Damian McNamara

November 05, 2013

ORLANDO, Florida — Preventable readmission rates for children are lower than all-cause readmission rates, according to a new study.

"The concern that many of us have is that there is much less to be gained from a major effort to reduce pediatric readmissions because so many are due to an unpredictable disease process," James Gay, MD, from Monroe Carell Jr. Children's Hospital at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News.

"Pediatricians try very hard to keep their patients out of the hospital in the first place," he explained, "so a large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall, and it might actually distract from efforts in other areas, such as concentrating on patient safety."

Dr. Gay presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Pressure is on at hospitals to reduce 30-day readmissions, which are considered by some regulators to be a metric of patient safety and quality care. The Affordable Care Act requires a hospital readmission reduction program for facilities that treat Medicare patients and imposes penalties for institutions with high rates.

 
A large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall.
 

Hospital administrators are therefore keen to identify preventable readmissions. Some state Medicaid programs use the 3M Potentially Preventable Readmissions grouping software; however, data on its use in pediatric readmissions are lacking, said Dr. Gay.

His team assessed 1,749,747 hospitalizations in 58 Children's Hospital Association member hospitals. They used the 3M software to calculate all-cause readmission rates with the company's proprietary list of 314 All Patient Refined Diagnostic Related Groups.

The software flagged 80% or more of all-cause readmissions as potentially preventable for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy. In contrast, the software suggested that more than 40% of 30-day readmissions were not preventable, including those for seizures, gastroenteritis, central line infections, urinary tract infections, and failure to thrive.

For the 20 leading patient diagnostic groups for all-cause readmissions, the software algorithm removed chemotherapy, acute leukemia, and cystic fibrosis from the list of potentially preventable reasons.

Table. All-Cause vs Preventable Pediatric Readmissions

Day All-Cause Readmissions (%) Preventable Readmissions (%)
7 4.9 2.5
15 8.5 4.1
30 13.0 6.2

 

"There are many fewer pediatric than adult hospitalizations in the first place, and the numbers and rates of readmissions are lower in children," Dr. Gay pointed out. According to Medicare estimates, "older adults have readmission rates of about 20% at 30 days. The overall pediatric rates are closer to 6% to 10%," he added.

Conditions that drive hospital readmission in children, or lead to admission in the first place, are very different from those in adults, Dr. Gay said. For example, adults are more likely to be readmitted within 30 days because of a high prevalence of chronic conditions, like congestive heart failure and chronic obstructive pulmonary disease, whereas children have more acute illnesses, such as pneumonia, bronchiolitis, and asthma.

"Because of these issues, many hospital pediatricians believe that readmission rates are not a good quality measure for pediatrics," Dr. Gay said.

Asked by Medscape Medical News to comment on this study, Mark Shen, MD, from Dell Children's Medical Center in Austin, Texas, noted that "in this study, the single most common reason for readmission was chemotherapy. We expect these kids to come back — we've wiped out their immune system."

Other children are discharged with the expectation they will return as well, he added. "Sometimes we know they're coming back. We're just giving them a break at home, such as children with sickle cell disease or ventricular shunts."

This study is useful because it indicates that the rate of 30-day hospital readmission is lower for children than for adults. Further research could focus on key chronic conditions associated with more readmissions in children, which so far only have been identified in adults. "But we're getting closer in pediatrics," Dr. Shen added.

The study authors caution that the 3M software might not completely reflect the reasons for pediatric readmissions, and future studies are warranted to validate its use in this population. The broader issue is whether efforts to track and reduce adult hospital readmissions apply equally to pediatric patients, Dr. Gay said.

Dr. Gay and Dr. Shen have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2013 National Conference and Exhibition: Abstract 7. Presented October 27, 2013.

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