Empirical examination of the indicator 'pediatric gastroenteritis hospitalization rate' based on administrative hospital data in Italy

Abstract

Background: Awareness of the importance of strengthening investments in child health and monitoring the quality of services in the pediatric field is increasing. The Pediatric Quality Indicators developed by the US Agency for Healthcare Research and Quality (AHRQ), use hospital administrative data to identify admissions that could be avoided through high-quality outpatient care. Building on this approach, the purpose of this study is to perform an empirical examination of the 'pediatric gastroenteritis admission rate' indicator in Italy, under the assumption that lower admission rates are associated with better management at the primary care level and with overall better quality of care for children.

Methods: Following the AHRQ process for evaluating quality indicators, we examined age exclusion/inclusion criteria, selection of diagnostic codes, hospitalization type, and methodological issues for the 'pediatric gastroenteritis admission rate'. The regional variability of hospitalizations was analyzed for Italian children aged 0-17 years discharged between January 1, 2009 and December 31, 2011. We considered hospitalizations for the following diagnoses: non-bacterial gastroenteritis, bacterial gastroenteritis and dehydration (along with a secondary diagnosis of gastroenteritis). The data source was the hospital discharge records database. All rates were stratified by age.

Results: In the study period, there were 61,130 pediatric hospitalizations for non-bacterial gastroenteritis, 5,940 for bacterial gastroenteritis, and 38,820 for dehydration. In <1-year group, the relative risk of hospitalization for non-bacterial gastroenteritis was 24 times higher than in adolescents, then it dropped to 14.5 in 1- to 4-year-olds and to 3.2 in 5- to 9-year-olds. At the national level, the percentage of admissions for bacterial gastroenteritis was small compared with non-bacterial, while including admissions for dehydration revealed a significant variability in diagnostic coding among regions that affected the regional performance of the indicator.

Conclusions: For broadest application, we propose a 'pediatric gastroenteritis admission rate' that consists of including bacterial gastroenteritis and dehydration diagnoses in the numerator, as well as infants aged <3 months. We also suggest adjusting for age and including day hospital admissions. Future evaluation by a clinical panel at the national level might be helpful to determine appropriate application for such measures, and make recommendations to policy makers.

Figure 1

Percentages of hospital admissions for non-bacterial and bacterial gastroenteritis by region (0–17 years). AP, autonomous province; VG, Venezia Giulia. Data source: Ministry of Health.

Figure 2

Caterpillar plot of age-standardized regional admission rates (per 1,000) for non-bacterial gastroenteritis and for non-bacterial and bacterial gastroenteritis combined (0–17 years). Note: Dashed lines, national averages. Data source: Ministry of Health.

Figure 3

Percentages of hospital admissions for gastroenteritis and dehydration by region (0–17 years). Note: Gastroenteritis comprises both non-bacterial and bacterial diagnoses. Data source: Ministry of Health.

Figure 4

Caterpillar plot of regional age-standardized admission rates (per 1,000) for gastroenteritis and for gastroenteritis and dehydration combined (0–17 years). Note: Dashed lines, national averages. Gastroenteritis comprises both non-bacterial and bacterial diagnoses. Data source: Ministry of Health.

Figure 5

Caterpillar plot of regional admission rates (per 1,000) for gastroenteritis and dehydration (<1-, 1- to 4-, and 5- to 9-year-olds). PIE, Piedmont; AOS, Aosta Valley; LOM, Lombardy; APB, Autonomous province of Bolzano; APT, Autonomous province of Trento; VEN, Veneto; FVG, Friuli-Venezia Giulia; LIG, Liguria; EMR, Emilia-Romagna; TUS, Tuscany; UMB, Umbria; MAR, Marche; LAZ, Lazio; ABR, Abruzzo; MOL, Molise; CAM, Campania; APU, Apulia; BAS, Basilicata; CAL, Calabria; SIC, Sicily; SAR, Sardinia. Note: Dashed lines, national averages. Gastroenteritis comprises both non-bacterial and bacterial diagnoses. Data source: Ministry of Health.