A team of researchers at Dartmouth’s Geisel School of Medicine, led by JoAnna Leyenaar, MD, PhD, MPH, will receive a $2.6 million funding award from the Patient-Centered Outcomes Research Institute (PCORI) to compare the effectiveness of direct admission and admission through emergency departments (EDs) for hospitalized children.
In a landmark report, the Institute of Medicine described the U.S. emergency medical system as “overburdened, fragmented,” and “at the breaking point.” A major factor in this crisis is the way that EDs have increasingly served as gateways for hospital admissions over the past 20 years—contributing to ED crowding and associated wait times. In fact, of the 1.5 million unplanned pediatric hospitalizations that occur each year, 75 percent now come from EDs.
The remaining 25 percent occur through direct admission from the community—from patients’ homes or from primary care or specialty clinics, and are typically facilitated by direct conversations between community-based and hospital-based healthcare providers.
But more purposefully designed direct admission systems are needed in hospitals to receive referrals from physicians in the community. And while ED utilization patterns have been well-studied, research comparing the effectiveness of direct and ED admissions is lacking, especially in children.
“Direct admission may offer benefits for both patients and healthcare systems, including reduced ED volumes, improved coordination between outpatient and hospital-based healthcare providers, and improved family experience of care,” says Leyenaar, an associate professor of pediatrics at Geisel and of The Dartmouth Institute for Health Policy and Clinical Practice.
The overall goals of the project will be to: implement pediatric direct admission systems at three different hospitals; compare the timeliness of healthcare delivery for children who are admitted directly and through EDs; determine which patient populations achieve the greatest benefits from direct admission; and identify barriers and facilitators of successful implementation.
The researchers will also look at patient-reported experience of care, emergency response calls, and rates of unplanned transfers to intensive care units. Forty-seven pediatric primary care practices will participate in the direct admission intervention, and outcomes will be examined in more than 1,200 children and adolescents.
The project will be the first prospective study to evaluate the comparative effectiveness of direct and ED admissions for children, engaging various stakeholders to identify the patient populations, settings, and processes that are most appropriate for the direct admission approach.
“In completing this research, we hope to generate knowledge that will be of interest to both patients and families and their healthcare teams, enabling evidence-informed decisions about how and when to admit children to the hospital through direct admission,” says Leyenaar.
The three-year study was selected through a highly competitive review process in which patients, caregivers, and other stakeholders joined scientists to evaluate the proposals.
“This project was selected by PCORI funding not only for its scientific merit and commitment to engaging patients and other healthcare stakeholders in a major study conducted in real-world settings, but also for its potential to answer important questions about the risks and benefits of hospital admission approaches and fill a crucial evidence gap,” says PCORI Executive Director Joe Selby, MD, MPH. “We look forward to following the study’s progress and working with Dr. Leyenaar and her team to share the results.”
PCORI is an independent, non-profit organization authorized by Congress in 2010 with the mission of funding research that will provide patients, their caregivers, and clinicians with the evidence-based information they need to make better-informed healthcare decisions.
The Geisel team’s award has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.