Trends in Preventable Hospitalization Rates for Children With or Without Observation Stay Data

Importance: Potentially preventable hospitalization rates are widely endorsed quality indicators that have been used to evaluate the impact of policies on access to high-quality primary and ambulatory care for children. Although potentially preventable hospitalization rates have been decreasing, little is known about how these trends are associated with the exclusive reliance on inpatient data, which omit observation status, a common designation for pediatric hospital stays.

Objective: To assess the implications of omitting observation stay data on potentially preventable hospitalization rate calculations over time.

Design, Setting, and Participants: In this retrospective cross-sectional study, inpatient and observation stays for patients aged 6 to 17 years related to pediatric ambulatory care sensitive conditions (ACSCs), were identified from the Healthcare Cost and Utilization Project state-specific databases from Georgia, Iowa, Maryland, Nebraska, and Vermont, 2010 to 2019, and from Wisconsin, 2012 to 2019. The units of analysis include an overall aggregate level, state level, and county level. Data were analyzed from February to November 2024.

Main Outcome and Measures: The main outcome was the pediatric quality indicator overall composite of potentially preventable hospitalization rates (hereafter the composite hospitalization rate) and was calculated using inpatient-only and combined (ie, inpatient and observation) hospital stay data per 100 000 children.

Results: Among a total of 64 846 identified hospital stays (median [IQR] age, 10 [8-14] years for inpatient stays and 10 [7-13] for observation stays; 32 733 [50.5%] male; 573 [0.9%] Asian or Pacific Islander, 20 042 [30.9%] Black, 3413 [5.3%] Hispanic, 168 [0.3%] American Indian or Alaska Native, 22 970 [35.4%] White, and 1842 [2.8%] Other), 22 275 (34.4%) were observation stays. The use of observation stays grew from 2090 of 6923 stays (30.2%) in 2010 to 2525 of 5531 stays (45.7%) in 2019. When using inpatient-only data, the overall aggregate-level composite hospitalization rate per 100 000 children was 141.7 in 2010 and decreased to 71.0 in 2019, and the annual percentage change was −6.8% (95% CI, −6.8% to −6.8%; P < .001). When using combined data, the composite hospitalization rate was 203.0 in 2010 and 130.7 in 2019, respectively, with an annual percentage change of −4.5% (95% CI, −4.5% to −4.5%; P < .001). Most state-level and county-level composite hospitalization rates exhibited declining trends when using inpatient-only data. After combining observation stay data, the declines were attenuated or even reversed in some cases.

Conclusion and Relevance: Decreases in the composite hospitalization rate for pediatric ACSCs were associated with the shifting of patient status from inpatient to observation stays. These findings emphasize the need for standardized reporting and inclusion of observation stay data to support disease surveillance, policy evaluation, and decision-making.