Estimating risk associated with care in alternative settings: deterioration among children hospitalized.

BACKGROUND Although managed care favors use of alternative settings in an attempt to avoid hospitalization, uncertainty about possible deterioration creates concern about their safety. OBJECTIVE To derive preliminary estimates for the risk of adverse outcome in children hospitalized with acute illness who met criteria for admission to potentially less-expensive, alternative settings (eg, short-stay unit, home nursing). DESIGN Description of hospitalization outcomes for a community-wide childhood population. SETTING AND POPULATION All 11591 hospitalizations for residents of Monroe County (Rochester), New York, aged 1 month to 18 years in 1991 and 1992. MEASUREMENTS To identify potential adverse outcomes in alternative settings (numerator estimate), hospital medical records for admissions to regular inpatient units were examined. To ascertain deterioration among these admissions, detailed record reviews were conducted if the child died or was transferred to another hospital or to a critical care unit. To estimate the total number of admissions eligible for care in alternative settings (denominator estimate), hospital discharge files were analyzed. RESULTS Deterioration was found in 83 medical admissions. Of these 83, major chronic problems (n=53) or severe illness at presentation (n=27) precluded alternative setting eligibility, leaving only 3 in whom alternative setting care might have been considered. The total number of admissions eligible for alternative setting care was estimated between 1661 (restrictive criteria) and 3322 (inclusive criteria) for the 2-year observation period. Based on these observations, best- and worst-case estimates for the risk of deterioration in candidates for care in alternative settings 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 from first indication of deterioration to arrival in the critical care unit was 3.0 hours. CONCLUSIONS These preliminary estimates suggest that alternative settings may be safe for the care of many children currently hospitalized. A randomized clinical trial to evaluate directly the potential benefits and harms of alternative setting care should be considered.