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

Seventy-Two-Hour Reutilization After Telemedicine Visits in Academic Pediatric Primary Care

Telemedicine has expanded due to the COVID-19 pandemic. However, the health care usage after telemedicine visits compared with similar in-person visits is not known. This study compared the 72-hour health care reutilization after telemedicine visits and in-person acute encounters in a pediatric primary care office. A retrospective cohort analysis was performed in a single quaternary pediatric health care system between March 1, 2020, and November 30, 2020. Reutilization information was collected for 72 hours following the index visit and included subsequent encounters within the health care system. The 72-hour reutilization rate for telemedicine encounters was 4.1% compared with 3.9% for in-person acute visits. Of revisits, patients who had a telemedicine visit most often sought additional care at the medical home, and patients with an in-person visit most often sought additional care to the emergency department or urgent care. Telemedicine does not result in higher total health care reutilization.

Modifiable factors associated with pediatric asthma readmissions: a multi-center linked cohort study

OBJECTIVES

To (a) identify rates of hospital readmission and emergency department (ED) re-presentation for asthma within a 12-month period, (b) estimate the effects of modifiable hospital, general practitioner (GP) and home environmental factors on hospital readmission, ED re-presentations and rescue oral corticosteroid use.

METHODS

We recruited 767 children aged 3-18 years who were admitted to 3 hospitals in Victoria, Australia between 2017 and 2018 with a validated diagnosis of asthma on chart review. Primary outcome was hospital readmission with asthma within 12 months of index admission. Secondary outcomes were ED re-presentation for asthma and rescue oral corticosteroid use. All outcomes were identified through linked administrative datasets. Their caregivers and 277 nominated GPs completed study surveys regarding the home environment and their usual asthma management practices respectively.

RESULTS

Within 12 months of an index admission for asthma 263 (34.3%) participants were readmitted to a hospital for asthma, with participants between the ages of 3-5 years accounting for 69.2% of those readmitted. The estimated effect of GP reported guideline discordant care on the odds of readmission was OR 1.57, 95% CI 1.00-2.47, p = 0.05. None of the hospital or home environmental factors appeared to be associated with hospital readmissions.

CONCLUSIONS

Hospital readmissions among Australian children with asthma are increasing, and linked datasets are important for objectively identifying the health services burden of asthma. They also confirm the important role of the GP in the management of pediatric 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.

Drug-related risk of hospital readmission in children with chronic diseases, a systematic review

BACKGROUND

Drug-related problems (DRPs) are one of the leading causes of hospital readmissions. Children with chronic diseases are more likely to experience DRPs than adults. The burden and characteristics of drug-related readmissions at and after hospital discharge in children remain unclear.

OBJECTIVE

We aimed to summarize the impact of DRPs at and after hospital discharge on the risk of readmissions in children with chronic diseases.

METHODS

We conducted a systematic review searching PubMed from inception until January 2022. Study selection criteria were studies assessing the impact of different factors at discharge and after discharge on the risk of hospital readmissions in children with chronic diseases, reporting an assessment of DRPs. DRP could be the only risk factor assessed or one among others. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Exposure (ROBINS-E) tool. We summarized the qualitative impact of the reported DRPs on hospital readmission as conclusive (significant association) or inconclusive.

RESULTS

Of the 4734 studies initially identified, 13 met inclusion criteria. Eleven studies were retrospective, using electronic health records. The studies assessed the impact of DRPs at or after discharge according to the type of medication (in 6 studies), number of medication (in 5 studies) and medication nonadherence (in 2 studies). From the 44 reported associations between DRPs and the risk of readmission 26 (59% [95% CI, 43%-73%]) were conclusive, of which 81% increased the risk and 19% decreased the risk, and 17 (39% [95% CI, 24%-55%]) were inconclusive.

CONCLUSION

The impact of DRPs on hospital readmissions in children with chronic diseases displayed conflicting results, estimated associations having potentially a serious risk of bias. We need more evidence with a lower risk of bias.

The Effect of Outdoor Environmental Exposure on Readmission Rates for Children and Adolescents with Asthma-A Systematic Review

The burden of asthma readmission for children and adolescents is approximately 10% worldwide. Research has been synthesised for behavioural and indoor impacts; however, no such synthesis has been conducted for outdoor environmental exposures. This systematic review aims to evaluate and synthesise the impact the outdoor environment has on readmission rates for children or adolescents with asthma. We conducted a systematic search of seven databases and hand searched reference lists of articles published up until 18 January 2021. There were 12 out of 392 studies eligible for inclusion. Overall, most studies showed that outdoor environments impact on readmission; however, the strength of association is seen to be stronger in a particular subpopulation of each study depending on the exposure investigated. The evidence for the association between outdoor environmental exposure and readmission rates for children or adolescents with asthma is increasing; however, it is complicated by potential confounders such as socioeconomic factors, ethnicity, indoor air pollutants, and other behavioural factors. Further research is required to differentiate between them. Additionally, further studies need to be undertaken in further countries other than the United States of America to understand the full relationship.

Comparing Artificial Intelligence and Traditional Methods to Identify Factors Associated With Pediatric Asthma Readmission

OBJECTIVE

To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling.

METHODS

This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve.

RESULTS

Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network.

CONCLUSIONS

Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.

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.

Systemic glucocorticoid at discharge after hospitalization for pediatric asthma: a prospective pilot study

OBJECTIVE: 

We examined asthma control in children hospitalized for status asthmaticus 7-10 days after discharge with or without an additional prescription for systemic corticosteroids.

METHODS: 

This was a prospective observational study of patients aged 5-17 years with a documented history of asthma or β-agonist responsive wheezing admitted to the hospital for an acute asthma exacerbation. We compared patients who had any systemic corticosteroid prescribed at discharge with those who were not prescribed systemic corticosteroids at discharge. The primary outcomes were asthma control after discharge, as defined by the Asthma Control Test (ACT), and missed school days, which we modeled with multivariable linear and Poisson regression, respectively.

RESULTS: 

A total of 56 patients were included in the study, 29 (52%) received dexamethasone inpatient and then were discharged without additional prescribed systemic corticosteroids. Those without a corticosteroid prescription at discharge were less likely to have received noninvasive ventilation (p = 0.02), pulmonology consultation (p = 0.02), and continuous albuterol (p = 0.01) during hospitalization. These patients also tended toward shorter length of stay (p = 0.07) compared to those receiving systemic corticosteroid prescription at discharge. In multivariable models, being discharged without systemic corticosteroid prescription was associated with poorer asthma control after discharge [beta (95% CI), -2.21 (-2.65 to -1.77)] and more missed school days [coefficient estimate (95% CI), 0.87 (0.07-1.68)].

CONCLUSIONS

After hospitalization for an asthma exacerbation, patients not given systemic corticosteroids at discharge tended to have worse asthma control following discharge despite having less severe disease and requiring less aggressive inpatient management.

Supplemental data for this article can be accessed at publisher's website.

Corticosteroid choice and clinical outcomes for asthma exacerbations in the primary care setting

OBJECTIVE

To evaluate clinical outcomes in young children with acute asthma exacerbations treated with prednisone/prednisolone versus dexamethasone in the primary care setting.

METHODS

Retrospective cohort study of children ages 3-9 years with a primary care clinic visit for asthma and an associated oral corticosteroid (OCS) prescription fill in the Colorado All Payers Claim Database between 2/2013-3/2019. This was a secondary analysis of a dataset extracted to analyze risk of future development of asthma in younger children. The primary outcome was subsequent ED visit or hospital admission for asthma within 2-14 days after the index clinic visit. Demographics and asthma health services characteristics were assessed. Multivariable logistic regression was used to estimate the association between type of OCS prescription filled within 1 day of the index clinic visit and the primary outcome.

RESULTS

There were 3236 index clinic visits for asthma for 1918 children during the study period. Sixty-two percent were male and 66% were 3-4 years old. Prednisone/prednisolone accounted for 84% of OCS prescriptions fills within 1 day of the index clinic visit. One percent visited the ED and 1% required hospital admission within 2-14 days. In multivariate analysis, there was no statistical association between type of OCS prescribed and the primary outcome (OR 0.82; 95% CI: 0.37-1.8).

CONCLUSIONS

There are no differences in clinical outcomes by type of OCS prescribed for acute asthma exacerbations in the primary care setting. Due to better adherence and side effect profile, primary care providers may consider to use dexamethasone as the preferred OCS.

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses

OBJECTIVE

Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses.

METHODS

This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors.

RESULTS

Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09).

CONCLUSIONS

Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.

Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014

OBJECTIVE

To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014.

METHODS

Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period.

RESULTS

The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days).

CONCLUSIONS

This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

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.

Management of acute asthma exacerbations

PURPOSE OF REVIEW

Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings.

RECENT FINDINGS

The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome.

SUMMARY

Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.