Academic journal article Health Sociology Review

The Paradox of Paediatric Social Admission

Academic journal article Health Sociology Review

The Paradox of Paediatric Social Admission

Article excerpt

Introduction

This paper argues that the hospitalisation of children for non-medical reasons presents a series of paradoxes requiring further exploration (Guttman et al 2002). Social admissions are actively discouraged in Australian hospitals where clinical practice is dominated by two interrelated paradigms: economic rationalism and evidence-based practice (Bensing 2000; Cleak 1995). The fi rst of these - economic rationalism - has resulted in a reduction in the number of hospital beds and a pressure to reduce costs by avoiding 'inappropriate admissions' (Jackson and Tobias 2001; Berman 2000; Esmail et al 2000). The second paradigm - evidence-based practice - has reinforced the biomedical model of health care by encouraging hospitals to adopt medically stringent admission criteria (Bensing 2000; Chamberlain et al 1998). Despite these trends, paediatric social admission (PSA) continues to be a common practice, both nationally and internationally (Katz et al 2002; Jackson and Tobias 2001; Mushlin and Appel 1976).

Paediatrics remains one of the few medical specialities where social factors are recognised by health professionals as legitimate grounds for hospital admission (Rovi et al 2004; Payne 2000; Wynn and Hull 1977). Despite this recognition by clinical practitioners, PSA is largely concealed due to a general ambivalence towards and disapproval by medical administrators of the non-medical admission of children (Guttman et al 2002). Hospital pressure to avoid non-urgent admissions ensures that PSA assumes the status of an open secret amongst health professionals as they actively translate social concerns into quasi-medical ones (Guttman et al 2002; Rothman 1990).

This study explores the ways in which health professionals recognise the need to admit children for social reasons but, because of the organisational and clinical pressures previously outlined, translate non-medical problems into medical 'diagnoses' for the purpose of admission. Whilst health professionals maintain a conceptual demarcation between social and medical factors, the outcome of PSA ironically involves a child's 'problems' being defi ned as a medical diagnosis and admission to the hospital system resulting in a clinical response rather than addressing of the underlying social concerns. Therefore one of the paradoxes of PSA is that it, inadvertently, 'medicalises' social concerns.

Defi ning paediatric social admission

Paediatric social admission is a colloquial term used in Australian hospitals, and in the international context refers to 'non-clinical', 'medically avoidable', or 'inappropriate' admissions (Esmail et al 2000; Werneke and MacFaul 1996). Data are diffi cult to obtain as most admissions are recorded in terms of major medical diagnoses, which are categories employed under a system referred to as Diagnostic Related Groups (DRG), for hospital fi nancing purposes. Most hospitals in Australia receive government funding for patients based on the DRG's that are identifi ed and recorded on admission. There are very few medical diagnostic codes that facilitate the recording of social reasons for hospitalisation. Hospitals have a vested fi nancial interest in recording medical diagnoses, as opposed to social factors as reasons for admission, given that funding is specifi ed by DRGs. Assessing the extent to which PSA is practiced is further complicated by the lack of documentation, as clinical training encourages health professionals not to record social and emotional issues, because they are considered to be 'too subjective' and outside of their fi eld of concern and control (Mechanic 1995).

Paediatric social admission is defi ned in medical as well as sociological literature as a non-acute medical diagnosis and set of symptoms together with contributing social or domestic circumstances, resulting in the hospital admission of a child under the age of 16 years (Katz et al 2002; Rajaratnam 1991; Wynn and Hull 1977). Such admissions frequently involve scenarios where the medical condition of the child is a relatively minor factor and would not necessarily warrant hospitalisation if it were not for the related social factors (Jackson and Tobias 2001; Soulen et al 1994; Krug et al 1997). …

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