed to improve outcomes.

Availability of Inpatient Pediatric Surgery in the United States

BACKGROUND

In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery.

METHODS

A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth.

RESULTS

Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation.

CONCLUSIONS

Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

EDITOR’S PERSPECTIVE

Patient Insurance Status Is Associated With Care Received After Transfer Among Pediatric Patients in the Emergency Department

OBJECTIVE

To determine whether frequency of interfacility transfer varied by insurance status among pediatric emergency department (ED) patients. Secondarily, we tested for an association between insurance status and odds of transfer with discharge from the second ED without observation or admission.

METHODS

We used the 2016 New York State ED and Inpatient Databases to identify all patients <18 years. ED and hospital characteristics were from American Hospital Association and National ED Inventory-USA. Among all ED patients, we calculated the proportion transferred stratified by insurance status (private, public, none). Among ED-to-ED transfers, we identified transfers without subsequent observation or admission, and used hierarchical logistic regression modeling (adjusting for patient and transferring ED/hospital characteristics) to determine whether insurance status was associated with odds of discharge from the second ED without observation or admission.

RESULTS

Of 1,303,575 pediatric ED visits, 6086 (0.5%) were transferred. Transfers were less frequent among patients with public or no insurance. Of 3801 ED-to-ED transfers, 1451 (38%) were without subsequent observation or admission. In bivariate and multivariable analysis, transferred patients with public and with no insurance were less likely to be discharged without observation or admission relative to privately insured patients.

CONCLUSION

Among ED-to-ED transfers, pediatric patients with public or without insurance were more often kept for observation or admission at the second hospital after transfer. Differences in disease acuity or in providers' perception of follow-up availability may play a role in explaining these patterns. This disparity merits further investigation.

Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study

BACKGROUND

Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers.

METHODS

We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality.

RESULTS

Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight).

CONCLUSIONS

Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.

Nationwide study of appendicitis in children

BACKGROUND

Paediatric surgical care is increasingly being centralized away from low-volume centres, and prehospital delay is considered a risk factor for more complicated appendicitis. The aim of this study was to determine the incidence of paediatric appendicitis in Sweden, and to assess whether distance to the hospital was a risk factor for complicated disease.

METHODS

A nationwide cohort study of all paediatric appendicitis cases in Sweden, 2001-2014, was undertaken, including incidence of disease in different population strata, with trends over time. The risk of complicated disease was determined by regression methods, with travel time as the primary exposure and individual-level socioeconomic determinants as independent variables.

RESULTS

Some 38 939 children with appendicitis were identified. Of these, 16·8 per cent had complicated disease, and the estimated risk of paediatric appendicitis by age 18 years was 2·5 per cent. Travel time to the treating hospital was not associated with complicated disease (adjusted odds ratio (OR) 1·00 (95 per cent c.i. 0·96 to 1·05) per 30-min increase; P = 0·934). Level of education (P = 0·177) and family income (P = 0·120) were not independently associated with increased risk of complicated disease. Parental unemployment (adjusted OR 1·17, 95 per cent c.i. 1·05 to 1·32; P = 0·006) and having parents born outside Sweden (1 parent born in Sweden: adjusted OR 1·12, 1·01 to 1·25; both parents born outside Sweden: adjusted OR 1·32, 1·18 to 1·47; P < 0·001) were associated with an increased risk of complicated appendicitis.

CONCLUSION

Every sixth child diagnosed with appendicitis in Sweden has a more complicated course of disease. Geographical distance to the surgical facility was not a risk factor for complicated appendicitis.

Visualizing Patterns in Pediatric and Adult Hospital Care

OBJECTIVES

We aimed to design a graphical tool for understanding and effectively communicating the complex differences between pediatric and adult hospital care systems.

PATIENTS AND METHODS

We analyzed the most recent hospital administrative data sets for inpatient admission and emergency department visits from 7 US states (2014: Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York; 2011: California). Probabilities of care completion (Pcc) were calculated for pediatric (<18 years old) and adult conditions in all acute-care hospitals in each state. Using the Pcc, we constructed interactive heatmap visualizations for direct comparison of pediatric and adult hospital care systems.

RESULTS

On average, across the 7 states, 70.6% of all hospitals had Pcc >0.5 for more than half of all adult conditions, whereas <14.9% of hospitals had Pcc >0.1 for half of pediatric conditions. Visualizations revealed wide variation among states with clearly apparent institutional dependencies and condition-specific gaps (full interactive versions are available at https://goo.gl/5t8vAw).

CONCLUSIONS

The functional disparities between pediatric and adult hospital care systems are substantial, and condition-specific differences should be considered in reimbursement strategies, disaster planning, network adequacy determinations, and public health planning.