Pediatric Readmissions, Revisits May Not Reflect Performance

Laurie Barclay, MD

August 26, 2013

Pediatric readmission and revisit rates are less valuable for quality assessment than in adult hospitals, as few children's hospitals are high- or low-performers for condition-specific rates, according to a retrospective analysis published online August 26 in Pediatrics.

"As a national way of assessing and tracking hospital quality, pediatric readmissions and revisits, at least for specific diagnoses, are not useful to families trying to find a good hospital, nor to the hospitals trying to improve their pediatric care," lead author Naomi Bardach, MD, assistant professor of pediatrics at University of California, San Francisco, Benioff Children's Hospital, said in a university news release. "Measuring and reporting them publicly would waste limited hospital and health care resources."

Although adult readmissions and revisit rates are a useful marker for quality assessment, it was previously unknown whether pediatric readmission rates varied meaningfully across hospitals or how many hospitals would be identified as high- or low-performers.

Using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project, the investigators identified visits for persons aged 1 to 20 years with 1 of 7 common inpatient pediatric conditions: asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy.

For all conditions, 30-day readmission rates were less than 10.0%, and most were less than 5%. The exceptions were epilepsy (6.1%), dehydration (6.0%), and mood disorders (7.6%).

"With average 30-day readmission rates hovering around 5 percent, there is little space for a hospital to be identified as having better performance," Dr. Bardach said in the release.

"The low number of outliers is likely due to the fact that most hospitals just don't admit very many kids, because children are healthier than adults," she concluded.

Thirty-day rates of inpatient or emergency department revisits ranged from 6.2% (appendicitis and epilepsy) to 11.0% (mood disorders). Among the 958 study hospitals, condition-specific visit volumes were low, and between 37.0% and 82.8% of hospitals had fewer than 25 visits.

On the basis of mixed logistic models, mood disorder was the only condition for which more than 1% of hospitals had 30-day risk-standardized revisit rates different from the mean.

Clinical Implications

To improve the usefulness of pediatric readmissions or revisits as a quality measurement, the investigators suggested looking at patients admitted with similar diagnoses as a group, which would increase the sample size at each hospital and identify more outliers.

"That has the potential to improve the usefulness of readmission rates as a quality indicator," Dr. Bardach said in the news release.

Limitations of this study include a lack of national generalizability, reliance on administrative data, and inclusion of unpreventable readmissions.

"Using currently available data and nationally accepted public reporting methods, these analyses demonstrate that although there is statistically significant variation overall across hospitals on condition-specific pediatric 30-day revisit rates, few performance outliers can be identified, likely because of low patient volumes at most hospitals," the study authors conclude. "Pooling across similar conditions, collecting better data for patient tracking, and focusing on children with [complex chronic conditions] in high-volume centers may have some potential to improve the utility of readmission rates as a performance measure."

All phases of this study were supported by the National Institute of Child Health and Human Development. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online August 26, 2013. Abstract

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