Background
Inappropriate admissions indicate that patients who could have been treated as outpatients received services as inpatients [
1,
2]. This phenomenon increases the average medical expenditure and waste in health resources [
3]. Some studies have reported that inappropriate admissions have substantially contributed to high hospitalisation rate [
4]. From 2003 to 2013, the hospitalisation rate for children aged 0–14 years in rural China increased by 2.86 times from 1.73 to 4.95% [
5]. The increasing hospitalisation rate for children expanded faster than the forecast, suggesting that inappropriate admissions might occur. Several studies have indicated that children are the high-risk group for inappropriate admissions [
6,
7]. In 2013, the rate of inappropriate admissions for children (aged 0–14 years) in county hospitals was 21.8%, which was higher than that for people aged 15–64 years (5.8%) and aged 65 years and older (5.6%) [
7]. The number of children in China has increased with the universal two-child policy. Inappropriate admissions can cause cross-infection and other threats to children’s health [
8]. Therefore, controlling the inappropriate admissions of children is important.
As a special group in society, children lack the ability to decide whether or not they should be hospitalised. Their admission often stems from their guardians or doctors [
8]. National conditions, including China’s long-term one-child policy, ensure that the inappropriate admissions of children in China are different from those in other countries in some way. On the one hand, urban areas include municipalities and prefecture-level cities; rural areas include counties or county-level cities and their subordinate towns and villages. Therefore, the establishment of medical institutions in China covers municipal hospitals, county hospitals, township hospitals and village clinics. The latter three of the above-mentioned medical institutions are rural medical institutions [
9]. Among them, county hospitals have the strongest capacity in providing medical services, so they play a leading role within counties. In terms of hospitalisation services, county hospitals treat more kinds of diseases than township hospitals. Meanwhile, village clinics generally do not provide inpatient services. Taking a prefecture-level city in China as an example, data show that among the pediatric inpatients classified by municipal hospitals, county hospitals, township hospitals and private hospitals, the number of hospitalised children in county hospitals accounts for 50.2% of the total number of hospitalised patients; children hospitalized in municipal hospitals and township hospitals was 39.4 and 7.3% of the total number of patients, respectively [
10]. The tendency of children patients to hospitalise in county hospitals affects the rate of inappropriate admissions of children in county hospitals. On the other hand, from the perspective of service providers, doctors tend to provide extended services to be on the safe side because children cannot truly describe their feelings. This phenomenon could lead defensive medicine which influences the occurrence of inappropriate admissions [
11,
12].
In recent years, the Chinese government has issued a series of policies, such as the payment reform of new rural cooperative medical system (NRCMS) and the family doctor contracting services, to guide patients to seek appropriate medical advices and prevent improper hospitalisation behaviours. However, the unreasonable demands and utilisations of inpatient services remain unresolved. Causes of this problem are not yet clear. It is necessary to identify the determinants of children’s inappropriate admissions, so as to improve the efficiency of the utilisation of hospital services, avoid unnecessary waste of medical resources, and ensure the quality and safety of children’s medical services.
Most studies on inappropriate admissions of children were based on their medical records provided by hospitals [
6,
13‐
23]. They mainly focused on evaluating the rate of inappropriate admissions, identifying the basic characteristics and influencing factors and further analysing health policies, hospital management system and health service behaviors behind them. In terms of characteristics, studies focused on the severity of illness and diseases in hospitalised children. For instance, De Marco et al. suggested that children with influenza-like illness are likely to have inappropriate admissions [
6]. On the analysis of influencing factors, Aida et al. found that the ratio of inappropriate admissions could be reduced by strengthening the relationship between hospitals and community service agencies [
15]. Magdy et al. believed that the rate of inappropriate admissions of children in Kuwait was up to 40%, which can be explained by its’ free health care services and easy access to hospital services [
13]. In China, a few studies were conducted about inappropriate admissions on the whole population including children were conducted. Meanwhile, the existing studies did not focus on the children in county hospitals. Given differences in the determinants of inappropriate admissions of children and other groups, factors influencing inappropriate admissions of children at the county hospitals are worthy of further investigation. Therefore, this study investigated the determinants of children’s inappropriate admissions. The research hypothesis of this study is that the appropriateness of children hospitalisation to county hospitals in rural China is related to the health policies and environments factors regarding children.
This study aims to investigate the level and determinants of the inappropriate admissions of children to provide comprehensive and targeted strategies for the managers and decision-makers in controlling this phenomenon.
Methods
Sample selection
We conducted this research in 2017, and the surveyed population was inpatient aged 0–14 years. In the eastern part of China, many rural areas rapidly became cities due to social development. Hence, county property attributes decreased. Therefore, this study did not include the eastern part of China in the research scope. We applied stratified random sampling and the principle of convenience in selected counties and county-level cities in China’s central (e.g. Dingyuan in Anhui Province) and western (e.g. Weiyuan and Huining in Gansu Province; Yilong in Sichuan Province) regions, which were designated as sample areas. The biggest county hospital in each county was used as the sample hospital. Table
1 shows the basic information and the service provision of the sample county hospitals in the year before this study was carried out.
Table 1
The fundamental state of the sample county hospitals
Designated bed capacity | 845 | 350 | 400 | 750 |
Number of actually available bed | 880 | 450 | 652 | 780 |
Number of on-post staff | 1233 | 328 | 951 | 851 |
Among them: |
Doctors | 319 | 81 | 157 | 198 |
Registered nurses | 499 | 49 | 483 | 376 |
Frequency of outpatient and emergency visits | 531.5 thousand person | 101.4 thousand person | 228.4 thousand person | 278.3 thousand person |
Number of discharged patients | 62.1 thousand person | 14.2 thousand person | 28 thousand person | 29.4 thousand person |
We believed that the NRCMS in different regions affected the inappropriate admissions for residents. Thus we also collected the compensation policies for NRCMS in the selected regions. Table
2 shows how the patients from the four counties benefited from the reimbursement policies of NRCMS. These counties shared the same financing policies in 2017. Reimbursement took two forms, namely, outpatient and inpatient reimbursements. The outpatient service in county hospitals was not covered. The reimbursement of inpatients ranged from 75 to 85% of the total reimbursements, and the deductible line was between 400 and 650 RMB. Overall, the NRCMS hospitalisation benefits were high in all regions.
Table 2
NRCMS reimbursement polices in the survey areas in 2017
Payment | Global budget | Payment for single disease | Payment for single disease | Global budget |
Reimbursement of Outpatient | Reimbursement Ratio | 45% for county hospitals | 60% for county hospitals | 60% for county hospitals | 60% for county hospitals |
50% for village clinic | 60% for village clinic | 60% for village clinic | 60% for village clinic |
Annual Payment Limitation | 150 RMB | 150 RMB | 300RMB | 120RMB |
Reimbursement of Inpatient | The Low Limit of Pay Line | 620 RMB for county hospitals | 500 RMB for county hospitals | 500 RMB for county hospitals | 400 RMB for county hospitals |
150 RMB for township hospitals | 150 RMB for township hospitals | 150 RMB for township hospitals | 100 RMB for township hospitals |
Reimbursement Ratio | 85% for county hospitals | 70% for county hospitals | 80% for county hospitals | 75% for county hospitals |
90% for township hospitals | 80% for township hospitals | 90% for township hospitals | 90% for township hospitals |
Single payment limitation |
-
| 15,000 RMB for county hospitals | 20,000 RMB for county hospitals | - |
3,000 RMB for township hospitals | 3,000 RMB for township hospitals |
Annual Payment Limitation | 200,000 RMB | 80,000RMB | 80,000RMB | 180,000RMB |
Sample size estimation
According to previous studies, the estimated inappropriate admission rate P is 40%, the expected error δ is 0.035 and the confidence level α is 0.05 in the sampling calculation:
$$ \mathrm{N}={\mathrm{Z}}_{\alpha /2}^2\times P\left(1-P\right)/{\updelta}^2={1.96}^2\times 0.40\times \left(1-0.40\right)/{0.035}^2=753 $$
Based on the population in the surveyed areas and the scale of operation of the surveyed hospitals, 220 hospitalised children medical records were selected in Dingyuan county of Anhui Province and Yilong of Sichuan Province and 175 hospitalised children medical records were selected in Weiyuan and Huining County of Gansu Province. Children were admitted in departments such as paediatrics, surgery, orthopaedics and internal medicine. Our study selected number of medical records in each department relative to the proportion of children in the department. After the non-evaluable medical records were removed, 771 medical records of inpatients in four counties were finally obtained.
Records appropriateness evaluation
Considering the actual situation of China, 771 admission records were collected at the beginning and identified through the improving rural appropriateness evaluation protocol (RAEP) which was culturally suitable and widely used in this country (Additional file
1). There were three specially trained experts evaluated the medical records collected, all of whom were Ph.D. and involved in health policy research more than five years. Experts who owned the rich of research experience and deep understanding of existing services in rural China enabled to make the fair judgment on records with strict accordance with standards. Furthermore, each record was examined by two judges to ensure the quality of the medical records. If two judges had different opinions, the medical record would be sent to a third party. We obtained the results after a comprehensive evaluation. The RAEP standard was based on the value of the medical records. Therefore, all RAEP related indexes were extracted firstly. The actual values were then compared with the standard values. If an index value corresponded to the standard value, the admission record was appropriate. If all the relevant values of the medical record did not conform to the evaluation table criteria, the record was an inappropriate admission.
Research content
First, information, including personal and hospitalisation information of patients, was collected from the inpatient medical records. The patient’s personal information included the patient number, gender, age, normal health status and whether to get the insurance compensation. Other inpatient information included the admission department, name of the doctor in charge, day of the week of admission, emergency admission, admission and discharge diagnosis, test results, operation conditions and the length of hospital stay (LOS). After obtaining the hospitals’ consent, we conducted a questionnaire survey of the doctors based on the doctor’s name displayed in the inpatient medical records. The doctors’ information involved age, educational background, their sense of the degree to which doctors believe they have autonomy in clinical decision-making, the degree to which doctors believe that they can understand the patient’s feelings, the degree to which they think the tension in doctor-patient relationship (Additional file
2).
Statistical analysis
Medical record information of inpatients was recorded through Epidata 3.2. Diseases were classified using the international classification of diseases 10th Edition (ICD-10).
The characteristics of patients inappropriately admitted to county hospitals were analysed using Pearson’s chi-square test in IBM SPSS Statistics 22.0. Given that Weiyuan County and Huining County were affiliated to the same province and considering the possible clustering between the regions, this study used the generalised estimating equation to build the model and set the job-related matrix type to unstructured firstly. However, in the correlation matrix, the main diagonal element was close to 1, and the remaining elements were near 0. Hence, no clustering occurred between the sampling regions. A binary logistic regression model was used to analyse the determinants of inappropriate admissions of children. The patient’s admission appropriateness (appropriate =0, inappropriate =1) was used as the dependent variable, whereas county, sex, age, compensation for medical insurance, normal health status, admission department, day of the week of admission, disease, the admission route (admitted emergency), LOS and information of doctors mentioned in the research content were the independent variables. Backward stepwise was used to establish the regression model as follows:
$$ Logit(P)=\mathit{\ln}\left(P/1-P\right)={\beta}_0+{\beta}_1 County+{\beta}_2 Normal\ health\ status+{\beta}_3 Department+{\beta}_4 Disease+{\beta}_5 LOS+{\beta}_6{Doctor}^{\prime }s\ \mathrm{understanding}\ {\mathrm{of}\ \mathrm{patient}}^{\prime}\mathrm{s}\ \mathrm{feelings}+\varepsilon . $$
P represents the probability of inappropriate admission for children, β0 is the constant term for the model and ε represents an uncontrollable random error term.
Results
Basic composition of Children’s inpatients and their doctors
The first column in Table
3 shows the children’s admission data: 61.09% were male, the average age was 4.25 years old (age range: 0–14 years old), 91.83% were patients who had gotten compensation after purchasing the NRCMS, and 89.11% were in good normal health. Most of the admissions were non-emergency, and the children with respiratory diseases accounted for 54.6% of the total number of children. The range of LOS was 1–33 days with average and median of 4.97 and 4.45 days, respectively.
Table 3
The Appropriation Distribution Characteristics about Children Inpatients in County Hospitals According to the Medical Records
All | 771(100.00) | 298(38.65) | 473(61.35) | | |
County |
Dingyuan | 219(28.40) | 63(28.77) | 156(71.23) | 68.083 | < 0.001 |
Weiyuan | 166(21.53) | 90(54.22) | 76(45.78) |
Huining | 171(22.18) | 95(55.56) | 76(44.44) |
Yilong | 215(27.89) | 50(23.26) | 165(76.74) |
Gender of patients | | |
Male | 471(61.09) | 181(38.43) | 290(61.57) | 0.025 | 0.874 |
Female | 300(38.91) | 117(39.00) | 183(61.00) |
Age of patients, (years) |
Less than 1 | 93(12.06) | 52(55.91) | 41(44.09) | 34.947 | < 0.001 |
1–5 | 437(56.68) | 138(31.58) | 299(68.42) |
6–9 | 151(19.58) | 56(37.09) | 95(62.91) |
10–14 | 90(11.67) | 52(57.78) | 38(42.22) |
Mean (SD) | 4.25(3.70) | | | | |
Whether patients get medical insurance compensation |
Yes | 708(91.83) | 276(38.98) | 432(61.02) | 0.403 | 0.526 |
No | 63(8.17) | 22(34.92) | 41(65.08) |
Normal heath of patients |
Good | 687(89.11) | 242(35.23) | 445(64.77) | 31.204 | < 0.001 |
General | 84(10.89) | 56(66.67) | 28(33.33) |
Department | | | | | |
Paediatrics | 654(84.82) | 212(32.42) | 442(67.58) | 70.661 | < 0.001 |
Others | 117(15.18) | 86(73.50) | 31(26.50) |
Day of the week of admission |
Saturday- Sunday | 196(25.42) | 73(37.24) | 123(62.76) | 0.219 | 0.64 |
Monday-Friday | 575(74.58) | 225(39.13) | 350(60.87) |
Disease category |
Respiratory disease | 421(54.6) | 116(27.55) | 305(72.45) | 95.079 | < 0.001 |
Digestive disease | 94(12.19) | 37(39.36) | 57(60.64) |
Injury and poisoning | 42(5.45) | 30(71.43) | 12(28.57) |
Conditions originating | 56(7.26) | 43(76.79) | 13(23.21) |
in perinatal period |
Infectious Diseases | 54(7.00) | 16(29.63) | 38(70.37) |
Symptoms and signs | 21(2.72) | 10(47.62) | 11(52.38) |
Circulatory disease | 18(2.33) | 5(27.78) | 13(72.22) |
Others | 65(8.43) | 41(63.08) | 24(36.92) |
Admitted emergency |
Yes | 611(79.25) | 255(41.73) | 356(58.27) | 11.808 | 0.001 |
No | 160(20.75) | 43(26.88) | 117(73.13) |
LOS, (days) |
Less than 5 | 400(51.88) | 119(29.75) | 281(70.25) | 40.007 | < 0.001 |
5–8 | 293(38.00) | 128(43.69) | 165(56.31) |
More than 9 | 78(10.12) | 51(65.38) | 27(34.62) |
Mean (SD) | 4.97(3.43) | | | | |
Median | 4.45 | | | | |
The first column in Table
4 shows the doctor status corresponding to each medical record: 42.41 and 79.12% of records indicate that the pediatricians were greater than or equal to 46 years old and they had bachelor’s degree or above. In most cases, doctors believed that they could sense patients’ feelings and that they had a moderate degree of autonomy in clinical decision-making. 47.21% of the records show that doctors thought the existing doctor-patient relationship was moderate.
Table 4
The Appropriation Distribution Characteristics about Children Inpatients in County Hospitals under the Perception of Doctors
Age of doctors, (years) |
Less than 36 | 207(26.85) | 92(44.44) | 115(55.56) | 6.190 | 0.045 |
36–45 | 237(30.74) | 95(40.08) | 142(59.92) |
46 years old and above | 327(42.41) | 111(33.94) | 216(66.06) |
Educational background of doctors |
Junior college and below | 161(20.88) | 60(37.27) | 101(62.73) | 0.164 | 0.685 |
Bachelor degree or above | 610(79.12) | 238(39.02) | 372(60.98) |
The degree to which doctors believe they have autonomy in clinical decision-making |
Low | 115(14.92) | 48(41.74) | 67(58.26) | 1.118 | 0.572 |
Moderate | 355(46.04) | 140(39.44) | 215(60.56) |
High | 301(39.04) | 110(36.54) | 191(63.46) |
The degree to which doctors believe they can understand the patient’s feelings |
Low | 159(20.62) | 56(35.22) | 103(64.78) | 1.085 | 0.581 |
Moderate | 577(72.24) | 229(39.69) | 348(60.31) |
High | 35(4.54) | 13(37.14) | 22(62.86) |
The degree to which doctors believe tensions between doctors and patients |
Low | 184(23.87) | 91(49.46) | 93(50.54) | 12.777 | 0.002 |
Moderate | 364(47.21) | 123(33.79) | 241(66.21) |
High | 223(28.92) | 84(37.67) | 139(62.33) |
Characteristics of children inappropriately admitted to county hospitals
Table
3 also shows the characteristics of the patients. A total of 61.35% of the records from the four sample areas indicated inappropriate admissions. The incidence rate varied in different regions (
P < 0.001) and ranged from 40 to 80%. The Yilong County of Sichuan province had the highest rate of inappropriate admissions.
In the distribution of individual characteristics, 1- to 5-year-old preschool children and 6- to 9-year-old primary school children were likely to be inappropriately admitted (P < 0.001). The children with good health and in normal status were likely to have inappropriate admissions (P < 0.001). No statistical difference was found in gender and inappropriate admissions, medical insurance compensation and inappropriate admissions. In terms of the distribution of inpatient characteristics, the children hospitalised in paediatrics were more likely to experience inappropriate admission than those hospitalised in other departments (P < 0.001). Inappropriate admission was concentrated in the children with respiratory, circulatory, infectious and digestive diseases (P < 0.001). The children admitted in emergency (P = 0.001) and those with short LOS (P < 0.001) were likely to have inappropriate admission. No statistical difference in the day of the week of admission was found between the two groups.
Table
4 shows that patients treated by doctors over 46-year-old were more likely to be hospitalised inappropriately than those treated by doctors under 45-year-old (
P = 0.045). Patients treated by doctors who thought the doctor-patient relationship moderate were more likely to be inappropriately admitted (
P = 0.002). There is no significant difference among groups on the degree of doctor’s educational backgrounds, the doctors’ self-determination in diagnosis and their understanding of patients’ feelings to children’s inappropriate admissions.
Probabilistic model of patients in children inappropriately admitted to county hospitals
The binary logistic regression model was used to analyse the determinants of inappropriate admissions of children in county hospitals. With the minimum value as the reference level, the first and ninth variable selection results are shown in Table
5.
Table 5
Logistic regression analysis of inappropriate admission of children inpatients (n = 771)
Step-1 |
County (Dingyuan) |
Weiyuan | 0.685 | 0.355–1.321 |
Huining | 0.506 | 0.275–0.929 |
Yilong | 2.116 | 1.056–4.239 |
Gender of patients (Male) | 0.976 | 0.686–1.389 |
Age of patients, (years) (Less than 1) |
1–5 | 1.688 | 0.920–3.098 |
6–9 | 1.472 | 0.724–2.995 |
10–14 | 1.204 | 0.539–2.690 |
Whether patients get insurance compensation (Yes) | 1.275 | 0.663–2.452 |
Normal heath of patients (Good) | 0.562 | 0.309–1.024 |
Department (Paediatrics) | 0.185 | 0.094–0.363 |
Day of the week of admission (Saturday- Sunday) | 0.685 | 0.459–1.023 |
Disease category (Respiratory disease) |
Digestive disease | 1.248 | 0.686–2.272 |
Injury and poisoning | 0.346 | 0.142–0.844 |
Conditions originating in perinatal period | 0.245 | 0.115–0.523 |
Infectious Diseases | 1.053 | 0.533–2.082 |
Symptoms and signs | 0.458 | 0.172–1.218 |
Circulatory disease | 1.304 | 0.341–4.979 |
Others | 0.556 | 0.276–1.120 |
Admitted Emergency (Yes) | 1.095 | 0.654–1.834 |
LOS, (days) (Less than 5) |
5–8 | 0.634 | 0.432–0.932 |
More than 9 | 0.505 | 0.266–0.958 |
Age of doctors, (years) (Less than 36) |
36–45 | 1.646 | 0.929–2.915 |
More than 46 | 1.264 | 0.756–2.113 |
Educational background of doctors (Junior college and below) | 0.994 | 0.580–1.703 |
The degree to which doctors believe they have autonomy in clinical decision-making (Low) |
Moderate | 0.632 | 0.307–1.301 |
High | 0.904 | 0.492–1.662 |
The degree to which doctors believe they can understand the patient’s feelings (Low) |
Moderate | 0.555 | 0.317–0.971 |
High | 2.156 | 0.789–5.889 |
The degree to which doctors think tensions between doctors and patients (Low) |
Moderate | 0.823 | 0.433–1.567 |
High | 0.654 | 0.297–1.440 |
Constant | 5.930 | |
Step-9 |
County (Dingyuan) |
Weiyuan | 0.597 | 0.346–1.031 |
Huining | 0.468 | 0.281–0.777 |
Yilong | 1.752 | 1.034–2.969 |
Normal heath (Good) | 0.545 | 0.305–0.974 |
Department (Paediatrics) | 0.173 | 0.092–0.324 |
Day of the week of admission (Saturday- Sunday) | 0.690 | 0.465–1.024 |
Disease category (Respiratory disease) |
Digestive disease | 1.305 | 0.728–2.339 |
Injury and poisoning | 0.401 | 0.165–0.970 |
Conditions originating in perinatal period | 0.215 | 0.104–0.446 |
Infectious Diseases | 1.058 | 0.539–2.077 |
Symptoms and signs | 0.536 | 0.206–1.396 |
Circulatory disease | 1.219 | 0.335–4.438 |
Others | 0.553 | 0.279–1.098 |
LOS, (days) (Less than 5) |
5–8 | 0.642 | 0.440–0.936 |
More than 9 days | 0.501 | 0.266–0.945 |
The degree to which doctors believe they can understand the patient’s feelings (Low) |
Moderate | 0.697 | 0.446–1.091 |
High | 2.302 | 0.862–6.149 |
Constant | 6.694 | |
Based on the logistic regression analysis, the major determinants of inappropriate admissions of children to county hospitals included county, normal health status, treating department, disease LOS and the doctor’s self-evaluation on the understanding about the degree of the patient’s feelings. With Dingyuan County as the control group, the possibility of inappropriate admission in Weiyuan (OR = 0.597) and Huining (OR = 0.468) was significantly low. The children with poorer normal health were more likely to have appropriate admission (OR = 0.545) than the children with good health. The children hospitalised in other departments had lower inappropriate hospitalisation rate than those in paediatric department (OR = 0.173). Compared with the children with respiratory diseases, children with certain conditions originating from perinatal period had a lower likelihood of inappropriate admissions (OR = 0.215). Moreover, the children with LOS of 5–8 days (OR = 0.642) and 9 days or more (OR = 0.501) or whose doctor believed that he/she could understand the patient’s feelings moderately (OR = 0.697) had the lower risk of inappropriate admissions than those others.
Conclusions
According to RAEP, the incidence of inappropriate admission of children to county hospitals in Chinese rural areas is high. This high incidence is directly related to the weak level of primary care services in the health service system, the initiative requirements of the children’s admission decision makers, the interests of the medical institutions and doctors. This study found that the government can control inappropriate admissions of children from the following aspects: 1) Improve the rural health service system. The inappropriate admissions of children can be controlled by improving children’s disease diagnosis and treatment in township hospitals and the level of primary medical treatment and two-way referrals. 2) Strengthen the leading role of medical insurance. Firstly, we should integrate the interests of medical service providers in the reformation and promotion of the mode of payment. Secondly, the role of medical insurance in the admission supervision of medical institutions should be strengthened. The regulatory content includes a clear admission standard. 3) Reinforce the health management of children. The primary medical staff can guide the parents’ effective medical treatment by educating the children’s guardians on the prevention and treatment of children’s common diseases to reduce the inappropriate admission rate.
Acknowledgements
The authors thank the Health and Family Planning Commission of Weiyuan county, Gansu province, for their willingness to provide us the data.