Indian Pediatrics

, Volume 55, Issue 12, pp 1041–1045 | Cite as

Pediatric Appropriate Evaluation Protocol for India (PAEP-India): Tool for Assessing Appropriateness of Pediatric Hospitalization

  • Manoja Kumar DasEmail author
  • Narendra Kumar Arora
  • Ramesh Poluru
  • Anju Seth
  • Anju Aggarwal
  • Anand Prakash Dubey
  • Pc Goyal
  • Geeta Gathwala
  • Ashraf Malik
  • Anil Kumar Goel
  • Aparna Chakravarty
  • Sugandha Arya
  • Amit Upadhyay
  • Madhur Gupta
  • Thomas Mathew
  • Rajamohanan K Pillai
  • John Mathai
  • Sivamani Manivasagan
  • S Ramesh
  • Mahesh Kumar Aggarwal
  • Chsirtine G Maure
  • Patrick Lf Zuber
Research Paper



To develop and assess Pediatric Appropriateness Evaluation Protocol for India (PAEP-India) for inter-rater reliability and appropriateness of hospitalization.


Cross-sectional study.


The available PAEP tools were reviewed and adapted for Indian context by ten experienced pediatricians following semi-Delphi process. Two PAEP-India tools; newborn (≤28 days) and children (>28 days-18 years) were developed. These PAEP-India tools were applied to cases to assess appropriateness of admission and inter-rater reliability between assessors.


Two sets of case records were used: (i) 274 cases from five medical colleges in Delhi-NCR [≤28 days (n=51); >28 days to 18 years (n=223)]; (ii) 622 infants who were hospitalized in 146 health facilities and were part of a cohort (n= 30688) from two southern Indian states.


Each case-record was evaluated by two pediatricians in a blinded manner using the appropriate PAEPIndia tools, and ‘admission criteria’ were categorized as appropriate, inappropriate or indeterminate.

Main outcome measures

The proportion of appropriate hospitalizations and inter-rater reliability between assessors (using kappa statistic) were estimated for the cases.


97.8% hospitalized cases from medical colleges were labelled as appropriate by both reviewers with inter-rater agreement of 98.9% (k=0.66). In the southerm Indian set of infants, both reviewers labelled 80.5% admissions as appropriate with inter-rater agreement of 96.1% (k= 0.89).


PAEP-India (newborn and child) tools are simple, objective and applicable in diverse settings and highly reliable. These tools can potentially be used for deciding admission appropriateness and hospital stay and may be evaluated later for usefulness for cost reimbursements for insurance proposes.


Bed use Cost Hospital stay In-patient Utilization 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Ministry of Health and Family Welfare, Government of India. Ayushman Bharat Yojana (2018–2022). Government of India; 2018. Available from: https://www.pradhan–bharat–yojana/. Accessed March 26, 2018.Google Scholar
  2. 2.
    Ministry of Health and Family Welfare, Government of India. National Health Policy, 2017. Government of India; 2017. Available from: Accessed July 19, 2017.Google Scholar
  3. 3.
    National Health Systems Resource Centre. National Health Accounts Estimates for India (2013–14). Ministry of Health and Family Welfare Government of India; 2016. Available from: 221471416058.pdf. Accessed July 19, 2017.Google Scholar
  4. 4.
    Planning Commission (Government of India). Report of the Working Group on Tertiary Care Institutions for 12th Five Year Plan 2012–2017. Government of India; 2011. Available from: Accessed July 19, 2017.Google Scholar
  5. 5.
    Ortiga B, Salazar A, Jovell A, Escarrabill J, Marca G, Corbella X. Standardizing admission and discharge processes to improve patient flow: A cross sectional study. BMC Health Serv Res. 2012;12:180.CrossRefGoogle Scholar
  6. 6.
    Strumwasser I, Paranjpe NV, Ronis DL, Share D, Sell LJ. Reliability and validity of utilization review criteria. Appropriateness evaluation protocol, standardized medreview instrument, and intensity–severity–discharge criteria. Med Care. 1990;28:95–111.Google Scholar
  7. 7.
    Kemper KJ, Fink HD, McCarthy PL. The reliability and validity of the pediatric appropriateness evaluation protocol. QRB Qual Rev Bull. 1989;15:77–80.CrossRefGoogle Scholar
  8. 8.
    McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharmacy. 2016;38:655–62.Google Scholar
  9. 9.
    Werneke U, Smith H, Smith IJ, Taylor J, MacFaul R. Validation of the paediatric appropriateness evaluation protocol in British practice. Arch Dis Child. 1997;77:294–8.CrossRefGoogle Scholar
  10. 10.
    Esmail A. Development of the paediatric appropriateness evaluation protocol for use in the United Kingdom. J Public Health Med. 2000;22:224–30.CrossRefGoogle Scholar
  11. 11.
    Esmaili A, Seyedin H, Faraji O, Arabloo J, Qahraman Bamdady Y, Shojaee S, et al. A pediatric appropriateness evaluation protocol for Iran children hospitals. Iran Red Crescent Med J. 2014;16:e16602.CrossRefGoogle Scholar
  12. 12.
    Smith HE, Sheps S, Matheson DS. Assessing the utilization of in–patient facilities in a Canadian pediatric hospital. Pediatrics. 1993;92:587–93.Google Scholar
  13. 13.
    Gloor JE, Kissoon N, Joubert GI. Appropriateness of hospitalization in a Canadian pediatric hospital. Pediatrics. 1993;91:70–4.Google Scholar
  14. 14.
    Henley L, Smit M, Roux P, Zwarenstein M. Bed use in the medical wards of Red Cross War Memorial Children’s Hospital, Cape Town. S Afr Med J. 1991;80:487–90.Google Scholar
  15. 15.
    Shafik MH, Seoudi TMM, Raway TS, Al Harbash NZ, Ahmad MMA, Al Mutairi HF. Appropriateness of pediatric hospitalization in a general hospital in Kuwait. Med Princ Pract. 2012;21:516–21.CrossRefGoogle Scholar
  16. 16.
    Kreger BE, Restuccia JD. Assessing the need to hospitalize children: Pediatric appropriateness evaluation protocol. Pediatrics. 1989;84:242–7.Google Scholar
  17. 17.
    Werneke U, MacFaul R. Evaluation of appropriateness of paediatric admission. Arch Dis Child. 1996;74:268–73.CrossRefGoogle Scholar
  18. 18.
    Bianco A, Pileggi C, Trani F, Angelillo IF. Appropriateness of admissions and days of stay in pediatric wards of Italy. Pediatrics. 2003;112:124–8.CrossRefGoogle Scholar
  19. 19.
    Formby DJ, McMullin ND, Danagher K, Oldham DR. The appropriateness evaluation protocol: application in an Australian children’s hospital. Aust Clin Rev. 1991;11:123–31.Google Scholar
  20. 20.
    Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361: 2226–34.CrossRefGoogle Scholar
  21. 21.
    Agarwal R, Deorari A, Paul VK. AIIMS Protocols in Neonatology. 1st ed. New Delhi: CBS Publishers; 2015.Google Scholar
  22. 22.
    National Neonatology Forum, India. Evidence based clinical practice guidelines. National Neonatology Forum; 2010. Available from: Accessed July 19, 2017.Google Scholar
  23. 23.
    Ministry of Health and Family Welfare, Government of India. Facility based new born care training packages. Government of India; 2014. Available from:–components/rmnch–a/child–healthimmunization/child–health/guidelines.html. Accessed April 16, 2016.Google Scholar
  24. 24.
    World Health Organization. Global Advisory Committee on Vaccine Safety, 15–16 June 2016. Wkly Epidemiol Rec. 2016;91:341–8.Google Scholar
  25. 25.
    Cohen J. A Coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20:37–46.CrossRefGoogle Scholar
  26. 26.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–74.CrossRefGoogle Scholar
  27. 27.
    Feinstein AR, Cicchetti DV. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol. 1990;43:543–9.CrossRefGoogle Scholar
  28. 28.
    Cicchetti DV, Feinstein AR. High agreement but low kappa: II. Resolving the paradoxes. J Clin Epidemiol. 1990;43:551–8.CrossRefGoogle Scholar
  29. 29.
    Chakravarty A, Parmar N, Bhalwar R. Inappropriate use of hospital beds in a tertiary care service hospital. Med J Armed Forces India. 2005;61:121–4.CrossRefGoogle Scholar
  30. 30.
    Kanwar V, Salaria N, Khanduja P. How do nurses perceive hospital bed utilization: A prerequisite for quality improvement in nursing care. Int J Health Sci Res. 2014;4135–41.Google Scholar

Copyright information

© Indian Academy of Pediatrics 2018

Authors and Affiliations

  • Manoja Kumar Das
    • 1
    • 18
    Email author
  • Narendra Kumar Arora
    • 1
  • Ramesh Poluru
    • 1
  • Anju Seth
    • 2
  • Anju Aggarwal
    • 3
  • Anand Prakash Dubey
    • 4
  • Pc Goyal
    • 5
  • Geeta Gathwala
    • 6
  • Ashraf Malik
    • 7
  • Anil Kumar Goel
    • 8
  • Aparna Chakravarty
    • 9
  • Sugandha Arya
    • 10
  • Amit Upadhyay
    • 11
  • Madhur Gupta
    • 12
  • Thomas Mathew
    • 13
  • Rajamohanan K Pillai
    • 14
  • John Mathai
    • 15
  • Sivamani Manivasagan
    • 15
  • S Ramesh
    • 15
  • Mahesh Kumar Aggarwal
    • 16
  • Chsirtine G Maure
    • 17
  • Patrick Lf Zuber
    • 17
  1. 1.The INCLEN Trust International, Okhla Industrial Area, Phase I, New DelhiDepartments of PediatricsNew DelhiIndia
  2. 2.Lady Hardinge Medical CollegeNew DelhiIndia
  3. 3.University College of Medical SciencesNew DelhiIndia
  4. 4.Maulana Azad Medical CollegeNew DelhiIndia
  5. 5.North DMC Medical College and Hindu Rao HospitalNew DelhiIndia
  6. 6.Pt BD Sharma Postgraduate Institute of Medical Sciences, RohtakHaryanaIndia
  7. 7.Jawahar Lal Nehru Medical College, Aligarh Muslim UniversityAligarhIndia
  8. 8.All India Institute of Medical SciencesRaipurIndia
  9. 9.Hamdard Institute of Medical Sciences and ResearchJamia HamdardNew DelhiIndia
  10. 10.Vardhman Mahavir Medical College and Safdarjang HospitalNew DelhiIndia
  11. 11.LLRM Medical College MeerutUttar PradeshIndia
  12. 12.WHO Country office IndiaNew DelhiIndia
  13. 13.Community Medicine, Government Medical CollegeThiruvananthapuramKeralaIndia
  14. 14.Government Medical CollegeThiruvananthapuramKeralaIndia
  15. 15.PSG Institute of Medical Sciences and Research, CoimbatoreTamil NaduIndia
  16. 16.Ministry of Health and Family WelfareGovernment of IndiaNew DelhiIndia
  17. 17.World Health OrganizationGeneva, SwitzerlandIndia
  18. 18.The INCLEN Trust InternationalNew DelhiIndia

Personalised recommendations