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Discharge From the ED After Enema Reduction of Intussusception: Is It a Safe and Cost-Effective Strategy?

Sunday, October 21, 2012: 10:00 AM
Versailles Ballroom (Hilton Riverside)
Samuel Rice-Townsend, MD1, Richard G. Bachur, MD, FAAP2, Atul Gawande, MD, MPH3, Mehul V. Raval, MD4, Michael J. Callahan, MD5, Jeff N. Barnes, BS6, Fizan Abdullah, MD, PhD7, Catherine Chen, MD, MPH, FAAP1, R. Lawrence Moss, MD, FAAP8, Douglas C. Barnhart, MD, MSPH9, Katherine J. Deans, MD, MHSc8 and Shawn J. Rangel, MD, MSCE, FAAP1, (1)Department of Surgery, Children's Hospital Boston, Boston, MA, (2)Department of Emergency Medicine, Children's Hospital Boston, Boston, MA, (3)Department of Surgery, Brigham and Women's Hospital, Boston, MA, (4)Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Children's Memorial Hospital, Chicago, IL, (5)Department of Radiology, Children's Hospital Boston, Boston, MA, (6)Child Health Corporation of America, Shawnee Mission, KS, (7)Pediatric Surgery, Johns Hopkins University, Baltimore, MD, (8)Department of Surgery, Nationwide Children's Hospital, Columbus, OH, (9)Department of Pediatric Surgery, Primary Children's Medical Center, Salt Lake City, UT

Purpose To characterize variation among Children's Hospitals with Emergency Department (ED) discharge following successful enema reduction of intussusception, and to explore the impact of this practice on readmission risk, cumulative resource utilization and patient outcomes.

Methods We conducted a 5-year audit (2007-2011) of the Pediatric Health Information System database to identify patients with intussusception who were successfully managed by enema reduction. Hospitals with a rate of ED discharge higher than the average rate from all 33 hospitals were analyzed as the "ED-Discharge" group (n=7), and those with a lower rate were analyzed as the "ED-Admit" group (n=26) (Figure). Groups were compared with readmission rate and total cumulative case-related hospital costs, charges, and length of stay (LOS) from index and readmission encounters. Rates of recurrent intussusception and operative management were also compared for the readmitted cohort.

Results 3,880 patients managed with enema reduction were identified from 33 hospitals. There was significant variability in the practice of ED discharge across hospitals (overall rate: 13%[506/3880]; range: 0-90.9%; p<0.0001; Figure). The ED discharge rate was 49.9% (428/857) for the ED-Discharge group (range: 20-90.9%) and 2.6% (78/3023) for the ED-Admit group (range: 0-7.7%). Compared with the ED-Admit group, ED-Discharge hospitals had a higher readmission rate (10.9%[93/855] vs. 8.0%[242/3033], OR: 1.4 [95%CI:1.1-1.8]; p=0.0076), but a shorter index and cumulative LOS (mean index LOS: 1.6 vs. 2.0days; p<0.0001; mean cumulative LOS: 1.8 vs. 2.2days; p<0.0001). Furthermore, patients treated at ED-Discharge hospitals had 44% lower median case-related hospital costs ($1438 [IQR:$813-$2322] vs. $2545 [IQR:$1972-$3517]; p<0.0001) and 38% lower median charges ($3857 [IQR:$2462-$5952] vs. $6232 [IQR:$4809-$8200]; p<0.0001) during the index admission, and 41% lower median cumulative hospital costs ($1540 [IQR:$881-$2524] vs. $2612 [IQR:$2013-$3735]; p<0.0001) and 36% lower cumulative charges ($4133 [IQR:$2606-$6393] vs. $6405 [IQR:$4919-$8668]; p<0.0001) after factoring in readmission encounters. Moreover, the median cumulative cost and charges at each of the 7 hospitals in the ED-Discharge group were lower than those from the collective ED-Admit group, suggesting that the relative cost-benefit was not due to any single outlier(s) within the ED Discharge group. For the readmitted cohort, patients treated at ED-Discharge hospitals were more likely to require repeat enema reduction at readmission (58.1%[54/93] vs. 34.3%[83/242]; p<0.0001) though there was no difference between groups with mean readmission LOS (2.0 vs. 2.1days; p=0.90) or the need for operative management (ED-Discharge 1.1%[1/93] vs. ED-Admit 4.1%[10/242]; p=0.16).

Conclusion Discharge from the ED following enema reduction is associated with markedly lower treatment-related costs, charges and length of stay compared with inpatient admission. Although there is an increased risk of readmission following ED discharge, this practice remains cost-effective and does not increase the need for operative management. Collaborative efforts should focus on further defining selection criteria to increase the generalizability of this treatment strategy.