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International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England


Objectives To compare emergency hospital use for infants in Ontario (Canada) and England.

Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission.

Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age.

Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.

  • emergency department
  • health services research
  • hospital medicine
  • paediatrics
  • healthcare quality improvement

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors KH performed the analysis and wrote the first draft of the manuscript. All authors contributed to interpretation of results and critically revising the manuscript.

  • Funding This study is funded by Wellcome Trust [103975/Z/14/Z] and supported by the Economic and Social Research Council through the Administrative Data Research Centre for England, University of Southampton (ES/L007617/1).

  • Competing interests None declared.

  • Ethics approval Approvals for the use of HES data were obtained as part of the standard Hospitals Episode Statistics approval process. Hospital Episode Statistics were made available by NHS Digital (Copyright © 2012, Re-used with the permission of NHS Digital. All rights reserved.) The study is exempt from UK NREC approval because it involved the analysis of an existing dataset of anonymous data for service evaluation. ICES datasets were linked using unique encoded identifiers and analysed at the Institute for Clinical Evaluative Sciences (ICES). Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI. Use of ICES data for this study was approved by the Institutional Review Board at Sunnybrook Health Sciences Centre, Toronto, Canada.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement HES data are available on application to the NHS Digital ( Publicly funded, not- for-profit researchers, students, policymakers or knowledge users can apply to use ICES data (

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