Thirty-day readmission rates following hospitalization for pediatric sickle cell crisis at freestanding children's hospitals: risk factors and hospital variation

Chronic automated red cell exchange therapy for sickle cell disease

BACKGROUND

The data to support chronic automated red cell exchange (RCE) in sickle cell disease (SCD) outside of stroke prevention, is limited, especially in adults.

STUDY DESIGN AND METHODS

A retrospective analysis was conducted of patients with SCD who were referred for chronic RCE at our institution over a 10-year period. Data that were evaluated included patient demographics, referral indications, and procedural details (e.g., vascular access, adverse events, etc.). In a subanalysis, the number of annual acute care encounters during 3 years of chronic RCE was compared with that in the year preceding the first RCE.

RESULTS

A total of 164 patients were referred for chronic RCE: median age was 28 years (interquartile range [IQR] = 22-36) at referral and 60% were female. Seventy (42.6%) were naïve to chronic transfusion (simple or RCE) prior to referral. The leading indications for referral were refractory pain (73/164, 44.5%) and iron overload (57/164, 34.7%). A total of 5090 procedures occurred during the study period (median = 19, IQR = 5-45). Of the 138 patients who had central vascular access, 8 (6%) and 16 (12%) had ≥1 central-line-related thrombosis and/or infection, respectively. Of those who were not RBC alloimmunized at initiation of RCE, 12/105 (11.4%) developed new antibodies during chronic RCE. In those 30 patients who were adherent to therapy for 3 years, there was no significant difference in acute care encounters following initiation of RCE.

CONCLUSION

Prospective clinical trials are needed to determine which patients are most likely to benefit from chronic RCE and refine selection accordingly.

Expert consensus on the management of infusion-related reactions (IRRs) in patients with sickle cell disease (SCD) receiving crizanlizumab: a RAND/UCLA modified Delphi panel

Crizanlizumab, a monoclonal antibody against P-selectin, has been shown to reduce vaso-occlusive crises (VOCs) compared to placebo in patients ≥ 16 years with sickle cell disease (SCD). However, there have been rare reports of patients experiencing severe pain and subsequent complications within 24 hours of crizanlizumab infusions. These events are defined as infusion-related reactions (IRRs). Informed by current literature and clinical experience, a group of content experts developed clinical guidelines for the management of IRRs in patients with SCD. We used the RAND/University of California, Los Angeles (UCLA) modified Delphi panel method, a valid, reproducible technique for achieving consensus. We present our recommendations for managing IRRs, which depend on patient characteristics including: prior history of IRRs to other monoclonal antibodies or medications, changes to crizanlizumab infusion rate and patient monitoring, pain severity relative to patient's typical SCD crises, and severe allergic symptoms. These recommendations outline how to evaluate and manage IRRs in patients receiving crizanlizumab. Future research should validate this guidance using clinical data and identify patients at risk for these IRRs.

Return visit rates after an emergency department discharge for children with sickle cell pain episodes

BACKGROUND

High return visit rates after hospitalization for people with sickle cell disease (SCD) have been previously established. Due to a lack of multicenter emergency department (ED) return visit rate data, the return visit rate following ED discharge for pediatric SCD pain treatment is currently unknown.

PROCEDURE

A seven-site retrospective cohort study of discharged ED visits for pain by children with SCD was conducted using the Pediatric Emergency Care Applied Research Network Registry. Visits between January 2017 and November 2021 were identified using previously validated criteria. The primary outcome was the 14-day return visit rate, with 3- and 7-day rates also calculated. Modified Poisson regression was used to analyze associations for age, sex, initial hospitalization rate, and a visit during the COVID-19 pandemic with return visit rates.

RESULTS

Of 2548 eligible ED visits, approximately 52% were patients less than 12 years old, 50% were female, and over 95% were non-Hispanic Black. The overall 14-day return visit rate was 29.1% (95% confidence interval [CI]: 27.4%-30.9%; site range 22.7%-31.7%); the 7- and 3-day return visit rates were 23.0% (95% CI: 21.3%-24.6%) and 16.7% (95% CI: 15.3%-18.2%), respectively. Younger children had slightly lower 14-day return visit rates (27.3% vs. 31.1%); there were no associations for site hospitalization rate, sex, and a visit occurring during the pandemic with 14-day returns.

CONCLUSION

Nearly 30% of ED discharged visits after SCD pain treatment had a return visit within 14 days. Increased efforts are needed to identify causes for high ED return visit rates and ensure optimal ED and post-ED care.

Impact of prenatal corticosteroid therapy on sickle cell disease in pregnant women

OBJECTIVE

To evaluate safety of prenatal corticosteroids in pregnancies of women with sickle cell disease.

METHODS

A multicenter observational study of patients with sickle cell disease, comparing vaso-occlusive crises (VOC) requiring hospital care between pregnancies with versus without prenatal corticosteroids.

RESULTS

In 40 pregnancies exposed to prenatal corticosteroids, compared with 370 unexposed pregnancies, VOC were not more frequent (62.5% vs 57.9%, P = 0.578) but they were more severe, with more intensive care hospitalizations (25.0% vs 12.9%, P = 0.039), emergency transfusions (44.7% vs 22.7%, P = 0.006), and acute chest syndromes (22.5% vs 8.9%, P = 0.010). These differences persisted after adjustment for severity and type of sickle cell syndrome (for intensive care admission adjusted odds ratio [aOR] 2.73, 95% confidence interval [CI] 1.10-6.79, P = 0.031 and for acute chest syndrome aOR 4.15, 95% CI 1.57-14.4, P = 0.008). VOC occurred on average 1.2 days following steroid administration. When comparing 36 patients receiving corticosteroids for fetal maturation with 58 patients who were hospitalized for obstetrical complications before 34 weeks of pregnancy but that did not receive corticosteroids, VOC incidence was not significantly higher (41.7% vs 31.5%, P = 0.323).

CONCLUSION

The present study was the first to study the impact of prenatal corticosteroids on sickle cell disease. They were associated with more severe VOC, suggesting that steroids should be avoided in these women.

Development and Validation of an Integrated Suite of Prediction Models for All-Cause 30-Day Readmissions of Children and Adolescents Aged 0 to 18 Years

IMPORTANCE

Readmission is often considered a hospital quality measure, yet no validated risk prediction models exist for children.

OBJECTIVE

To develop and validate a tool identifying patients before hospital discharge who are at risk for subsequent readmission, applicable to all ages.

DESIGN, SETTING, AND PARTICIPANTS

This population-based prognostic analysis used electronic health record-derived data from a freestanding children's hospital from January 1, 2016, to December 31, 2019. All-cause 30-day readmission was modeled using 3 years of discharge data. Data were analyzed from June 1 to November 30, 2021.

MAIN OUTCOMES AND MEASURES

Three models were derived as a complementary suite to include (1) children 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), (2) children 6 months or older with no prior hospitalizations in the last 6 months (new admission model [NAM]), and (3) children younger than 6 months (young infant model [YIM]). Generalized mixed linear models were used for all analyses. Models were validated using an additional year of discharges.

RESULTS

The derivation set contained 29 988 patients with 48 019 hospitalizations; 50.1% of these admissions were for children younger than 5 years and 54.7% were boys. In the derivation set, 4878 of 13 490 admissions (36.2%) in the RAM cohort, 2044 of 27 531 (7.4%) in the NAM cohort, and 855 of 6998 (12.2%) in the YIM cohort were followed within 30 days by a readmission. In the RAM cohort, prior utilization, current or prior procedures indicative of severity of illness (transfusion, ventilation, or central venous catheter), commercial insurance, and prolonged length of stay (LOS) were associated with readmission. In the NAM cohort, procedures, prolonged LOS, and emergency department visit in the past 6 months were associated with readmission. In the YIM cohort, LOS, prior visits, and critical procedures were associated with readmission. The area under the receiver operating characteristics curve was 83.1 (95% CI, 82.4-83.8) for the RAM cohort, 76.1 (95% CI, 75.0-77.2) for the NAM cohort, and 80.3 (95% CI, 78.8-81.9) for the YIM cohort.

CONCLUSIONS AND RELEVANCE

In this prognostic study, the suite of 3 prediction models had acceptable to excellent discrimination for children. These models may allow future improvements in tailored discharge preparedness to prevent high-risk readmissions.

Effects of corticosteroids in patients with sickle cell disease and acute complications: a systematic review and meta-analysis

Whether corticosteroids improve outcome in patients with acute complications of sickle cell disease (SCD) is still debated. We performed a systematic review of the literature with the aim of estimating effects of corticosteroids on the clinical course of vaso-occlusive crisis (VOC) or acute chest syndrome (ACS) in patients with SCD. The primary outcome was transfusion requirement during hospitalization. Studies were identified by search of MEDLINE and CENTRAL database. Three randomized clinical trials (RCT) and three retrospective cohort studies (RCS) were included, involving 3,304 participants and 5,562 VOC or ACS episodes. There was no difference between corticosteroids and standard treatment regarding transfusion requirement overall (odds ratio [OR]=0.98, 95% confidence interval [CI]: 0.38-2.53) but there was a significant interaction of the study type (P<0.0001): corticosteroid therapy was associated with a lower risk of transfusion in RCT (OR=0.13, 95% CI: 0.04-0.45) and a higher risk of transfusion in RCS (OR=2.12, 95% CI: 1.33-3.40. In RCT, the length of hospital stay was lower with corticosteroids as compared with standard treatment: mean difference - 24 hours (95% CI: -35 to -14). Corticosteroids were associated with an increased risk of hospital readmission as compared with standard treatment, in RCT, RCS, and the entire cohort: OR=5.91, 95% CI: 1.40-24.83; OR=3.28, 95% CI: 1.46-7.36 and OR=3.21, 95% CI: 1.97-5.24, respectively. Corticosteroids were associated with reduced number of transfusions and length of stay in RCT but not in RCS, with more rehospitalizations overall. Additional RCT should be conducted while minimizing the risk of rehospitalizations.

Navigating Ethical Challenges for Pediatric Sickle Cell Pain Management in the Context of the Opioid Epidemic

OBJECTIVES

The aim was to describe the impact of the opioid epidemic on pain management practices in pediatric sickle cell disease (SCD) and propose a conceptual framework for navigating ethical decision-making in pediatric sickle cell pain management.

METHODS

A review of the literature on ethical challenges in the management of sickle cell pain was conducted and considered in the context of the opioid epidemic and psychosocial factors affecting youth with SCD. The Integrated Ethical Framework for Pain Management (IEFPM) was applied to pediatric sickle cell pain management using a clinical case example.

RESULTS

Implicit bias, health-related stigma, and potential neurocognitive impairment all present unique challenges in ethical decision-making for youth with SCD. National guidelines for prescribing opioid medication may complicate providers' clinical decision-making and affect their sickle cell pain management practices. The IEFPM was found to be applicable to ethical decision-making for pediatric sickle cell pain and captures both patient-related and provider-related aspects of clinical pain management.

DISCUSSION

The opioid epidemic has exacerbated existing ethical challenges for pain management among youth with SCD. The IEFPM provides a conceptual model that can be integrated into health care settings to facilitate ethical decision-making and promote greater health equity in the clinical management of pediatric sickle cell pain.

Predictors for early readmission in patients hospitalized with new onset pediatric lupus nephritis

OBJECTIVE

The objective is to determine the 30-day hospital readmission rate following a hospitalization due to pediatric lupus nephritis of recent onset and characterize the risk factors associated with these early readmissions.

METHODS

The study included 76 children hospitalized from 01/01/2008 to 4/30/2017 due to a new diagnosis of lupus nephritis. We calculated the 30-day hospital readmission rate and compared the characteristics of the patients that were readmitted to patients that were not readmitted using univariable and multivariable analysis.

RESULTS

The 30-day readmission rate was 17.1%. Factors that predicted hospital readmission in unavailable analysis were male gender (38.5 vs 14.3%, p = 0.04), not receiving pulse steroids (30.8 vs 3.2%, p = < .001), receiving diuretic treatment (69.2 vs 34.9%, p = .02), receiving albumin infusions (46.2 vs 12.7%, p = .004), stage 2 hypertension on day one of admission (76.9 vs 41.3%, p = .02), a higher white blood cell count on discharge (13.7 × 10³/mm³ vs 8.8 × 10³/mm3^, p = .023), need for non-angiotensin converting enzyme (ACE) antihypertensive drugs (76.9 vs 46%, p = .042), and being discharged on nonsteroidal anti-inflammatory drugs (NSAIDs) (23.1 vs 4.8%, p = .025). Multivariable analysis demonstrated an increased risk of readmission for patients not treated with intravenous pulse methylprednisolone (IVMP) (OR = 17.5 (1.81-168.32) p = .013), and for those who required intravenous albumin assisted diuresis for hypervolemia (OR=6.25 (1.29-30.30) p = .022).

CONCLUSION

In all, 17% of children hospitalized due to new onset lupus nephritis were readmitted within 30 days of discharge. Absence of IVMP and receiving intravenous albumin assisted diuresis during initial hospitalization increase the risk of early readmission in new onset pediatric lupus nephritis.

Racism and Health-Related Quality of Life in Pediatric Sickle Cell Disease: Roles of Depression and Support

INTRODUCTIONS

Sickle cell disease (SCD) is the most commonly inherited blood disorder in the United States, and it predominately affects the Black community. SCD is characterized by a number of symptoms, including unpredictable pain, which can lead to hospitalizations. Data indicate that people with SCD experience racism and ample data indicate that racism predicts depressive symptoms and impaired health-related quality of life (HRQOL). In contrast, research suggests that social support might buffer the impact of racism on depression. The aim of this study was to explore associations among perceived racism, depressive symptoms, and HRQOL in adolescents with SCD. Consistent with the literature, it was predicted that perceived racism would predict HRQOL through depression, and social support would moderate the negative impact of racism on depression.

METHODS

In a cross-sectional design, 75 inpatient adolescents with SCD completed measures of perceived racism, depressive symptoms, HRQOL, and social support.

RESULTS

This results indicated a moderated mediation model with greater perceived racism predicting more depressive symptoms, which in turn related to poorer HRQOL; greater access to social support from individuals with SCD strengthened the perceived racism-depressive symptom association.

CONCLUSIONS

Findings suggest a model for how racism, depressive symptoms, HRQOL, and social support might interact in hospitalized adolescents with SCD. Longitudinal or experimental designs are needed to substantiate directionality among these variables. Results highlight several areas for future research and clinical avenues to improve the welfare of youth with SCD.

The controversial role of red cell transfusions for sickle cell pain

PURPOSE OF REVIEW

Red cell transfusions are one of the most common and important therapies used for patients with sickle cell disease (SCD). For prevention of strokes, there is abundant evidence that transfusions are efficacious, whereas for other indications, such as prevention of pain, there are less data. Nonetheless, with few therapeutic options, the use of transfusion for prevention of acute pain has increased in children and adults with SCD without a clear understanding of its benefits.

RECENT FINDINGS

Although it makes conceptual sense that red cell transfusions would prevent pain that arises from vaso-occlusion, we now know that the mechanism of pain is more complex than vaso-occlusion alone. Recent taxonomies recognize a chronic pain syndrome that is both common in adults with SCD and affects the presentation of acute pain. It is not known if acute pain on the background of chronic pain responds differently to sickle cell therapies, such as hydroxyurea and blood transfusion.

SUMMARY

In this review, we will examine the studies that have investigated whether red cell transfusions are efficacious for preventing pain. In the absence of high-quality data that specifically addresses this question, we will outline our approach, which might soon change with new drugs and curative therapies on the horizon.

Achievable Benchmarks of Care for Pediatric Readmissions

BACKGROUND

Most inpatient care for children occurs outside tertiary children's hospitals, yet these facilities often dictate quality metrics. Our objective was to calculate the mean readmission rates and the Achievable Benchmarks of Care (ABCs) for pediatric diagnoses by different hospital types: metropolitan teaching, metropolitan nonteaching, and nonmetropolitan hospitals.

METHODS

We used a cross-sectional retrospective study of 30-day, all-cause, same-hospital readmission of patients less than 18 years old using the 2014 Healthcare Utilization Project National Readmission Database. For each hospital type, we calculated the mean readmission rates and corresponding ABCs for the 17 most common readmission diagnoses. We define outlier as any hospital whose readmission rate fell outside the 95% CI for an ABC within their hospital type.

RESULTS

We analyzed 690,949 discharges at 525 metropolitan teaching hospitals (550,039 discharges), 552 metropolitan nonteaching hospitals (97,207 discharges), and 587 nonmetropolitan hospitals (43,703 discharges). Variation in readmission rates existed among hospital types; however, sickle cell disease (SCD) had the highest readmission rate and ABC across all hospital types: metropolitan teaching hospitals 15.7% (ABC 7.0%), metropolitan nonteaching 14.7% (ABC 2.6%), and nonmetropolitan 12.8% (ABC not calculated). For diagnoses in which ABCs were available, outliers were prominent in bipolar disorders, major depressive disorders, and SCD.

CONCLUSIONS

ABCs based on hospital type may serve as a better metric to explain case-mix variation among different hospital types in pediatric inpatient care. The mean rates and ABCs for SCD and mental health disorders were much higher and with more outlier hospitals, which indicate high-value targets for quality improvement.

Increased Patient Activation Is Associated with Fewer Emergency Room Visits and Hospitalizations for Pain in Adults with Sickle Cell Disease

OBJECTIVE

Recurrent vaso-occlusive pain episodes, the most common complication of sickle cell disease (SCD), cause frequent health care utilization. Studies exploring associations between patient activation and acute health care utilization for pain are lacking. We tested the hypothesis that increased activation and self-efficacy are associated with decreased health care utilization for pain in SCD.

METHODS

In this cross-sectional study of adults with SCD at a tertiary medical center, we collected demographics, SCD phenotype, Patient Activation Measure levels, and self-efficacy scores using structured questionnaires. We reviewed charts to obtain disease-modifying therapy and acute health care utilization, defined as emergency room visits and hospitalizations, for vaso-occlusive pain episodes. Negative binomial regression analyses were used to test the hypothesis.

RESULTS

We surveyed 67 adults with SCD. The median age was 27.0 years, 53.7% were female, and 95.5% were African American. Median health care utilization for pain over one year (range) was 2.0 (0-24). Only one-third of participants (38.8%) were at the highest activation level (median [range] = 3 [1-4]). Two-thirds (65.7%) of participants had high self-efficacy (median [range] = 32.0 [13-45]). Regressions showed significant association between health care utilization and activation (incidence rate ratio [IRR] = 0.663, P = 0.045), self-efficacy (IRR = 0.947, P = 0.038), and male sex (IRR = 0.390, P = 0.003). Two outliers with high activation, self-efficacy, and health care utilization also had addictive behavior.

CONCLUSIONS

Many individuals with SCD have suboptimal activation and reduced self-efficacy. Higher activation and self-efficacy were associated with lower health care utilization for pain. Additional studies are needed to evaluate interventions to improve activation and self-efficacy and reduce acute health care utilization for pain.

Hospital Readmission of Adolescents and Young Adults With Complex Chronic Disease

IMPORTANCE

Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners.

OBJECTIVE

To assess variation across CCDs in the likelihood of readmission for AYA with increasing age.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014.

EXPOSURES

Increasing age at index admission.

MAIN OUTCOMES AND MEASURES

Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital.

RESULTS

Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years.

CONCLUSIONS AND RELEVANCE

These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.

Social and Behavioral Factors in Sickle Cell Disease: Employment Predicts Decreased Health Care Utilization

THE PURPOSE

to determine frequency of health care encounters among people with sickle cell disease (SCD) seeking treatment for a vaso-occlusive crisis (VOC). Health care encounters are categorized by visit type (day hospital, ED visit, hospitalization), prevalence of self-reported behavioral and social factors, and any associations between behavioral and social factors and health care encounters. Ninety-five people with SCD were enrolled in a prospective descriptive study in North Carolina. Patients were interviewed concerning behavioral-social factors, and a report of health care encounters was produced, generated by ICD codes associated with VOCs between October 2011 and March 2014. Among 95 patients, there were a total of 839 day hospital and 1,990 ED visits, and 1,101 hospital admissions. Prevalent behavioral and social factors were depression (29%), anxiety (34%), illicit drug use (6%); unstable home situation (17%); and unemployment (81%). Employment and stable home were significantly associated with decreased frequency of health care encounters.

Characteristics and predictors of 7- and 30-day hospital readmissions to pediatric neurology

Objective

Hospital readmission is an important quality improvement measure that has not been well-studied in pediatric neurology. We examined predictors of 7-day and 30-day readmissions for pediatric patients hospitalized with a neurologic diagnosis.

Methods

This was a retrospective study of hospital readmission rates in pediatric neurology patients admitted to a tertiary children's hospital from January 2017 to December 2017. Inclusion criteria were age ≤18 years and a primary neurologic diagnosis on admission, with an unplanned readmission within 7 or 30 days. Demographic and clinical data were collected, including age, sex, income, insurance type, discharge occurring on a weekend, admission to the pediatric intensive care unit (PICU), use of multiple antiepileptic drugs (AEDs), and involvement of multiple subspecialties.

Results

There were 923 neurology admissions, and 64 readmissions within 30 days. Total unplanned readmission rate was 6.9%, with 56% (36/64) readmitted within 30 days, 44% (28/64) readmitted within 7 days, and 11% (7/64) admitted multiple times within 30 days. The most common readmission diagnosis was seizure (62%), followed by other neurologic diagnosis (21%), headache (8%), encephalitis/meningitis (7%), stroke (1%), and ataxia (1%). Readmission was significantly associated with multiple AED, PICU admission, seizure with major complication or comorbidity, and presence of a major complication or comorbidity irrespective of diagnosis (p < 0.05).

Conclusions

This study identifies factors associated with higher rates of readmission for pediatric neurology patients. Patients with epilepsy and chronic neurologic conditions should be targeted for future discharge-related interventions to reduce hospital readmission and ensure safe transitions from the inpatient to the outpatient setting.

Risk factors associated with paediatric unplanned hospital readmissions: a systematic review

OBJECTIVE

To synthesise evidence on risk factors associated with paediatric unplanned hospital readmissions (UHRs).

DESIGN

Systematic review.

DATA SOURCE

CINAHL, EMBASE (Ovid) and MEDLINE from 2000 to 2017.

ELIGIBILITY CRITERIA

Studies published in English with full-text access and focused on paediatric All-cause, Surgical procedure and General medical condition related UHRs were included.

DATA EXTRACTION AND SYNTHESIS

Characteristics of the included studies, examined variables and the statistically significant risk factors were extracted. Two reviewers independently assessed study quality based on six domains of potential bias. Pooling of extracted risk factors was not permitted due to heterogeneity of the included studies. Data were synthesised using content analysis and presented in narrative form.

RESULTS

Thirty-six significant risk factors were extracted from the 44 included studies and presented under three health condition groupings. For All-cause UHRs, ethnicity, comorbidity and type of health insurance were the most frequently cited factors. For Surgical procedure related UHRs, specific surgical procedures, comorbidity, length of stay (LOS), age, the American Society of Anaesthesiologists class, postoperative complications, duration of procedure, type of health insurance and illness severity were cited more frequently. The four most cited risk factors associated with General medical condition related UHRs were comorbidity, age, health service usage prior to the index admission and LOS.

CONCLUSIONS

This systematic review acknowledges the complexity of readmission risk prediction in paediatric populations. This review identified four risk factors across all three health condition groupings, namely comorbidity; public health insurance; longer LOS and patients<12 months or between 13-18 years. The identification of risk factors, however, depended on the variables examined by each of the included studies. Consideration should be taken into account when generalising reported risk factors to other institutions. This review highlights the need to develop a standardised set of measures to capture key hospital discharge variables that predict unplanned readmission among paediatric patients.

Risk factors for hospitalizations and readmissions among individuals with sickle cell disease: results of a U.S. survey study

OBJECTIVE

Hospital admissions are significant events in the care of individuals with sickle cell disease (SCD) due to associated costs and potential for quality of life compromise.

METHODS

This cross-sectional cohort study evaluated risk factors for admissions and readmissions between October 2014 and March 2016 in adults with SCD (n = 201) and caregivers of children with SCD (n = 330) at six centres across the U.S. Survey items assessed social determinants of health (e.g. educational attainment, difficulty paying bills), depressive symptoms, social support, health literacy, spirituality, missed clinic appointments, and outcomes hospital admissions and 30-day readmissions in the previous year.

RESULTS

A majority of adults (64%) and almost half of children (reported by caregivers: 43%) were admitted, and fewer readmitted (adults: 28%; children: 9%). The most common reason for hospitalization was uncontrolled pain (admission: adults: 84%, children: 69%; readmissions: adults: 83%, children: 69%). Children were less likely to have admissions/readmissions than adults (Admissions: OR: 0.35, 95% CI: [0.23,0.52]); Readmissions: 0.23 [0.13,0.41]). For all participants, missing appointments were associated with admissions (1.66 [1.07, 2.58]) and readmissions (2.68 [1.28, 6.29]), as were depressive symptoms (admissions: 1.36 [1.16,1.59]; readmissions: 1.24 [1.04, 1.49]). In adults, difficulty paying bills was associated with more admissions, (3.11 [1.47,6.62]) readmissions (3.7 [1.76,7.79]), and higher spirituality was associated with fewer readmissions (0.39 [0.18,0.81]).

DISCUSSION

Missing appointments was significantly associated with admissions and readmissions. Findings confirm that age, mental health, financial insecurity, spirituality, and clinic attendance are all modifiable factors that are associated with admissions and readmissions; addressing them could reduce hospitalizations.

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department

BACKGROUND

Vaso-occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP).

METHODS

A multi-disciplinary quality improvement team was assembled. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were created through retrospective chart review for our 80 highest resource users. Pediatric residents, ED residents, and ED attending physicians were instructed on use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to opiate administration. Our primary outcome was admission rate. Length of stay and 72-hr return to the ED were assessed as balancing measures.

RESULTS

Overall, admission rate decreased by 24% following implementation compared with the previous 5 years (P = 0.046). IPPs were created for 78% of patients and followed by ED staff in 86% of visits. Admission rate was significantly lower for patients receiving a second opiate dose within 45 min of the first dose (P < 0.01). There was no difference in readmission rate or 72-hr return rate to ED.

CONCLUSIONS

This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission.

Hydroxycarbamide adherence and cumulative dose associated with hospital readmission in sickle cell disease: a 6-year population-based cohort study

Sickle cell disease (SCD) is a congenital haemoglobinopathy that causes frequent acute care/emergency room visits and hospital admissions for affected individuals. Evidence from population-based studies demonstrating the role of hydroxycarbamide (HC, also termed hydroxyurea) in reducing hospital readmission rates is limited. Our objective was to describe the use of HC and its association with acute care utilization and readmission rates using a large, nationally-representative US health insurance claims database over a 6-year period between 2009 and 2014. We identified 20 721 SCD-related inpatient and acute care encounters. Patients had been exposed to HC within 6 months prior to admission in 4263 (21%) of SCD-related admission events. HC use was more common among children aged 10-17 years and young adults aged 18-29 years. HC was associated with lower 30-day all-cause readmission rates in adults treated with average daily doses ≥1 g (odds ratio [OR], 0·72, 95% confidence interval [CI] 0·52-0·99) and doses of 0·5-1 g (OR, 0·73, 95% CI 0·57-0·93), compared to HC treatment with average daily doses of <0·5 g; adherence to HC with proportion of days covered of ≥0·80 was also associated with significantly lower 30-day all-cause readmission risks (OR, 0·59, 95% CI 0·41-0·84). Optimal therapeutic dosing and adherence to HC treatment significantly reduces 30-day readmissions among patients with SCD.

The corticosteroid compounds prednisolone and vamorolone do not alter the nociception phenotype and exacerbate liver injury in sickle cell mice

Clinicians often hesitate prescribing corticosteroids to treat corticosteroid-responsive conditions in sickle cell disease (SCD) patients because their use can be associated with complications (increased hospital readmission, rebound pain, strokes, avascular necrosis, acute chest syndrome). Consequently, SCD patients may receive suboptimal treatment for corticosteroid-responsive conditions. We conducted a preclinical trial of dissociative (vamorolone) and conventional (prednisolone) corticosteroid compounds to evaluate their effects on nociception phenotype, inflammation, and organ dysfunction in SCD mice. Prednisolone and vamorolone had no significant effects on nociception phenotype or anemia in homozygous mice. Conversely, prednisolone and vamorolone significantly decreased white blood cell counts and hepatic inflammation. Interestingly, the effects of vamorolone were milder than those of prednisolone, as vamorolone yielded less attenuation of hepatic inflammation compared to prednisolone. Compared to controls and heterozygotes, homozygotes had significant liver necrosis, which was significantly exacerbated by prednisolone and vamorolone despite decreased hepatic inflammation. These hepatic histopathologic changes were associated with increases in transaminases and alkaline phosphatase. Together, these results suggest that, even in the setting of decreasing hepatic inflammation, prednisolone and vamorolone were associated with significant hepatic toxicity in SCD mice. These findings raise the possibility that hepatic function deterioration could occur with the use of corticosteroids (conventional and dissociative) in SCD.

Innovative Discharge Process for Families with Pediatric Short Bowel Syndrome: A Prospective Nonrandomized Trial

BACKGROUND

Home parenteral nutrition (HPN) is a life-sustaining therapy for short bowel syndrome (SBS) and other severe digestive diseases, but complications are common. We evaluated a predischarge HPN hands-on training course to reduce complications in children with SBS, including hospital readmissions.

METHODS

We conducted a prospective, nonrandomized controlled research study between April 1, 2014, and April 30, 2017. Eligible participants were children aged <18 years old with SBS and anticipated HPN dependence duration ≥6 months. Excluded participants had a previous history of discharge with a central venous catheter (CVC), HPN, or intravenous fluids or strictly palliative goals of care. An intervention group practiced hands-on HPN within the hospital room for 24 hours using infusion equipment. The groups received standard teaching (CVC care, home infusion pump operation, HPN preparation and administration).

RESULTS

Nine children were assigned to the intervention group and 12 served as controls. The median age was 8.4 months, and length of stay (LOS) was 82 days. All participants experienced ≥1 event, with a total of 47 issues related to HPN. There were no significant associations between group assignment and 30-day postdischarge events. Each additional week of LOS was associated with 11% increase in the odds of an emergency department visit (OR 1.11; 95% CI, 1.01-1.26) and 16% increase in the odds of readmission (OR 1.16; 95% CI, 1.04-1.37).

CONCLUSIONS

Postdischarge events remained widespread despite HPN bedside interventions offered by this pilot intervention. With refinement of HPN discharge processes, quality benchmarks are needed.

Quantitative sensory testing is feasible and is well-tolerated in patients with sickle cell disease following a vaso-occlusive episode

Introduction

Sickle cell disease (SCD) is an inherited blood disorder characterized by abnormally shaped sickle cells. The hallmark of this disease is intermittent, painful vaso-occlusive episodes (VOE), but a subset of individuals with SCD experience chronic pain. The mechanism of transition to chronic pain is not well understood in SCD, but there is evidence of altered pain processing in individuals with SCD. The impact of VOE on pain sensitivity is not established. The objective of this study was to determine the feasibility and tolerability of quantitative sensory testing (QST) in SCD following a VOE to better understand the contribution of VOE to the development of chronic pain.

Methods

As part of a larger pain sensitivity study, pediatric patients with SCD were offered QST following a VOE-related Emergency Room visit or inpatient hospitalization. The feasibility of recruitment and completion of QST was measured, and tolerability of QST was determined using post-QST assessments of pain, and compared with measurements at steady state.

Results

Ten participants completed QST following a VOE. The median age was 16.5, and 60% were female. Overall, 10 of 16 (62.5%) patients approached for QST following VOE completed QST. This included 8 of 12 patients who had previously completed QST at steady state. There were no statistically significant differences in pain intensity and Gracely Box scores after QST following a VOE, when compared to steady-state QST.

Conclusion

QST is feasible and is well-tolerated following a VOE in patients with SCD. Large prospective studies are needed to determine the impact of VOE on experimental pain sensitivity and must take into account all factors contributing to pain sensitivity.

Predictors of Readmissions and Reoperations Related to Venous Thromboembolic Events After Spine Surgery: A Single-Institution Experience with 6869 Patients

BACKGROUND

Readmission and reoperation are used as hospital and surgeon quality metrics. Venous thromboembolic (VTE) events, including deep vein thrombosis and pulmonary embolism (PE), are a major cause of readmission, morbidity, and mortality after spine surgery. Specific procedural, perioperative, and patient characteristics may be associated with these outcomes.

METHODS

We retrospectively examined records from 6869 consecutive spine surgeries at our institution. We collected data on patient demographics, surgery, hospital course, and 30-day rates of VTE, readmission, reoperation, and epidural hematoma. Stepwise multivariable logistic regression was used to identify independent predictors of each outcome.

RESULTS

Factors associated with VTE within 30 days of surgery include a history of VTE (odds ratio [OR] 3.92 [confidence interval 1.83-8.36], P < 0.001), estimated blood loss (EBL; OR 1.017 [1.005-1.029], P = 0.004), fracture (OR 5.42 [2.09-14.05], P = 0.001), history of PE (OR 4.04 [1.22-13.42], P = 0.023), and transfusion (OR 2.26 [1.07-4.77], P = 0.033). Factors associated with readmission were a history of PE (OR 3.27 [1.07-9.97], P = 0.038), PE (OR 8.07 [2.26-28.8], P = 0.001), transfusion (OR 2.54 [1.55-4.17], P < 0.001), comorbid disease burden (OR 1.35 [1.01-1.80], P = 0.041), and tumor surgery (OR 2.84 [1.32-6.10], P = 0.007). Factors associated with reoperation were EBL (OR 1.024 [1.006-1.042], P = 0.008), transfusion (OR 3.86 [1.38-10.79], P = 0.01), and PE (OR 6.05 [1.03-35.62], P = 0.046). Transfusion was associated with epidural hematoma within 30 days (OR 7.38 [1.37-39.83], P = 0.02).

CONCLUSIONS

Transfusion and EBL are associated with numerous negative outcomes. Transfusion is an independent predictor of VTE, readmission, reoperation, and epidural hematoma requiring evacuation. Specific pathologies were associated with specific negative outcomes.

Association of Guideline-Adherent Antibiotic Treatment With Readmission of Children With Sickle Cell Disease Hospitalized With Acute Chest Syndrome

IMPORTANCE

Acute chest syndrome (ACS) is a common, serious complication of sickle cell disease (SCD) and a leading cause of hospitalization and death in both children and adults with SCD. Little is known about the effectiveness of guideline-recommended antibiotic regimens for the care of children hospitalized with ACS.

OBJECTIVES

To use a large, national database to describe patterns of antibiotic use for children with SCD hospitalized for ACS and to determine whether receipt of guideline-adherent antibiotics was associated with lower readmission rates.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study including 14 480 hospitalizations in 7178 children (age 0-22 years) with a discharge diagnosis of SCD and either ACS or pneumonia. Information was obtained from 41 children's hospitals submitting data to the Pediatric Health Information System from January 1, 2010, to December 31, 2016.

EXPOSURES

National Heart, Lung, and Blood Institute guideline-adherent (macrolide with parenteral cephalosporin) vs non-guideline-adherent antibiotic regimens.

MAIN OUTCOMES AND MEASURES

Acute chest syndrome-related and all-cause 7- and 30-day readmissions.

RESULTS

Of the 14 480 hospitalizations, 6562 (45.3%) were in girls; median (interquartile range) age was 9 (4-14) years. Guideline-adherent antibiotics were provided in 10 654 of 14 480 hospitalizations for ACS (73.6%). Hospitalizations were most likely to include guideline-adherent antibiotics for children aged 5 to 9 years (3230 of 4047 [79.8%]) and declined to the lowest level for children 19 to 22 years (697 of 1088 [64.1%]). Between-hospital variation in antibiotic regimens was wide, with use of guideline-adherent antibiotics ranging from 24% to 90%. Children treated with guideline-adherent antibiotics had lower 30-day ACS-related (odds ratio [OR], 0.71; 95% CI, 0.50-1.00) and all-cause (OR, 0.50; 95% CI, 0.39-0.64) readmission rates vs children who received other regimens (cephalosporin and macrolide vs neither drug class).

CONCLUSIONS AND RELEVANCE

Current approaches to antibiotic treatment in children with ACS vary widely, but guideline-adherent therapy appears to result in fewer readmissions compared with non-guideline-adherent therapy. Efforts to increase the dissemination and implementation of SCD treatment guidelines are warranted as is comparative effectiveness research to strengthen the underlying evidence base.

Opioid prescription practices at discharge and 30-day returns in children with sickle cell disease and pain

BACKGROUND

Acute pain episodes in children with sickle cell disease (SCD) represent a leading cause of readmissions. We examined prescription practices at the time of discharge in children with SCD presenting with acute pain to determine their impact on 30-day emergency department (ED) revisits and readmissions.

METHODS

In this single-institution, 5-year retrospective study, we reviewed 290 encounters of patients with SCD aged 7-21 years hospitalized or discharged from the ED with acute pain. We reviewed demographic, treatment and discharge data, and 30-day returns, defined as ED revisits and readmissions within 30 days of discharge. Bivariate and multivariable analyses were performed to evaluate the association between discharge prescription practices and 30-day returns.

RESULTS

Compared to hospitalizations, treat-and-release ED visits for acute pain were associated with a higher incidence of 30-day returns (OR = 2.7 [95% CI: 1.5-4.8], P < 0.01). We found no association between prescribed opioid frequency (scheduled vs. as-needed) and 30-day returns (OR = 1.12 [95% CI: 0.62-2.02], P = 0.70). By multivariable logistic regression, the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) only, without opioids, after treat-and-release ED visits was independently associated with a higher frequency of 30-day ED revisits (OR = 6.9 [95% CI: 1.3-37.3], P = 0.03) but not readmissions.

CONCLUSION

Variability exists in opioid prescription practices after discharge in children with SCD and pain episodes. Prescription of NSAIDs only, without opioids, was an independent predictor of higher 30-day ED revisits. Formalized studies to better understand factors that influence returns, including outpatient opioid management, are warranted in this population.

Older red cell units are associated with an increased incidence of infection in chronically transfused adults with sickle cell disease

BACKGROUND

In adults with sickle cell disease (SCD), the effects of the red cell storage lesion are not well defined. The objectives of this study were to: (1) describe the distribution of storage ages provided to adults with SCD, and (2) evaluate clinical outcomes associated with storage age.

PATIENTS AND METHODS

We performed a retrospective cohort study of adults with SCD managed with prophylactic simple transfusion regimens. Units were universally pre-storage leukocyte reduced and CEK-matched. Age of the unit was 42 days minus the difference between the expiration and transfusion dates. A mixed effects model, which accounts for a subject's contribution to repeated transfusion encounters, was used to investigate the association between storage age and the incidence of hospital encounters for infection and pain crises prior to the next red cell transfusion.

RESULTS

Over the study interval, twenty-eight steady-state adults with SCD received 627 units via simple transfusion over 281 outpatient encounters. Overall median unit storage age was 22 days (range: 2-42 days). Receipt of older units was associated with an increased incidence of emergency department or hospital admission for infection prior to the next transfusion (p=0.04). There was no association between unit storage age and admission for pain (p=0.4).

DISCUSSION

In a cohort of chronically transfused adults with SCD, we provide evidence that receipt of older units is associated with a higher rate of admission for infection. Prospective studies will need to validate these data and explore potential mechanisms by which these older units promote infection.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children

OBJECTIVE

To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges.

METHODS

This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children's hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan-do-study-act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies.

RESULTS

Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05).

CONCLUSIONS

Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non-children's hospital settings.

The intersection between asthma and acute chest syndrome in children with sickle-cell anaemia

Acute chest syndrome is a frequent cause of acute lung disease in children with sickle-cell disease. Asthma is common in children with sickle-cell disease and is associated with increased incidence of vaso-occlusive pain events, acute chest syndrome episodes, and earlier death. Risk factors for asthma exacerbation and an acute chest syndrome episode are similar, and both can present with shortness of breath, chest pain, cough, and wheezing. Despite overlapping risk factors and symptoms, an acute exacerbation of asthma or an episode of acute chest syndrome are two distinct entities that need disease-specific management strategies. Although understanding has increased about asthma as a comorbidity in sickle-cell disease and its effects on morbidity, substantial gaps remain in knowledge about best management.

Association between Hospital Volume and Within-Hospital Intensive Care Unit Transfer for Sickle Cell Disease in Children's Hospitals

OBJECTIVE

To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD).

STUDY DESIGN

We conducted a retrospective cohort study of 83,477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS.

RESULTS

Of 83,477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific volumes. When results were stratified according to all-cause volume, high SCD-specific volume was associated with lower odds of ICU transfer at low all-cause volume (OR 0.46, 95% CI 0.38-0.55). High hospital volumes, both all-cause (OR 0.94, 95% CI 0.92-0.97) and SCD-specific (OR 0.86, 95% CI 0.84-0.88), were associated with shorter LOS.

CONCLUSIONS

Children's hospitals vary substantially in their transfer of children with SCD to the ICU according to hospital volumes. Understanding the practices used by different institutions may help explain the variability in ICU transfer among hospitals caring for children with SCD.

Hospitalization Events among Children and Adolescents with Sickle Cell Disease in Basra, Iraq

Objectives. Despite improvements in the management of sickle cell disease (SCD), many patients still experience disease-related complications requiring hospitalizations. The objectives of this study were to identify causes of hospitalization among these patients and factors associated with the length of hospital stay (LOS) and readmission. Methods. Data from 160 patients (<14 years old) with SCD who were admitted to the Basra Maternity and Children's Hospital from the first of January 2012 through July 2012 were analyzed. Results. The main causes of hospitalization were acute painful crises (73.84%), infections (9.28%), acute chest syndrome (8.02%), and acute splenic sequestration crisis (6.32%). The mean LOS was 4.34 ± 2.85 days. The LOS for patients on hydroxyurea (3.41 ± 2.64 days) was shorter than that for patients who were not (4.59 ± 2.86 days), P < 0.05. The readmission rate (23.1%) was significantly higher among patients with frequent hospitalizations in the previous year (OR 9.352, 95% CI 2.011–43.49), asthma symptoms (OR 4.225, 95% CI 1.125–15.862), and opioid use (OR 6.588, 95% CI 1.104–30.336). Patients on hydroxyurea were less likely to be readmitted (OR 0.082, 95% CI 0.10–0.663). Conclusions. There is a relatively high readmission rate among patients with SCD in Basra. The use of hydroxyurea significantly decreases the LOS and readmission rate.

Clinical and Geographic Characterization of 30-Day Readmissions in Pediatric Sickle Cell Crisis Patients

BACKGROUND AND OBJECTIVES

Sickle cell disease (SCD) is a blood disorder affecting many US children that is often associated with hospital readmission. Although previous studies have reported on the clinical factors that influence readmission risk, potential geographic factors have not been fully investigated. The goal of this study was to investigate the importance of geographic risk factors and to confirm previously derived clinical risk factors that influence readmissions for SCD pain crises.

METHODS

Retrospective analyses were performed on pediatric inpatients with sickle cell crises at a single center. Readmission rates and risk factors were assessed. Geospatial analysis was conducted on point variables that represented health service access, and multivariable logistic regression models were constructed.

RESULTS

The study identified 373 patients experiencing sickle cell crises, with 125 (33.5%) having at least one 30-day readmission. Age (mean difference: 2.2 years; P<0.001), length of stay (median difference: 1 day; P<.001), admission pain score>7 of 10 (odds ratio [OR]: 2.21; P<0.01), discharge pain score>4 of 10 (OR: 2.098; P<.01), living within 5 miles of the center's main hospital (OR: 0.573; P=.04), and >3 hospital utilizations in the previous 12 months (OR: 5.103; P<.001) were identified as potential indicators of 30-day readmission risk. Logistic regression models for 30-day readmissions yielded similar results.

CONCLUSIONS

Increased age, high admission and discharge pain scores, decreased length of stay, and increased hospital utilizations were found to be associated with an increased risk of readmission for sickle cell crisis. Patient's residence was also found to be a significant risk indicator, supporting the utility of geospatial analysis in assessing readmission risk.

Derivation and preliminary validation of a risk score to predict 30-day ED revisits for sickle cell pain

BACKGROUND

Emergency department (ED) revisits and 30-day readmissions have been proposed as markers for quality of ED care for sickle cell disease (SCD).

OBJECTIVE

To create a scoring system that quantifies the risk of 30-day revisit after ED discharge for SCD vaso-occlusive pain

METHODS

This was a dual-center retrospective derivation and validation cohort study. The derivation was performed at an academic, tertiary care center and the validation at an urban community hospital. The primary outcome was revisit to the ED within 30 days after an ED discharge for SCD pain. Recursive partitioning was used to derive a scoring system to predict 30-day revisits.

RESULTS

Of a total of 1456 ED visits for SCD pain, there were 680 ED discharges (admission rate of 53%) in 193 unique individuals included in the derivation cohort. There were 240 (35.3%) 30-day revisits. Of a total of 126 ED visits for SCD, there were 79 ED discharges in 41 unique individuals in the validation cohort. The final risk score included 4 variables: (1) age, (2) insurance status, (3) triage pain score, and (4) amount of opioids administered during the ED visit. Possible scores range from 0 to 6. The areas under the receiver operating characteristic curves were 0.746 (95% confidence interval, 0.71-0.78-derivation cohort) and 0.753 (95% confidence interval, 0.65-0.86-validation cohort). A cutoff of 4 or greater identified 60% of 30-day ED revisits in the derivation cohort and 80% of revisits in the validation cohort.

CONCLUSIONS

A risk score can identify ED visits for SCD pain with high risk of 30-day revisit.

Blood transfusion and 30-day readmission rate in adult patients hospitalized with sickle cell disease crisis

BACKGROUND

Sickle cell disease (SCD) patients hospitalized with vasoocclusive pain crisis tend to have prolonged length of stay (LOS) and high 30-day readmission rates. We investigated the associations of demographic characteristics, comorbidities, and blood transfusion during hospitalization with these outcomes.

STUDY DESIGN AND METHODS

Repeated regression analysis was used to analyze 39,324 admissions of 4348 adults with sickle cell crisis from 2007 to 2012 in the Truven Health MarketScan Medicaid Databases.

RESULTS

The mean (95% range) LOS was 5.9 (1.0-19.0) days and the 30-day readmission rate was 39.6% (95% confidence interval [CI], 39.1%-40.0%). Older age; chronic cardiopulmonary, renal, or liver disease; and sepsis were associated with both longer LOS and greater 30-day readmission rate. Female sex, iron overload, acute chest syndrome, acute renal failure, and stroke were additional predictors of longer LOS. Simple red blood cell transfusion was administered in 31.8% of the admissions, and these patients tended to have more severe disease (chronic cardiopulmonary or kidney disease, acute chest syndrome, acute kidney or liver failure, sepsis). Nevertheless, transfusion was associated with a reduced estimated odds ratio (OR) of inpatient mortality of 0.75 (95% CI, 0.57-0.99) and a decreased OR of 30-day readmission of 0.78 (95% CI, 0.73-0.83).

CONCLUSION

Our findings point to blood transfusion as a potential means to reduce the 30-day readmission rate among Medicaid patients hospitalized with sickle cell crisis. There is a need for a prospective study to examine the potential benefit and safety of simple blood transfusion for this purpose.

Single-dose intravenous gammaglobulin can stabilize neutrophil Mac-1 activation in sickle cell pain crisis

Intravenous immunoglobulin (IVIG) decreases neutrophil adhesion to endothelium and red blood cell-neutrophil interactions in sickle cell mice undergoing vaso-occlusion. In this Phase I clinical trial of sickle cell anemia (SCA) patients admitted with pain crisis, we evaluated the status of adhesion molecules on neutrophils in control and IVIG-treated subjects pre- and post-infusion up to 800 mg/kg, the same dose used in murine studies. Mac-1 function significantly decreased from baseline in the low-dose IVIG (200-400 mg/kg) cohorts. IVIG-related adverse events may have occurred in the high-dose (600-800 mg/kg) cohorts. There were no significant increases in neutrophil and leukocyte counts, suggesting that IVIG may more selectively inhibit Mac-1 function as opposed to neutrophil adhesion. This study provides the first in-human validation of pre-clinical murine studies that IVIG can decrease Mac-1 function.

Pediatric readmission classification using stacked regularized logistic regression models

BACKGROUND

Regulations and privacy concerns often hinder exchange of healthcare data between hospitals or other healthcare providers. Sharing predictive models built on original data and averaging their results offers an alternative to more efficient prediction of outcomes on new cases. Although one can choose from many techniques to combine outputs from different predictive models, it is difficult to find studies that try to interpret the results obtained from ensemble-learning methods.

METHODS

We propose a novel approach to classification based on models from different hospitals that allows a high level of performance along with comprehensibility of obtained results. Our approach is based on regularized sparse regression models in two hierarchical levels and exploits the interpretability of obtained regression coefficients to rank the contribution of hospitals in terms of outcome prediction.

RESULTS

The proposed approach was used to predict the 30-days all-cause readmissions for pediatric patients in 54 Californian hospitals. Using repeated holdout evaluation, including more than 60,000 hospital discharge records, we compared the proposed approach to alternative approaches. The performance of two-level classification model was measured using the Area Under the ROC Curve (AUC) with an additional evaluation that uncovered the importance and contribution of each single data source (i.e. hospital) to the final result. The results for the best distributed model (AUC=0.787, 95% CI: 0.780-0.794) demonstrate no significant difference in terms of AUC performance when compared to a single elastic net model built on all available data (AUC=0.789, 95% CI: 0.781-0.796).

CONCLUSIONS

This paper presents a novel approach to improved classification with shared predictive models for environments where centralized collection of data is not possible. The significant improvements in classification performance and interpretability of results demonstrate the effectiveness of our approach.

Measuring pediatric hospital readmission rates to drive quality improvement

The Pediatric Quality Measures Program is developing readmission measures for pediatric use. We sought to describe the importance of readmissions in children and the challenges of developing readmission quality measures. We consider findings and perspectives from research studies and commentaries in the pediatric and adult literature, characterizing arguments for and against using readmission rates as measures of pediatric quality and discussing available evidence and current knowledge gaps. The major topic of debate regarding readmission rates as pediatric quality measures is the relative influence of hospital quality versus other factors within and outside of health systems on readmission risk. The complex causation of readmissions leads to disagreement, particularly when rates are publicly reported or tied to payment, about whether readmissions can be prevented and how to achieve fair comparisons of readmission performance. Despite these controversies, the policy focus on readmissions has motivated widespread efforts by hospitals and outpatient providers to evaluate and reengineer care processes. Many adult studies demonstrate a link between successful initiatives to improve quality and reductions in readmissions. More research is needed on methods to enhance adjustment of readmission rates and on how to prevent pediatric readmissions.

Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients

Object

Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery.

Methods

The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR.

Results

The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91).

Conclusions

There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

Quality and safety in pediatric hematology/oncology

Many principles of quality of care and patient safety are at the foundation of pediatric hematology/oncology. However, we still see too many errors, continue to have problems with communication, and the culture in many of our areas is still one of worrying about retribution when mentioning a problem. This review explores why specialists in pediatric hematology/oncology should be leaders in the field of quality and safety in healthcare.

Systemic corticosteroids in acute chest syndrome: friend or foe?

Acute chest syndrome(ACS) is the most common pulmonary complication of sickle cell disease (SCD), the second most common cause of hospitalization and the primary cause of death in patients with sickle cell disease. Its highest prevalence is in early childhood. The pathogenesis of ACS is unknown but many predisposing conditions and mechanisms have been implicated including infections, pulmonary fat embolism, asthma and ischemic reperfusion injury. These conditions are associated with inflammation and therefore, the use of corticosteroids has been advocated because of their anti-inflammatory properties. Although, significant benefits from their use have been shown, there is great reluctance in using them because of reports of serious adverse effects, such as readmission to the hospital due rebound pain crisis, stroke, renal infarction, coma and even death. The current article reviews the evidence in favor and against the use of corticosteroids in ACS. Emphasis is given on the potential benefits vs. risks among the different types of corticosteroids, the importance of the dosing regimen and the role of underlying co-morbidities.

Hospital readmission and parent perceptions of their child's hospital discharge

OBJECTIVE

To describe parent perceptions of their child's hospital discharge and assess the relationship between these perceptions and hospital readmission.

DESIGN

A prospective study of parents surveyed with questions adapted from the care transitions measure, an adult survey that assesses components of discharge care. Participant answers, scored on a 5-point Likert scale, were compared between children who did and did not experience a readmission using a Fisher's exact test and logistic regression that accounted for patient characteristics associated with increased readmission risk, including complex chronic condition and assistance with medical technology.

SETTING

A tertiary-care children's hospital.

PARTICIPANTS

A total of 348 parents surveyed following their child's hospital discharge between March and October 2010.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Unplanned readmission within 30 days of discharge.

RESULTS

There were 28 children (8.1%) who experienced a readmission. Children had a lower readmission rate (4.4 vs. 11.3%, P = 0.004) and lower adjusted readmission likelihood [odds ratio 0.2 (95% confidence interval 0.1, 0.6)] when their parents strongly agreed (n = 206) with the statement, 'I felt that my child was healthy enough to leave the hospital' from the index admission. Parent perceptions relating to care management responsibilities, medications, written discharge plan, warning signs and symptoms to watch for and primary care follow-up were not associated with readmission risk in multivariate analysis.

CONCLUSIONS

Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.

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.

Parental and other factors associated with hydroxyurea use for pediatric sickle cell disease

BACKGROUND

Hydroxyurea (HU) is highly effective treatment for sickle cell disease (SCD). While pediatric use of HU is accepted clinical practice, barriers to use may impede its potential benefit.

PROCEDURE

A survey of parents of children ages 5-17 years with SCD was performed across five institutions to assess factors associated with HU use.

RESULTS

Of the 173 parent responses, 65 (38%) had children currently taking HU. Among parents of children not taking HU, the most commonly cited reasons were that their hematology provider had not offered it, their child was not sufficiently symptomatic and concerns about potential side effects. Even parents of HU users reported widespread concern about effectiveness, long-term safety, and off-label use. In bivariate analyses, children's ages, parental demographics such as education level, or travel time to their hematology provider were not correlated with HU use. Bivariate analysis and multivariate logistic regression revealed three significant factors associated with current HU use: better parental knowledge about its major therapeutic effects (P < 0.001), sickle genotype (P = 0.005), and institution of clinical care (P = 0.04).

CONCLUSIONS

Pervasive concerns about HU safety exist, even among parents of current users. Varying knowledge among parents appears to be independent of their demographics, and is associated with HU use. Inter-institutional variability in parental knowledge and drug uptake highlights potentially potent site-specific influences on likelihood of HU use. Overall, these survey data underscore the need for strategies to bolster parental understanding about benefits of HU and address concerns about its safety.

Integration of Administrative Data and Chart Review for Reporting Health Care Utilization Among Children With Sickle Cell Disease

Health care utilization of children with sickle cell disease (SCD) has been well documented due to an increase in the use of administrative data sets. While use of such data sources is relatively efficient and low cost, questions remain as to whether they provide sufficient information to fully characterize health care use. The aim of this study was to determine whether administrative data have the capacity to fully assess health care utilization among children with SCD. We studied the health care utilization of 154 low-income children with SCD in a managed care organization combining administrative data and medical record review. In our comparison, we found that administrative claims provided key information on the scope and location of health service use and that sole reliance on medical record review may undercount unique members and encounters.

Variation in occult injury screening for children with suspected abuse in selected US children's hospitals

OBJECTIVE

To describe variation across selected US children's hospitals in screening for occult fractures in children <2 years old diagnosed with physical abuse and in infants <1 year old who have injuries associated with a high likelihood of physical abuse.

METHODS

We performed a retrospective study of children <2 years old with a diagnosis of physical abuse and infants <1 year old with non-motor vehicle crash-associated traumatic brain injuries or femur fractures admitted to 40 hospitals within the Pediatric Hospital Information System database from January 1, 1999, to December 31, 2009. We examined variation among the hospitals in the performance of screening for occult fractures as defined by receipt of skeletal survey or radionuclide bone scan. Marginal standardization implemented with logistic regression analysis was used to examine hospital variation after adjusting for patient demographic characteristics, injury severity, and year of admission.

RESULTS

Screening for occult fractures was performed in 83% of the 10,170 children <2 years old with a diagnosis of physical abuse, 68% of the 9942 infants who had a traumatic brain injury, and 77% of the 2975 infants who had femur fractures. After adjustment for patient characteristics, injury severity, and year of admission, hospitals varied significantly in use of screening for occult fractures in all 3 groups of children.

CONCLUSIONS

The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.

Sickle cell pain: a critical reappraisal

Sickle cell pain includes 3 types: acute recurrent painful crises, chronic pain syndromes, and neuropathic pain. The acute painful crisis is the hallmark of the disease and the most common cause of hospitalization and treatment in the emergency department. It evolves through 4 phases: prodromal, initial, established, and resolving. Each acute painful episode is associated with inflammation that worsens with recurrent episodes, often culminating in serious complications and organ damage, such as acute chest syndrome, multiorgan failure, and sudden death. Three pathophysiologic events operate in unison during the prodromal phase of the crisis: vaso-occlusion, inflammation, and nociception. Aborting the acute painful episode at the prodromal phase could potentially prevent or minimize tissue damage. Our hypothesis is that managing these events with hydration, anti-inflammatory drugs, aggressive analgesia, and possibly vasodilators could abort the crisis and prevent or minimize further damage. Chronic pain syndromes are associated with or accompany avascular necrosis and leg ulcers. Neuropathic pain is not well studied in patients with sickle cell disease but has been modeled in the transgenic sickle mouse. Management of sickle cell pain should be based on its own pathophysiologic mechanisms rather than borrowing guidelines from other nonsickle pain syndromes.