Rising Use of Observation Status for Pediatric Populations in Six States, 2012-2019

OBJECTIVE(S): Despite a wide adoption of observation status policy for Medicare beneficiaries with diverse conditions across U.S., little is known about population-level changes in observation status use for children. This study aimed to examine statewide trends in observation status use for pediatric population. METHODS: This repeated cross-sectional analysis used statewide hospital discharge data from six states from 2012 through 2019 to characterize inpatient and observation stays for patients <18 years old with conditions that may require short-term hospital stay (i.e., <3 days). The population-level use of observation status was measured by observation stay rate, defined as the number of observation stays per 100,000 children per year for each state. Population-level changes were examined using linear regressions with generalized estimating equations to account for within-state clustering. Subgroup analyses were conducted by patient demographics, neighborhood socioeconomic characteristics, diagnosis groups, chronic condition status, and length of stay. RESULTS: Among 808,181 hospital stays, 299,483 (37.1%) were observation stays. From 2012 through 2019, observation stay rates increased in all six states, with an average annual growth of 17.8 (95% Confidence Interval (CI): 10.4-25.3) per 100,000 children. Observation stay rates significantly increased for children who were <6 years old, non-White, and publicly insured. Red blood cell disorders had the fast-growing use of observation status, with a percentage increase of 25.7% (95%CI: 18.6%-33.3%). CONCLUSION: Although descriptive, we found substantial yet differential increases in observation-status use among children, especially for younger, non-White, publicly insured children and for conditions previously cared under an inpatient designation, using multi-state population-level data.