Rehospitalization of children with asthma

Factors associated with future hospitalization among children with asthma: a systematic review

OBJECTIVE

Asthma is a leading cause of emergency department (ED) visits and hospitalizations in children, though many could be prevented. Our study objective was to identify factors from the published literature that are associated with future hospitalization for asthma beyond 30 days following an initial asthma ED visit.

DATA SOURCES

We searched CINAHL, CENTRAL, MEDLINE, and Embase for all studies examining factors associated with asthma-related hospitalization in children from January 1, 1992 to February 7, 2022.Selecting Studies: All citations were reviewed independently by two reviewers and studies meeting inclusion criteria were assessed for risk of bias. Data on all reported variables were extracted from full text and categorized according to identified themes. Where possible, data were pooled for meta-analysis using random effects models.

RESULTS

Of 2262 studies, 68 met inclusion criteria. We identified 28 risk factors and categorized these into six themes. Factors independently associated with future hospitalization in meta-analysis include: exposure to environmental tobacco smoke (OR = 1.94 95%CI 0.67-5.61), pets exposure (OR = 1.67 95%CI 1.17-2.37), and previous asthma hospitalizations (OR = 3.47 95% CI 2.95-4.07). Additional related factors included previous acute care visits, comorbid health conditions (including atopy), allergen exposure, severe-persistent asthma phenotype, inhaled steroid use prior to ED visit, poor asthma control, higher severity symptoms at ED presentation, warmer season at admission, longer length of stay or ICU admission, and African-American race/ethnicity.

CONCLUSIONS

We identified multiple factors that are consistently associated with future asthma hospitalization in children and could be used to identify those who would benefit from targeted preventative interventions.

Thirty-day unplanned readmission in hospitalised asthma patients in the USA

INTRODUCTION

Hospital quality improvement and hospital performance are commonly evaluated using parameters such as average length of stay (LOS), patient safety measures and rates of hospital readmission. Thirty-day readmission (30-DR) rates are widely used as a quality indicator and a quantifiable metric for hospitals since patients are often readmitted for the exacerbation of conditions from index admission. The quality of patient education and postdischarge care can influence readmission rates. We report the 30-DR rates of patients with asthma using a national dataset for the year 2013.

OBJECTIVES

The aim of our study was to assess the 30- day readmission (30-DR) rate as well as, the causes and predictors of readmissions.

STUDY DESIGNS/METHODS

Using the Nationwide Readmission Database (NRD) (2013), we identified primary discharge diagnoses of asthma by using International Classification of Diseases, Ninth Revision, Clinical Modification code '493'. Categorical and continuous variables were assessed by a χ² test and a Student's t-test, respectively. The independent predictors of unplanned 30-DR were detected by multivariate analysis. We used sampling weights, which are provided in the NRD, to generate the national estimates.

RESULTS

There were 130 490 (weighted N=311 173) inpatient asthma admissions during 2013. The overall 30-DR for asthma was 11.9%. The associated factors for 30-DR were age 45-84 years (40.32% vs 29.05%; p<0.001), enrolment in Medicare (49.33% vs 30.61% p<0.001), extended LOS (mean, 4.40±0.06 vs 3.25±0.04 days; p<0.001), higher mean cost (US$8593.91 vs US$6741.31; p<0.001) and higher disposition against medical advice (DAMA) (4.14% vs 1.51%; p<0.001). The factors that increased the chance of 30-DR were advanced age (≥45-64 vs ≤17 years; OR 4.61, 95% CI 4.04 to 5.27, p<0.0001), male sex (OR 1.19, 95% CI 1.13 to 1.26, p<0.0001), a higher Charlson Comorbidity Index (CCI) (OR 1.16, 95% CI 1.14 to 1.18, p<0.0001), DAMA (OR 2.32, 95% CI 2.08 to 2.59, p<0.0001), non-compliance with medication (OR 1.34, 95% CI 1.24 to 1.46, p<0.0001), post-traumatic stress disorder (OR 1.48, 95% CI 1.22 to 1.79, p<0.0001), alcohol use (OR 1.45, 95% CI 1.27 to 1.65, p<0.0001), gastro-oesophageal reflux disease (OR 1.20, 95% CI 1.14 to 1.27, p<0.0001), obstructive sleep apnoea (OR 1.11, 95% CI 1.03 to 1.18, p<0.0042) and hypertension (OR 1.11, 95% CI 1.06 to 1.17, p<0.0001).

CONCLUSIONS

We found that the overall 30-DR rate for asthma was 11.9% all-cause readmission. Major causes of 30-DR were asthma exacerbation (36.74%), chronic obstructive pulmonary disease (11.47%), respiratory failure (6.46%), non-specific pneumonia (6.19%), septicaemia (3.61%) and congestive heart failure (3.32%). One-fourth of the revisits occurred in the first week, while half of the revisits took place in the first 2 weeks. Education regarding illness and the importance of medicine compliance could play a significant role in preventing asthma-related readmission.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review

OBJECTIVE

To systematically review the literature on pediatric asthma readmission risk factors.

STUDY DESIGN

We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk.

RESULTS

Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4).

CONCLUSIONS

Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions.

TRIAL REGISTRATION

CRD42018107601.

Pediatric asthma hospitalization: individual and environmental characteristics of high utilizers in South Texas

OBJECTIVE

Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma from a low-income community with a high number of hospitalizations.

METHODS

The study population included 902 children admitted at least once to a children's hospital in South Texas because of asthma from 2010 to 2016. The population was divided into three groups by utilization frequency (high: ≥4 times, medium: 2-3 times, or low: 1 time). Individual-level factors at index admission and environmental factors were included for the analysis. Unadjusted and adjusted multivariate ordered logistic regression models were applied to identify significant characteristics of high hospital utilizers.

RESULTS

The high utilization group comprised 2.4% of total patients and accounted for substantial hospital resource utilization: 10.8% of all admissions and 13.5% of days stayed in the hospital. Patients in the high utilization group showed longer length of stay (LOS) and shorter time between admissions on average than the other two groups. The multivariate ordered logistic regression models revealed that age of 5-11 years (OR = 0.57, 95%CI = 0.35-0.93), longer LOS (2 days: OR = 1.80, 95%CI = 1.15-2.84; ≥3 days: OR = 3.38, 95%CI = 2.10-5.46), warm season at index admission (OR = 1.49, 95%CI = 1.01-2.20), and higher average ozone level in children's residential neighborhoods (OR = 1.78, 95%CI = 1.01-3.14) were significantly associated with a higher number of asthma hospitalizations.

CONCLUSIONS

The findings suggest the importance of monitoring high hospital utilizers and establishing strategies for such patients based on their characteristics to reduce repeated hospitalizations and to increase optimal use of hospital resources.

Predictors of Hospital Reuse Among Publicly Insured Children Hospitalized for Status Asthmaticus

BACKGROUND

Asthma is a common cause of pediatric hospitalization. Nonadherence to asthma medications is associated with worse outcomes; however, there is a paucity of data regarding posthospitalization prescription filling and hospital reuse. Our objective was to identify patients at risk for hospital reuse after being hospitalized for asthma.

METHODS

This is a retrospective study of patients with asthma who were discharged from a children's hospital in which we use Medicaid claims data to evaluate prescription fills within 30 days and 12 months. Chart reviews were used for demographics, chronic asthma severity, admission severity, and hospital reuse. t and χ² tests were performed for continuous and categorical variables. A generalized linear mixed model was fitted to predict the odds of hospital reuse, which was defined as requiring an emergency department visit or rehospitalization. Survival analysis using log-rank testing was used for modeling the time to hospital reuse.

RESULTS

Fifty-four percent of patients discharged with asthma had hospital reuse within 1 year of discharge. There was no association between hospital reuse and prescription filling for systemic steroids (odds ratio [OR] 1.30; confidence interval [CI]: 0.85-2.00; P = .21) or controller medications (OR 1.5; CI: 0.92-2.52; P = .10). There was a higher number of controller and systemic steroid prescription fills over 12 months for patients with hospital reuse. The factors associated with greater odds of hospital reuse were severity of chronic asthma diagnosis (P = .03) as well as African American race (OR 1.92; CI: 1.17-3.13; P = .01).

CONCLUSIONS

For Medicaid-insured patients discharged with asthma, worse chronic asthma severity and African American race were associated with greater odds of hospital reuse. Decreased prescription filling was not associated with greater odds of hospital reuse.

Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis

BACKGROUND

Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature.

METHODS

We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma.

RESULTS

Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission.

CONCLUSION

Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers.

National estimates of 30-day readmissions among children hospitalized for asthma in the United States

OBJECTIVE

Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions.

METHODS

Data (n = 12,842) for children aged 6-18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors.

RESULTS

Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12-18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33-4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories.

CONCLUSION

A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years.

METHODS

Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions.

RESULTS

From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions.

CONCLUSION

A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Association between Postdischarge Oral Corticosteroid Prescription Fills and Readmission in Children with Asthma

OBJECTIVES

To assess the relationships between postdischarge emergency department visits, oral corticosteroid (OCS) use, and 15- to 90-day asthma readmission in children.

STUDY DESIGN

Retrospective study of 9288 children from 12 states in the Truven MarketScan Database, ages 2-18 years, hospitalized between January 1, 2009, and June 30, 2011, with asthma, and continuously enrolled in Medicaid for 6 months prior and 3 months after hospitalization. The primary outcome was 15- to 90-day readmission for asthma. Secondary outcomes were postdischarge emergency department visits (within 28 days) and outpatient OCS prescription fills (6-28 days postdischarge or earlier if coinciding with an outpatient asthma visit). Logistic regression was used to assess the relationship of hospital readmission with patient characteristics and asthma health services surrounding the index admission.

RESULTS

Median age at index admission was 6 years (IQR, 3-9); 62% were male and 49% were black; 2.8% had a 15- to 90-day readmission (median, 50 days; IQR, 32-70). After index discharge, 4% had an emergency department visit (median, 17 days; IQR, 12-24) and 11% had an outpatient OCS fill (median, 14 days; IQR, 6-21). In multivariable analysis, children with a postdischarge outpatient OCS fill (OR, 3.2; 95% CI, 2.4-4.6) or hospitalization within 6 months preceding the index admission (OR, 2.9; 95% CI, 2.0-4.0) had the greatest likelihood for hospital readmission.

CONCLUSIONS

OCS fill within 28 days of hospital discharge was most strongly associated with 15- to 90-day hospital readmission. This finding may inform evolving strategies to reduce asthma readmissions in children.

Risk factors associated with 30-day asthma readmissions

OBJECTIVES

Assess factors that increase the odds of 30-day asthma readmissions to hospitals.

METHODS

Retrospective chart review between 1/1/2002 to 12/31/2012 of pediatric and adult patients with the primary diagnosis of asthma readmitted within 30 days after the index admission was performed. Patients were identified from billing database for asthma ICD 9 code (493.9). Inclusion criteria were: physician confirmed asthma diagnosis, one or more asthma admissions and accessible medical records.

RESULTS

A total of 95 patients with multiple asthma readmissions were included in the final analysis. Thirty-seven patients (39%) were readmitted for asthma within 30 days and 58 patients (61%) had readmission in a 30-365-day period. Demographic characteristics were not significantly different between groups. Bivariate analysis showed that factors associated with higher likelihood of readmissions were a higher frequency of previous admissions, ED visits, inpatient hospitalizations, ICU stays, intubations, chest X-rays, history of chronic sinusitis, gastroesophageal reflux disease, anxiety, and the use of tiotropium or a long-acting beta-agonist (LABA). Multivariable analysis confirmed that prior hospital admissions and a history of GERD are the strongest predictive factors for early asthma readmissions, yet a history of environmental allergies might be a protective factor (p = 0.053).

CONCLUSIONS

Non-allergic asthma patients with multiple prior admissions, ED visits and inpatient hospitalizations, on multiple medications with history of GERD, sinusitis, and anxiety are more likely to be readmitted within 30 days irrespective of other factors. Patients with these characteristics should be assessed for interventions in an effort to reduce early readmissions.

Risk factors associated with hospital readmission in pediatric asthma

Asthma is a leading cause of hospitalization among children, and about 15-50% of pediatric patients are readmitted after an index admission. The purpose of this integrative review is to explore contemporary scientific findings on the association between pediatric asthma readmission and various demographic, environmental, psychosocial and clinical risk factors. An electronic database search resulted in a sample of 29 studies. African American, public or no insurers, previous admission and complex chronic comorbidity were identified as risk factors associated with pediatric asthma readmission. However, more interdisciplinary and well-designed investigations are warranted to further explicate the spectrum of environmental and psychosocial correlates.

Post-hospital syndrome in adults with asthma: a case-crossover study

BACKGROUND

Post-hospital syndrome refers to the period of generalized risk of adverse health outcomes among patients who are recently discharged from hospital. This period is associated with a short-term increased risk of readmission which may not be related to the original condition. While the majority of studies of post-hospital syndrome have focused on all-cause readmissions, whether and to what extent such a phenomenon exists within discrete medical conditions is not yet known.

OBJECTIVE

To investigate whether the risk of admission due to asthma is increased in individuals who are discharged following any-cause hospital admission.

METHODS

Using administrative health data for the period 1997 to 2007 from the province of British Columbia, Canada, we created a cohort of adults with asthma. Using a case-crossover design, we assessed the association between discharge from a hospital (exposure) within 30 days before an asthma-related hospitalization (the outcome), using two 30-day control periods within the same subject. Conditional logistic regression was performed to calculate the relative risk (RR) of the outcome in association with exposure. We performed several sensitivity and subgroup analyses.

RESULTS

The final cohort included 3,852 patients experiencing 6,333 instances of the outcome. Mean age at the time of the outcome was 43.7 (SD 14.2), 69.0% of such outcomes belonged to females. The RR of the outcome within the next 30 days of a previous any-cause discharge was 1.40 (95% CI 1.22 - 1.59). However, the association was mainly caused by discharge from asthma-related admission [RR = 1.99 (95% CI 1.65 - 2.39)]. The RR associated with non-asthma-related discharge was 0.88 (95% CI 0.74 - 1.04) and was not statistically significant. Similar results were obtained in a range of sensitivity analyses.

DISCUSSION

Our results indicate that in patients with asthma, the 30-day risk of asthma-related admission is increased after an episode of asthma-related hospitalization, but not after an episode of non-asthma-related hospitalization.

Should readmission within 30 days after discharge of children hospitalized for a neurologic disorder be considered a quality assurance failure?

The Affordable Care Act penalizes hospitals with high readmission rates. Children's hospitals are not yet among these hospitals, although that is likely to change. Because chronic neurologic conditions represent a sizable proportion of all children's hospitals costs, and because some/many of the readmissions might not be easily prevented, children's hospitals and neurologists who care for children might be inappropriately penalized for some readmissions. We encourage more study to identify the correlates of readmission of children who have a neurologic disorder.

An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions

Background

Hospital patient-to-nurse staffing ratios are associated with quality outcomes in adult patient populations but little is known about how these factors affect paediatric care. We examined the relationship between staffing ratios and all-cause readmission (within 14 days, 15–30 days) among children admitted for common medical and surgical conditions.

Methods

We conducted an observational cross-sectional study of readmissions of children in 225 hospitals by linking nurse surveys, inpatient discharge data and information from the American Hospital Association Annual Survey. Registered Nurses (N=14 194) providing direct patient care in study hospitals (N=225) and children hospitalised for common conditions (N=90 459) were included.

Results

Each one patient increase in a hospital's average paediatric staffing ratio increased a medical child's odds of readmission within 15–30 days by a factor of 1.11, or by 11% (95% CI 1.02 to 1.20) and a surgical child's likelihood of readmission within 15–30 days by a factor of 1.48, or by 48% (95% CI 1.27 to 1.73). Children treated in hospitals with paediatric staffing ratios of 1 : 4 or less were significantly less likely to be readmitted within 15–30 days. There were no significant effects of nurse staffing ratios on readmissions within 14 days.

Discussion

Children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. Lower patient-to-nurse ratios hold promise for preventing unnecessary hospital readmissions for children through more effective predischarge monitoring of patient conditions, improved discharge preparation and enhanced quality improvement success.

The Joint Commission Children's Asthma Care quality measures and asthma readmissions

BACKGROUND AND OBJECTIVES

The Joint Commission introduced 3 Children's Asthma Care (CAC 1-3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission's measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1-3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).

METHODS

The study included children aged 2 to 17 years who were admitted to a tertiary care children's hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005-December 31, 2007), implementation (January 1, 2008-March 31, 2009), and postimplementation (April 1, 2009-December 31, 2010) periods. Changes in provider compliance with CAC 1-3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.

RESULTS

A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.

CONCLUSIONS

Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.

State-level child health system performance and the likelihood of readmission to children's hospitals

OBJECTIVES

To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located.

STUDY DESIGN

We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund.

RESULTS

A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge.

CONCLUSIONS

Hospital readmission rates are significantly related to the performance of the surrounding health care system.

Regional and racial disparities in asthma hospitalizations in Mississippi

BACKGROUND

In the United States, asthma hospitalization rates are disproportionately high among blacks compared with other racial/ethnic groups and vary by geographic region. These disparities among asthma hospitalizations might be affected by social, environmental, and health-care access factors.

OBJECTIVE

To determine demographic risk factors for asthma hospitalizations in urban versus rural areas of Mississippi.

METHODS

A cross-sectional study using data from the Mississippi Asthma Surveillance System was conducted to compare asthma hospitalizations in the urban Jackson metropolitan statistical area and rural Delta regions of Mississippi from 2003 to 2005. Factors including race, sex, age, and household income that might be associated with multiple hospitalizations for asthma (3 or more during the study period) were assessed using logistic regression.

RESULTS

Asthma hospitalization rates were significantly higher among all demographic groups in the rural Delta region compared with the urban Jackson Metropolitan Statistical Area (P < .001). In both regions, hospitalization rates were higher among blacks and females (P < .001). Asthma hospitalization rates were highest among children (0-17 years) and older adults (>or=65 years). In both regions, blacks were more likely to have 3 or more asthma hospitalizations (P < .001). Residents of the Delta had higher odds for multiple hospitalizations controlling for race, sex, age, and household income (P < .05).

CONCLUSION

Blacks with asthma are more likely to have multiple asthma hospitalizations in Mississippi. Higher odds of multiple asthma discharges for Delta residents were not explained by race, sex, age, or income, indicating that other contributing factors (eg, environmental, social, and access to care factors) need further investigation.

Use of inhaled corticosteroids decreases hospital admissions for asthma in young children

BACKGROUND

An active use of inhaled corticosteroids for asthma has been associated with less asthma exacerbations and hospital admissions in children aged more than 2 years. The present study aimed to investigate hospital admission rates in young children from two populations in relation to the age-specific use of maintenance medication for asthma.

METHODS

Annual data on children aged less than 24 months treated for asthma, including data on the use of maintenance medication based on the purchases of prescribed medications, and annual numbers of admissions to hospital and proportions of readmissions, were collected from 1995 to 1999 in two provinces of Finland. The inclusion criteria, three or more doctor-diagnosed wheezing episodes, were individually checked by the authors in each case. The mean number of children aged less than 24 months during the years of the study was 5490 in Kuopio and 9914 in Oulu area.

RESULTS

In the Kuopio area, during the years of the study, 16.5/1000 children aged less than 24 months were on maintenance medication for asthma, and 90% of them were receiving inhaled corticosteroids. In the Oulu area, the respective figures were 13.5/1000 (P<0.001) and 99%. The average admission rate was 7.9/1000 in the Kuopio area and 8.7/1000 in the Oulu area (P<0.05). The readmissions indicated the higher admission rates in the Oulu (40% of all admissions) than in the Kuopio (28%) area (P<0.01).

CONCLUSION

Active use of maintenance therapy by inhaled corticosteroids was associated with a decreased need of hospital treatment in young children <24 months old with asthma, mainly because of less readmissions.

Hospital readmissions for childhood asthma: the role of individual and neighborhood factors

OBJECTIVES

This study used a Cox proportional hazards model to determine whether neighborhood characteristics are associated with risk of readmission for childhood asthma independently of individual characteristics.

METHODS

Rhode Island Hospital Discharge Data from 2001 to 2005 were used to identify children younger than 19 years of age at the time of the index (i.e., first) asthma admission, defined as a primary diagnosis of asthma or a primary diagnosis of respiratory illness with a secondary or tertiary diagnosis of asthma (n=2,919). Hazard ratios of repeat hospitalizations for childhood asthma from 2001 to 2005 were estimated, controlling for individual- and neighborhood-level variables.

RESULTS

During the study period, 15% of the sample was readmitted for asthma (n=451). In the unadjusted cumulative hazard curves, children residing in the census tracts with the highest proportion of crowded housing conditions, racial minority residents, or neighborhood-level poverty had higher cumulative hospital readmission rates as compared with children who resided in less disadvantaged neighborhoods. In the fully adjusted models, children insured by Medicaid at the time of their index admission had readmission rates that were 33% higher than children who were privately insured.

CONCLUSION

Our findings suggest that differences in health-care coverage are associated with higher readmission rates for pediatric asthma, but the relationship between neighborhood inequality and repeat hospitalizations for pediatric asthma requires further exploration. Social indicators such as minority race, Medicaid health insurance, and neighborhood markers of economic disadvantage are tightly interwoven in the U.S. and teasing these relationships apart is important in asthma disparities research.

How well can hospital readmission be predicted in a cohort of hospitalized children? A retrospective, multicenter study

BACKGROUND

Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization.

METHODS

This was a retrospective cohort study. Hospital administrative data were collected from 38 children's hospitals in the United States for the years 2003-2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission.

RESULTS

Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model.

CONCLUSIONS

Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Predictors of early hospital readmission for asthma among inner-city children

Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma. Cases were readmitted with asthma within 30 days of discharge. Controls were not readmitted. Conditional logistic regression analysis was used. History of asthma hospitalization within the past 12 months was an independent predictor of early readmission (OR 1.89, p = 0.021). Modifiable factors such as medical treatment and management during and upon discharge from the index admission did not predict early asthma readmission.

Fatores de risco para readmissão hospitalar de crianças e adolescentes asmáticos

OBJETIVO: Verificar a importância da admissão hospitalar de lactentes jovens na readmissão futura por asma. MÉTODOS: Realizou-se uma avaliação retrospectiva de prontuários de 202 pacientes, menores de quinze anos, registrados em ambulatório de Pneumologia Pediátrica, que foram reinternados uma ou mais vezes. O tempo decorrido entre a primeira hospitalização e a subseqüente readmissão foi analisado pelo método de Kaplan Meier, ao passo que a comparação entre as curvas de sobrevivência para diferentes faixas etárias foi analisada pelo teste log-rank. Empregou-se ainda análise multivariada para avaliação dos fatores de risco associados à readmissão. RESULTADOS: Readmissões foram observadas na quase totalidade dos pacientes nos dezoito meses seguintes à primeira hospitalização (94,5%). Quando a idade à primeira admissão hospitalar foi =12 meses, a readmissão foi mais precoce, comparada à do grupo com doze meses ou mais (p = 0,001). Os fatores de risco associados à readmissão foram: idades à primeira admissão inferiores a doze meses (odds ratio: 2,55, intervalo de confiança de 95%: 1,18 - 5,48) e entre treze e 24 meses (odds ratio: 3,54, intervalo de confiança de 95%: 1,31 - 9,63), e gravidade do quadro clínico de asma (odds ratio: 3,86, intervalo de confiança de 95%: 2,02 - 7,4). CONCLUSÃO: Após a primeira hospitalização, as crianças com asma devem ter acompanhamento rigoroso, pois o risco de readmissão é elevado nos primeiros meses após a alta, principalmente nos menores de dois anos. Os serviços de saúde devem se organizar adequadamente para enfrentar este problema, inclusive quanto à ampla dispensação de medicação profilática.

Gaps in enrollment from a Medicaid managed care program: effects on emergency department visits and hospitalizations for children with asthma

BACKGROUND

For high-risk children with asthma enrolled in Medicaid, loss of Medicaid coverage is a potential threat to access to quality asthma care.

OBJECTIVE

We sought to quantify the effect of gaps in enrollment on emergency department visits and hospitalizations for children with asthma in TennCare, Tennessee's managed care program for Medicaid-eligible and uninsured children.

METHODS

Children with asthma were identified from a research database of files maintained by the state. Gaps in enrollment in the state insurance program were measured between 1998 and 2002. Children with gaps were compared with children without gaps with respect to emergency department visits and hospitalizations for asthma, respiratory illnesses, croup, and other diagnoses.

RESULTS

Among children who met study definitions of asthma, 2373 experienced a gap in enrollment during the study period (10.4%). The rate of hospitalizations and emergency department visits for children with gaps (7402/10,000 person years) was significantly lower than the rate of study events for children with no gaps (9230/10,000 person years) (adjusted incidence rate ratio 0.88; 95% confidence interval 0.81-0.96). The rate of hospitalizations for asthma and other respiratory conditions was not different between the 2 groups; however, there was a significantly lower rate of hospitalizations for other reasons for children with gaps (adjusted incidence rate ratio 0.59; 95% confidence interval 0.41-0.86).

CONCLUSIONS

Children with asthma who had gaps in a Medicaid managed care insurance program had no increase in asthma related emergency department visits and hospitalizations. Children who had gaps did have fewer nonrespiratory emergency department visits and hospitalizations than their non-gap counterparts. Further study is needed to explore the reasons for this unexpected finding.

The relationship between the quality of prescribing and practice appointment rates with asthma management data in those admitted to hospital due to an acute exacerbation

Specific targeting of patients with a previous asthma hospitalisation could be more focused if predictors could be identified. This study was an observational retrospective analysis using ridge and linear multivariate regression analysis. Patient asthma management data were extracted from the hospital and general practice notes of those that had been admitted with an acute exacerbation of their asthma over a 5-year period. From the prescribing data, the annual doses of preventer (P) and reliever (R) medication were converted to defined daily doses then divided to give a P:R ratio. Preliminary statistical analysis was used to identify any association between either the P:R ratio or for the number of general practitioner (GP) practice appointments (PA) and their asthma management data. Multivariate regression analysis was applied to the P:R ratio and to PA to determine a model between each of these and asthma management data/events. GPs gave consent to access the data of 115 (out of 440) asthmatics, age >5 years, admitted to a district general hospital for asthma exacerbations between 1994 and 1998. The multivariate analysis revealed that PA was associated with oral prednisolone rescue courses (PRCs) and age whilst the P:R ratio was associated to PRCs and more reliever usage but not preventers. Patients with low preventer usage with respect to their reliever medication should be targeted for medication review as these were the patients prescribed more prednisolone courses and their increased PAs reflect this. This could decrease visits to the doctor and acute exacerbations.

Risk Factors for Readmission After Neonatal Cardiac Surgery

BACKGROUND

Repeat hospitalizations place a significant burden on health care resources. Factors predisposing infants to unplanned hospital readmission after congenital heart surgery are unknown.

METHODS

This is a single-center, case-control study. Cases were rehospitalized or died within 30 days of discharge following an arterial switch operation (ASO) or Norwood procedure (NP) between 1992 and 2002. Controls underwent an ASO or NP between 1992 and 2002, and were neither readmitted nor died within 30 days of discharge. Patients and controls were matched by gender, year of birth, and procedure. Potential risk factors examined included indices of medical status at the time of discharge, determinants of access to health care, and provider characteristics.

RESULTS

Forty-eight patients were readmitted; 19 of 498 (3.8%) following an ASO and 29 of 254 (11.4%) after a NP (p < 0.001). Six infants died within 30 days of discharge; 1 after an ASO and 5 after a NP. In multivariate analysis, predictors of readmission or death were: residual hemodynamic problem(s) (odds ratio [OR] 4.10 [1.18, 14.3], p = 0.026); an intensive care unit stay greater than 7 days (OR 5.17 [1.12, 23.9] p = 0.035) (ASO); residual hemodynamic problem(s) (OR 5.84 [1.98, 17.2], p = 0.001); and establishment of full oral intake less than 2 days before discharge (OR 5.83 [1.83, 18.6], p = 0.003) (NP). Combining both groups, living in a low income Zip Code (< 30,000 dollars/annum) was associated with a lower likelihood of readmission (OR 0.25 [0.07, 0.85], p = 0.027).

CONCLUSIONS

Residual hemodynamic problem(s) predispose to hospital readmission after the ASO and NP. Low socioeconomic status may reduce the likelihood of readmission even when problems arise.

A Cox regression analysis of covariates for asthma hospital readmissions

BACKGROUND

Asthma hospital admissions and readmissions are unacceptably high, thus, a method to identify those at greatest risk could be helpful.

METHODS

An observational retrospective study using a Cox regression to determine the relationship between the time interval between admissions and possible covariates of a readmission. The covariates were age, sex, ethnicity, smoking habit, history of allergy or eczema/hay fever, age of onset, Townsend index (TI), Jarman score (JS), and drugs on discharge. Those with p < 0.2, together with interacting covariates, from the preliminary analysis were eligible for the multivariate Cox regression analysis.

RESULTS

Of the 523 patients admitted between 1994 and 1998 because of their asthma, complete data were available for 440. Of these, 112 were readmitted. Eligible covariates for the multivariate Cox regression analysis were sex, allergy status, history of eczema/hay fever, the JS and TI together with interactions between JS and TI, JS and allergy, and allergy with eczema/hay fever. There were 278 subjects (71 with a readmission) with complete data for these eligible covariates. The multivariate analysis revealed that female sex (odds ratio [OR] = 2.65, 95% confidence interval [CI] 1.42, 4.92), high JS (OR = 2.03, 95% CI 1.13-3.65), and history of allergy (OR = 1.88, 95% CI 1.06-3.32) formed the final model as significant predictors of readmission.

CONCLUSION

Females with a history of allergy that were registered at a practice with a high workload (JS) had a higher risk of readmission. The analysis method used highlights how those at risk of readmission can be identified so that they can be targeted post discharge.

Hospital readmissions for childhood asthma: a 10-year metropolitan study

Studies of asthma admissions in the St. Louis metropolitan area have disclosed substantial numbers of children with readmissions. To determine the magnitude of readmissions and attributes of children with readmissions, a retrospective analysis of 8,761 children with 14,905 asthma hospitalizations for January 1, 1990 through December 31, 1999 at the two university affiliated children's hospitals in St. Louis was undertaken. Patient attributes of age, sex, race/ethnicity, residence, payor status, length of stay, and month of admission were compared between patients admitted once during that period and patients admitted multiple times. Main outcome measures were the total number of admissions and time to readmission during the study interval. A Lin, Wei, Yang, and Ying model of time to readmission showed that African-American children with Medicaid or no insurance are at higher risk of readmission (risk ratio 1.28) than are African-American patients with commercial insurance or white/other race/ethnicity patients regardless of insurance. Probability of readmission increased from 30% after a first admission, 46% after a second, and 59% after a third. Prior admission was a more specific indicator of readmission with greater positive predictive value than ethnicity or insurance status or their combination.

Inadequate asthma treatment practices and noncompliance in Israel

Childhood asthma morbidity and mortality are increasing despite improvements in asthma therapy. The changes over the past decade in the guidelines for treatment of children with severe asthma have led to a reduction in admissions and readmissions to the pediatric intensive care unit (PICU). The Israeli medical infrastructure is exemplary in its capability of extending appropriate medical services to its entire population. Our objective was to look at the background of preventive maintenance treatment and treatment during an acute episode in children admitted to PICUs with severe asthma, and to identify areas that could be targeted for change. A 5-year retrospective chart audit on acute asthma admissions was conducted in two PICUs of general community hospitals representative of the provision of medical care in Israel. The prehospitalization preventive management and acute treatment prior to PICU admission were evaluated, and the number of admissions and readmissions was recorded. The index admission was the first episode of acute asthma for only 3% of the children: 25% of patients required readmission, and 15% of these to the PICU. In spite of a proven history of acute exacerbations of the disease, only 60% were on continuous treatment between attacks, and 29% of them had abruptly discontinued treatment, most of them shortly before the onset of the index attack. Inhaled steroids were used as maintenance and preventive treatment by less than one-third of the children, with the other two-thirds receiving mainly beta-2 agonists drugs. In conclusion, an unacceptably large proportion of asthmatic children do not receive the recommended maintenance and preventive treatment because of poor compliance, lack of education, or insufficient healthcare provision. This has probably led to avoidable recurrences of acute asthma exacerbations and unnecessary use of PICU facilities. These findings suggest that steps for implementing recommended guidelines and an educational program are needed.

Reasons for and costs of hospitalization for pediatric asthma: a prospective 1-year follow-up in a population-based setting

The aims of this study were to examine the frequency of, and the reasons for, emergency hospitalization for asthma among children. In addition, the costs of hospital treatment, preventive medication, and productivity losses of the caregivers were evaluated in a population-based setting during 1 year. Data on purchases of regular asthma medication were obtained from the Social Insurance Institution. In total, 106 (2.3/1000) children aged up to 15 years were admitted 136 times for asthma exacerbation to the Kuopio University Hospital in 1998. This represented approximately 5% of all children with asthma in the area. The trigger for the exacerbation was respiratory infection in 63% of the episodes, allergen exposure in 24%, and unknown in 13%. The age-adjusted risk for admittance was 5.3% in children on inhaled steroids, 5.8% in those on cromones, and 7.9% in those with no regular medication for asthma. The mean direct cost for an admission was $1,209 (median $908; range $454-6,812) and the indirect cost was $358 ($316; $253-1,139). The cost of regular medication for asthma was, on average, $272 per admitted child on maintenance. The annual total cost as a result of asthma rose eight-fold if a child on regular medication was admitted for asthma.