ESTIMATING RISK ASSOCIATED WITH CARE IN ALTERNATIVE SETTINGS - DETERIORATION AMONG CHILDREN HOSPITALIZED

Background: Although managed care favors use of alternative settings i n an attempt to avoid hospitalization, uncertainty about possible dete rioration creates concern about their safety. Objective: To derive pre liminary estimates for the risk of adverse outcome in children hospita lized with acute illness who met criteria for admission to potentially less-expensive, alternative settings (eg, short-stay unit, home nursi ng). Design: Description of hospitalization outcomes for a community-w ide childhood population. Setting and Population: All 11591 hospitaliz ations for residents of Monroe County (Rochester), New York, aged 1 mo nth to 18 years in 1991 and 1992. Measurements: To identify potential adverse outcomes in alternative settings (numerator estimate), hospita l medical records for admissions to regular inpatient units were exami ned. To ascertain deterioration among these admissions, detailed recor d reviews were conducted if the child died or was transferred to anoth er hospital or to a critical care unit. To estimate the total number o f admissions eligible for care in alternative settings (denominator es timate), hospital discharge files were analyzed. Results: Deterioratio n was found in 83 medical admissions. Of these 83, major chronic probl ems (n = 53) or severe illness at presentation (n = 27) precluded alte rnative setting eligibility, leaving only 3 in whom alternative settin g care might have been considered. The total number of admissions elig ible for alternative setting care was estimated between 1661 (restrict ive criteria) and 3322 (inclusive criteria) for the 2-year observation period. Based on these observations, best- and worst-case estimates f or the risk of deterioration in candidates for care in alternative set tings were 0.6 and 1.8 per 1000, respectively. For the 3 children for whom alternative setting care might have been considered, the shortest period fi om first indication of deterioration to arrival in the crit ical care unit was 3.0 hours. Conclusions: These preliminary estimates suggest that alternative settings may be safe for the care of many ch ildren currently hospitalized. A randomized clinical trial to evaluate directly the potential benefits and harms of alternative setting care should be considered.