Frequent, potentially avoidable readmissions are major driver of pediatric health care costs

Among a group of children's hospitals, nearly 20 percent of admissions and one-quarter of inpatient expenditures were accounted for by a small percentage of patients who have frequent recurrent admissions, according to a study in the February 16 issue of JAMA.

Hospital readmission is increasingly considered an indicator of quality of care. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data regarding the impact of their rehospitalizations, according to background information in the article. "Children with chronic conditions may require multiple, unavoidable, and necessary hospitalizations (such as chemotherapy for leukemia) to improve their health status. On the other hand, repeat admissions felt to be amenable to high-quality outpatient care (asthma- and seizure-related admissions, for example) or related to the same medical problem may be considered potentially avoidable."

Jay G. Berry, M.D., M.P.H., of Children's Hospital Boston and Harvard Medical School, and colleagues examined the inpatient resource usage of children experiencing recurrent hospital readmissions and evaluated the clinical and demographic characteristics of patients and the reasons for readmission. The analysis included 317,643 patients (n = 579,504 admissions) admitted to 37 U.S. children's hospitals in 2003 with follow-up through 2008. Among the outcomes measured included the maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period.

Among the sample, 69,294 patients (21.8 percent) experienced 1 or more readmission within 365 days of a prior admission. Among them, 9,237 patients (2.9 percent) experienced 4 or more readmissions within a 365-day interval with a median (midpoint) of 37 days between their admissions. Despite comprising only 2.9 percent of patients in the group, these patients accounted for 18.8 percent (109,155) of admissions, 23.4 percent (491,815) of bed-days, and 23.2 percent ($3.42 billion) of total inpatient charges for the study group during the entire follow-up period.

As readmission frequency increased from 0 to 4 or more, there was an increase in the percentage of children ages 13 to 18 years; adult patients older than 18 years; patients who had public insurance; non-Hispanic black patients; and patients with 1 or more complex chronic conditions (CCC). Also, as readmission frequency increased from 0 to 4 or more, the percentage of technology assistance increased and the percentage of hospitalizations associated with an ambulatory care-sensitive condition (ACSC) decreased.

Among patients with 4 or more readmissions within a 365-day interval, 28.5 percent were hospitalized for a problem in the same organ system during the interval.

Neuromuscular CCCs were the most prevalent disease group among patients frequently readmitted; asthma was the most common ACSC and a respiratory problem was one of the most common major diagnostic categories encountered repeatedly across patients' multiple readmissions.

The authors write that the attributes of pediatric patients at risk for recurrent readmissions observed in this study suggest that heightened complexity of discharge care planning may be needed to ensure their safe transition from the hospital. "Those patients with multiple CCCs and technology assistance may require communication, proactive care planning, and follow-up appointments with multiple outpatient specialty providers, equipment specialists, and home nurses at discharge. High-quality discharge care planning, including timely communication with outpatient providers regarding hospitalization course and postdischarge care instructions, may be an important mitigating factor to minimize readmission. However, this planning may not prevent multiple future readmissions in children at risk for them if the outpatient providers and health system are underequipped to meet their health care needs, optimally manage their acute illnesses, and minimize their chronic illness exacerbations."