Benchmarking hospital admission rates by ages
Identifying patterns for age groups will be crucial
By Ronald Lagoe, Executive Director Hospital Executive Council,Syracuse, NY
It has been demonstrated that acute hospital care is still the largest and most expensive sector of the health care system of the United States. For this reason, both payers and providers have attempted to limit hospital admissions and discharges as they seek to improve the outcomes and efficiency of care.
In the June Healthcare Benchmarks, a study of aggregate hospital admission rates per population in 30 U.S. cities was outlined. In that study, conducted by the Hospital Executive Council, com munities with the lowest admission rates were identified. The experiences of those areas were used to develop benchmark ranges for hospital admissions per population for individual major diagnostic categories and diagnosis related groups.
In the current health care system, it also is necessary to identify hospital admission rates for particular segments of populations. Most managed care and indemnity health plans focus on nonelderly patients. Within this group, children, young adults, and older adults typically generate different admission patterns. Increased efforts are being made to provide managed care coverage to Medicare populations, suggesting the need to define admission rate benchmarks for the elderly. In their efforts to develop inpatient and outpatient services for specific populations, health care providers also need to define admission rate benchmarks by age levels.
Population
The study identified benchmarks for hospital admissions and discharges per 1,000 resident population by age level. It was based on the two communities identified in the previous study as producing the lowest admission and discharge rates per capita, San Diego and Seattle. (For details, see "Benchmark admissions identify areas for improvement," Healthcare Benchmarks, June 1998, p. 81.)
Data for these populations were obtained from the California Office of Statewide Health Planning and Development and the Washington State Department of Health. That information was produced for the latest available calendar year at the time the study was carried out, 1995 for San Diego and 1996 for Seattle. Data generated for the study included all resident discharges for San Diego County and King County for the two time periods. In addition to those data, population statistics for the two areas were used to generate hospital admission and discharge rates.
Method
In order to produce benchmark utilization levels for San Diego and Seattle, resident hospital admission and discharge rates were identified for the following age levels. These categories have been widely used in health planning because they delineate changes in hospital admission rates (this point was confirmed by data in the previous study):
· 0 to 19: children and adolescents;
· 20 to 44: young adults;
· 45 to 64: mature adults;
· 65 and older: elderly.
Within each age level, resident hospital admission rates were identified for surgical and medical patients within each federal major diagnostic category. The rates for San Diego and Seattle then were used to develop benchmark admission rate ranges. In addition, admission rates for the two communities were identified for collections of diagnosis related groups that were major sources of hospital utilization. These rates were also used to construct benchmark ranges.
Results
Information concerning admission and discharge benchmarks for children and adolescents (ages 0 to 19 years) and young adults (ages 20 to 44 years) is summarized in Table 1 (pp. 106-107). This information demonstrates that hospital admissions per 100,000 population excluding normal newborns, psychiatry, and treatment of substance abuse, ranged from 385.4 in Seattle to 451.9 in San Diego.
For most categories, such as neurosurgery, neurology, circulatory surgery, and circulatory medicine (cardiology), admission rates for the two communities showed little variation. The resulting levels of admissions per 100,000 population provide benchmarks for evaluation of utilization elsewhere.
For patients ages 0 to 19, the largest differences in admission rates were produced in obstetrics and neonatal care and accounted for most of the variation in total admission rates. These differences could have been generated by variations in birth rates and in assignment of infants to neonatal or normal newborn categories.
Information concerning hospital admission and discharge rates for young adults (ages 20 to 44) also is summarized in Table 1. These data indicate that hospital admission per 100,000 population excluding psychiatry and treatment of substance abuse ranged from 596.1 in Seattle to 632.8 in San Diego, a difference of only 6%.
The data demonstrated that hospital admission rates for the two communities by major diagnostic category were closer for this population than for children and adolescents. For categories such as neurosurgery, neurology (nervous system), respiratory medicine, and circulatory surgery, the rates were almost identical.
The largest differences in admission rates involved obstetrics, gynecology, and orthopedic surgery. Because of the low communitywide admission rates for these populations, the ranges identified appear to be useful benchmarks for evaluation of hospital admissions for young adults elsewhere.
Information on hospital admission and discharge rates for older adults (45 to 64 years) is summarized in Table 2 (pp. 108-109). These data indicate that hospital admissions per 100,000 population excluding psychiatry and substance abuse treatment for this population were almost identical (727.7 vs. 733.1 ).
That development also was reflected in similar admission rates for major sources of admissions such as neurosurgery, neurology (nervous system), respiratory medicine, circulatory surgery, and cardiology (circulatory medicine). Only in a few major diagnostic categories, such as gynecology surgery, did differences in admission rates exceed 10%.
Information concerning hospital admission and discharge rates for the elderly (ages 65 and over) also is summarized in Table 2. These data indicated that total admissions per 100,000 population excluding psychiatry and treatment of substance abuse differed by 4.7% between the communities. As in the case of other age levels, admission rates for a number of major sources of utilization such as neurosurgery, respiratory medicine, circulatory surgery, and cardiology (circulatory medicine) were almost identical. The largest differences in admission rates for major sources of utilization among the elderly involved orthopedic surgery.
The benchmark information in Tables 1 and 2 also produced comparisons of efficient admission rates for individual major diagnostic categories across age levels. For example, admission rates for cardiology patients ages 65 and over were more than four times the rates of those patients ages 45 to 64, which were about seven times the rates of patients ages 20 to 44. It was notable that these ratios between admission rates for age levels remained consistent in both communities across a wide range of diagnoses and procedures. The fact that most of the benchmark ranges were both narrow and consistent makes it possible to compare efficient admission levels with some degree of precision.
The study also included identification of resident hospital admissions per 100,000 population in the two metropolitan areas for collections of diagnosis related groups with the highest utilization levels. The data in Table 3 (p. 110) demonstrate that the 12 categories with the highest admission rates produced approximately 50% of the admissions in the two communities. Most of these categories related to neonatal care because the appropriate hospitalization of children for other causes is minimal. The data in Table 3 also indicated that obstetrics (vaginal and cesarean deliveries ) were responsible for more than 80% of admissions in San Diego and Seattle. Other major sources of admissions covered a wide range of diagnoses.
The data in Table 4 (p. 111) identified diagnostic categories that were major sources of admissions for mature adults and the elderly. The 12 largest sources of admissions for patients ages 45 to 64 accounted for about one-third of total admissions. Of these categories, six concerned cardiac surgery and cardiology, two included respiratory medicine, and two concerned the digestive system. The 12 diagnostic categories that were major sources of admissions for patients 65 years and over in the two communities also accounted for approximately one-third of total utilization. Major sources of admission for this group also included categories such as cardiac surgery, cardiology, and respiratory medicine, as well as orthopedics. The information in Table 4 reflected the impact of chronic disorders such as heart and respiratory disease on mature adults and the elderly.
Conclusions
The data in this study identified ranges of hospital admissions by age level for a full range of general major diagnostic categories (see table 5, p. 112) as well as specific diagnoses and procedures. The similarity and efficiency of total admission rates for San Diego and Seattle appeared to generate similar admission levels for individual categories within age ranges. The fact that these data were based on the most efficient utilization in the United States should provide both payers and hospitals with stable reference points for the planning of future acute care and services.
To continue monitoring the efficiency of hospital admissions by age level, the data in this study should be compared with the experiences of other communities. Through that process, a national consensus concerning efficient hospital admission rates will be developed.
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