Risk factors associated with hospital readmission in pediatric asthma

Pediatric Asthma Exacerbations: 14-Day Emergency Department Return Visit Risk Factors

BACKGROUND

Asthma, the most common chronic disease of childhood, can affect a child's physical and mental health and social and emotional development.

OBJECTIVE

The aim of this study was to identify factors associated with emergency department (ED) return visits for asthma exacerbations within 14 days of an initial visit.

METHODS

This was a retrospective review from Cerner Real-World Data for patients aged from 5 to 18 years and seen at an ED for an asthma exacerbation and discharged home at the index ED visit. Asthma visits were defined as encounters in which a patient was diagnosed with asthma and a beta agonist, anticholinergic, or systemic steroid was ordered or prescribed at that encounter. Return visits were ED visits for asthma within 14 days of an index ED visit. Data, including demographic characteristics, ED evaluation and treatment, health care utilization, and medical history, were collected. Data were analyzed via logistic regression mixed effects model.

RESULTS

A total of 80,434 index visits and 17,443 return visits met inclusion criteria. Prior ED return visits in the past year were associated with increased odds of a return visit (odds ratio [OR] 2.12; 95% CI 2.07-2.16). History of pneumonia, a concomitant diagnosis of pneumonia, and fever were associated with increased odds of a return visit (OR 1.19; 95% CI 1.10-1.29; OR 1.15; 95% CI 1.04-1.28; OR 1.20; 95% CI 1.11-1.30, respectively).

CONCLUSIONS

Several variables seem to be associated with statistically significant increased odds of ED return visits. These findings indicate a potentially identifiable population of at-risk patients who may benefit from additional evaluation, planning, or education prior to discharge.

Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort

Background

Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia.

Methods

This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission.

Findings

Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission.

Interpretation

Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care.

Funding

The Bill & Melinda Gates Foundation (OPP1131320).

Asthma outcomes in pediatric patients with 30-day follow-up after an asthma hospitalization in a Medicaid-managed care program

BACKGROUND

National asthma guidelines recommend an outpatient follow-up after hospitalization for asthma. Our aim is determine if a follow-up visit within 30 days after an asthma hospitalization impacts risk for re-hospitalization and emergency department visits for asthma within the following year.

METHODS

This was a retrospective cohort study of claims data of Texas Children's Health Plan (a Medicaid managed care program) members age 1 to <18 years and hospitalized for asthma between January 1, 2012, and December 31, 2018. Primary outcomes were days to re-hospitalization and emergency department visit between 30 days and 365 days following the index hospitalization.

RESULTS

We identified 1,485 children age 1 to <18 years hospitalized for asthma. Comparing those with a 30 day follow-up to those without, there was no difference in days to re-hospitalization (adjusted hazard ratio 1.23, 95% Confidence Interval (CI) 0.74-2.06) or emergency department visit for asthma (aHR 1.08, 95% CI 0.88-1.33). Inhaled corticosteroid and short acting beta agonist dispensing were greater in the group completing the 30 day follow-up (means of 2.8 and 4.8 respectively for those with follow-up, 1.6 and 3.5 respectively for those without, p < 0.0001).

CONCLUSION

Having a follow-up outpatient visit within 30 days of an asthma hospitalization is not associated with a decrease in asthma re-hospitalization or emergency department visit in the 30-365 day period following the index hospitalization. Non-adherence to regular use of inhaled corticosteroid medication was high in both groups. These findings suggest need for improvement in the quality and quantity of post hospital asthma follow-up.

Parents’ Decision Making During Their Child’s Asthma Attack: Qualitative Systematic Review

Objective

To conduct a systematic review and synthesis of qualitative evidence exploring the factors that influence a parent’s decision to seek medical assistance while their child is having an asthma attack.

Methods

Studies were included if they used qualitative methodologies and explored parent or carers’ experience of caring for a child (2 to 12 years) during an acute asthma attack at home or in the community. We searched MEDLINE (OVID interface, 1948 onwards), EMBASE (OVID interface, 1980 onwards) and CINAHL (EBSCO) electronic databases. Quality appraisal was assessed by the Critical Appraisal Skills Program CASP for qualitative research, and the qualitative studies in this review were analyzed by thematic synthesis.

Results

From 4798 identified studies, 17 met the inclusion criteria. Synthesis revealed two distinct processes used by parents to aid their decision to seek medical intervention for their child. The first, past experiences informing future decisions and secondly facilitators that drive parents’ to actively pursue medical help.

Conclusion

This review highlights the importance of providing asthma education that not only focuses on the provision of information on symptoms, triggers, medication, and device use but asthma education that targets parents’ unique experience. Using a family strength approach education can impact parents’ future behavior when deciding to seek medical assistance for their child when experiencing an asthma attack. There was not a specific funding source, which supported this review. This review was registered with PROSPERO Identification Number CRD4201912740.

Factors Related to Pediatric Readmissions of Four Major Diagnostic Categories in Hawai`i

Readmissions are a key quality measure for health care decision making and understanding variables associated with readmissions has become a crucial research area. This study identified patient-level factors that might be associated with pediatric readmissions using a database that included inpatient data from 2008 to 2017 from Hawai`i. Four major diagnostic categories with the most pediatric readmissions in the state were identified: respiratory, digestive, mental, and nervous system diseases and disorders. The associations between readmission and patient-level variables, such as age, sex, race/ethnicity, insurance status, and Charlson Comorbidity Index (CCI), were determined for each diagnosis and for overall readmissions. CCI and insurance were the strongest predictors when all diagnoses were combined. However, for some diagnoses, there was weak or no association between CCI, insurance, and readmission. This suggests that diagnosis-specific analysis of predictors of readmission may be more useful than looking at predictors of readmission for all diagnoses combined. While this study focused on patient variables, future studies should also incorporate how hospital variables may also be related to diagnosis.

Health Effects of the Asthma Care Program under the Universal Coverage Scheme in Children and Young Adults in Thailand

This study aimed to evaluate the effect of the asthma care program available under the Universal Coverage Scheme (UCS) in Thailand on hospital admissions per 100,000 population, its regional and seasonal variation, readmission within 28 days, and the asthma-specific fatality rate of patients aged 0–29 years in 2009–2016 compared with those in 2007–2008. A retrospective study was conducted using data sources from the UCS register and in-patient databases from the National Health Security Office (NHSO), Thailand. Hospital admissions per 100,000 population was the highest among those aged 0–4 years, but the trends decreased from 470.8 to 288.1 per 100,000 population in 2010–2014. The hospital admission rates were high in Southern Thailand and common in rainy seasons. The readmission rates within 28 days slightly decreased in all age groups in 2016 compared to those in 2007. The case fatality rate of patients aged 20–29 years decreased from 0.40% in 2007 to 0.34% in 2016. The readmission rate within 28 days and case fatality rate were the highest in patients aged 20–29 years. In conclusion, the asthma hospital admission, readmission, and case fatality rates declined over time along with the investment in the asthma care program under the UCS in Thailand. The highest hospital admission rates in patients aged 0–4 years and the readmission and case fatality rates in patients aged 20–29 years should be given more attention. Recordings of individual service utilization data in asthma patients, including quality of care provided, should be monitored to improve the asthma care system.

Applicability of predictive models for 30-day unplanned hospital readmission risk in paediatrics: a systematic review

OBJECTIVES

To summarise multivariable predictive models for 30-day unplanned hospital readmissions (UHRs) in paediatrics, describe their performance and completeness in reporting, and determine their potential for application in practice.

DESIGN

Systematic review.

DATA SOURCE

CINAHL, Embase and PubMed up to 7 October 2021.

ELIGIBILITY CRITERIA

English or German language studies aiming to develop or validate a multivariable predictive model for 30-day paediatric UHRs related to all-cause, surgical conditions or general medical conditions were included.

DATA EXTRACTION AND SYNTHESIS

Study characteristics, risk factors significant for predicting readmissions and information about performance measures (eg, c-statistic) were extracted. Reporting quality was addressed by the 'Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis' (TRIPOD) adherence form. The study quality was assessed by applying six domains of potential biases. Due to expected heterogeneity among the studies, the data were qualitatively synthesised.

RESULTS

Based on 28 studies, 37 predictive models were identified, which could potentially be used for determining individual 30-day UHR risk in paediatrics. The number of study participants ranged from 190 children to 1.4 million encounters. The two most common significant risk factors were comorbidity and (postoperative) length of stay. 23 models showed a c-statistic above 0.7 and are primarily applicable at discharge. The median TRIPOD adherence of the models was 59% (P₂₅-P₇₅, 55%-69%), ranging from a minimum of 33% to a maximum of 81%. Overall, the quality of many studies was moderate to low in all six domains.

CONCLUSION

Predictive models may be useful in identifying paediatric patients at increased risk of readmission. To support the application of predictive models, more attention should be placed on completeness in reporting, particularly for those items that may be relevant for implementation in practice.

Demographics and Risk Factors of Pediatric Pulmonary Hypertension Readmissions

BACKGROUND AND OBJECTIVES

Pulmonary hypertension (PH) leads to significant morbidity and mortality in pediatric patients and increases the readmission rates for hospitalizations. This study evaluates the risk factors and comorbidities associated with an increase in 30-day readmissions among pediatric PH patients.

METHODS

National Readmission Database (NRD) 2017 was searched for patients less than 18 years of age who were diagnosed with PH based on the International Classification of Diseases, 10th Revision (ICD-10). Statistical Package for the Social Sciences (SPSS) software v25.0 (IBM Corp., Armonk, NY) was used for statistical analysis.

RESULTS

Of 5.52 million pediatric encounters, 10,501 patients met the selection criteria. The 30-day readmission rate of 14.43% (p < 0.001) was higher than hospitalizations from other causes {Odds Ratio (OR) 4.02 (3.84-4.20), p < 0.001}. The comorbidities of sepsis {OR 0.75 (0.64-0.89), p < 0.02} and respiratory infections {OR 0.75 (0.67-0.85), p < 0.001} were observed to be associated with lower 30-day readmissions. Patients who required invasive mechanical ventilation via endotracheal tube {OR 1.66 (1.4-1.96), p < 0.001} or tracheostomy tube {OR 1.35 (1.15-1.6), p < 0.001} had increased unplanned readmissions. Patients with higher severity of illness based on All Patients Refined Diagnosis Related Groups (APR-DRG) were more likely to get readmitted {OR 7.66 (3.13-18.76), p < 0.001}.

CONCLUSION

PH was associated with increased readmission rates compared to the other pediatric diagnoses, but the readmission rate in this study was lower than one previous pediatric study. Invasive mechanical ventilation, Medicaid insurance, higher severity of illness, and female gender were associated with a higher likelihood of readmission within 30 days.

Revealing the racial and spatial disparity in pediatric asthma: A Kansas City case study

Black and other socially disadvantaged children are disproportionately burdened by high rates of pediatric asthma. Intraurban variation in environmental risk factors and limited access to high-resolution health data make it difficult to identify vulnerable patients, communities, or the immediate exposures that may contribute to pediatric asthma exacerbation. This article presents a novel, interdisciplinary health disparities research and intervention strategy applied to the problem of pediatric asthma in Kansas City. First, address-level electronic health records from a major children's hospital in the Kansas City region are used to map the distribution of asthma encounters in 2012 at a high spatial resolution. Census tract Environmental Justice Screening Method (EJSM) indicators are then developed to scan for patterns in both the population health risks and vulnerabilities that may contribute to the burden of asthma in different communities. A Bayesian Profile Regression cluster analysis is used to systematically explore the complex relationships between census tract EJSM indicators and pediatric asthma incidence rates, helping to identify population characteristics and risk factors associated with both high and low rates of pediatric asthma throughout the region. The EJSM scanning exercise and BPR analysis demonstrate that each community faces a distinct set of risks and vulnerabilities that can contribute to the rate of acute pediatric asthma acute care encounters, providing targets for research and intervention. It is clear, however, that different forms of social disadvantage are driving high rates of pediatric asthma, which is closely tied to uneven development patterns and racial residential segregation. The results provide a starting point for designing place-based health disparities research and intervention strategies catered to the unique needs of vulnerable patients and communities; disparities-focused research and intervention strategies that leverage local knowledge and resources through community-based practices.

Understanding caregiver perspectives on challenges and solutions to pediatric asthma care for children with a previous hospital admission: a multi-site qualitative study

OBJECTIVE

Pediatric hospital admissions for asthma provide an opportunity to trigger a review of the current management with an aim of preventing readmissions. However, caregiver voices on how best to improve care are missing.

METHODS

As part of a larger, mixed methods cohort study, we identified caregivers of children aged 3-18 years who had an index hospital admission to a tertiary pediatric, mixed adult and pediatric, or regional hospital in Victoria, Australia, between 1st September 2017 and 31st August 2018 with a discharge diagnosis of "Asthma" or "Wheeze" based on International Classification of Disease-10 coding. We conducted qualitative semi-structured interviews with a purposive sample of 39 caregivers. We used content analysis to identify themes from the data.

RESULTS

Caregivers identified both challenges associated with asthma care for children with a previous hospital admission as well as solutions to improve care and potentially reduce readmissions. Key challenges included: unclear pathways for follow up care, inconsistent advice, lack of personalized management, delays in getting a diagnosis, delays in the prescription of a preventer medication, and difficulty accessing primary care during exacerbations. Follow up with an "asthma specialist", early access to a trial of preventer medication, personalized Written Asthma Action Plans and increased access to and quality of community-based asthma support services were identified as key solutions.

CONCLUSIONS

Caregivers have identified several potential solutions that could be implemented to improve care and possibly reduce pediatric asthma hospital readmissions. The challenge now is to co-design, embed and evaluate these in healthcare systems.

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

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.

Adverse childhood experiences and risk factors associated with asthma among children in the United States: the intersection of sex and race/ethnicity

OBJECTIVE

The objectives of this cross-sectional study were to examine: 1) the association between adverse childhood experiences (ACEs) and asthma among children, and 2) the interaction between sex and race/ethnicity on asthma.

METHODS

Data for this study were obtained from the 2017-2018 National Survey of Children's Health. Binary logistic regression was conducted on an analytic sample of 49,000 children ages 0-17 years with asthma as the outcome variable and ACEs as the main explanatory variable.

RESULTS

Based on parent reports, we found that 11.5% of children had asthma and about 42% had at least one ACE, with 9.7% having ≥3 ACEs. Controlling for other factors, children with ≥3 ACEs had 1.45 times higher odds of having asthma when compared to children with no ACEs. Non-Hispanic Black males and females were more likely to have asthma when compared to non-Hispanic White males.

CONCLUSIONS

The findings of this study demonstrate an association between ACEs and asthma with children exposed to ≥3 ACEs more likely to have asthma underscoring the importance of cumulative effect of ACEs on asthma. Our study also revealed an interaction between sex and race/ethnicity on asthma among children. Additional studies are needed to understand the mechanisms through which ACEs is associated with asthma among children.

Derivation and validation of a prediction model for neonate unplanned rehospitalization in a tertiary center in China

BACKGROUND

To construct and externally validate a prediction model for neonate unplanned rehospitalization within 31 days of discharge.

METHODS

A retrospective study was performed in the Department of Neonatology of the Children's Hospital of Fudan University. A binominal regression method was applied to construct and validate the prediction model. Analysis was performed on a total of 11,116 neonates with an index admission between 11/1/2016 and 12/31/2018. Neonates admitted from 11/1/2016 to 1/31/2018 were used for the selection of prognostic variables and construction of the model. Model validation was then performed with neonates admitted from 2/1/2018 to 12/31/2018.

RESULTS

The rehospitalization rate for neonates was 3.27% (373/11,116). A total of 512 neonates were enrolled for the construction of the prediction model. Gestational age (GA), NICU length of stay (LOS), nonmedical order discharge and younger maternal age were strongly correlated with rehospitalization. By incorporating these 4 strong risk factors, we constructed a model to predict neonate unplanned rehospitalization within 31 days of discharge. The formula was turned into a nomogram for use in clinical practice. The nomogram has a total score of 180, with a predicted risk from 0 to 100%. Neonates are at high risk for rehospitalization if they have a total score greater than 39 points, according to the cutoff point established by the Youden index. The model was shown to have good discriminatory ability, with area under the receiver operating characteristic curves of 0.68 and 0.65 in the model construction and validation datasets, respectively. A total of 39 points is the cutoff for follow-up.

CONCLUSIONS

The model is able to predict neonate unplanned rehospitalization well. A total score greater than 39 indicates that follow-up is necessary.

Risk factors associated with 30-day all-cause unplanned hospital readmissions at a tertiary children's hospital in Western Australia

AIM

To identify risk factors associated with 30-day all-cause unplanned hospital readmission at a tertiary children's hospital in Western Australia.

METHODS

An administrative paediatric inpatient dataset was analysed retrospectively. Patients of all ages discharged between 1 January 2010 and 31 December 2014 were included. Demographic and clinical information at the index admission was examined using multivariate logistic regression analysis.

RESULTS

A total of 3330 patients (4.55%) experienced at least one unplanned readmission after discharge. Readmission was more likely to occur in patients who were either older than 16 years (odds ratio (OR) = 1.46; 95% confidence interval (CI) 1.07-1.98), utilising private insurance as an inpatient (OR = 1.16; 95% CI 1.00-1.34), with greater socio-economic advantage (OR = 1.20; 95% CI 1.02-1.41), admitted on Friday (OR = 1.21; 95% CI 1.05-1.39), discharged on Friday/Saturday/Sunday (OR = 1.26, 95% CI 1.10-1.44; OR = 1.34, 95% CI 1.15-1.57; OR = 1.24, 95% CI 1.05-1.47, respectively), with four or more diagnoses at the index admission (OR = 2.41; 95% CI 2.08-2.80) or hospitalised for 15 days or longer (OR = 2.39; 95% CI 1.88-2.98). Area under receiver operating characteristic curve of the predictive model is 0.645.

CONCLUSIONS

A moderate discriminative ability predictive model for 30-day all-cause same hospital readmission was developed. A structured discharge plan is suggested to be commenced from admission to ensure continuity of care for patients identified as being at higher risk of readmission. A recommendation is made that a designated staff member be assigned to co-ordinate the plan, including assessment of patients' and primary carers' readiness for discharge. Further research is required to establish comprehensive paediatric readmission rates by accessing linkage data to capture different hospital readmissions.

Risk factors for readmission of children hospitalized with acute asthma attacks in South China

OBJECTIVE

Asthma seriously endangers the health of children. Re-hospitalization for childhood asthma consumes a large amount of medical and health resources. The present study aimed to assess the rates and risk factors for hospital readmission of children with acute asthma attacks in south China.

METHODS

We retrospectively enrolled 1702 acute asthma patients aged < 18 years from 1/1/2007 to 12/31/2015. Patients who were readmitted within one year after index hospital discharge were divided into a readmission group. Index hospitalization data were acquired from clinical records. Chi-square tests and multivariate logistic regression analyses were used to evaluate the risk factors.

RESULTS

There were 90 (5.29%) readmitted patients from 1702 acute asthma patients. Considering the large sample differences between readmitted and single-admitted patients, 123 single-admitted patients (1.5-fold as many as the readmitted group) were randomly selected. Further univariate Chi-square tests and multivariate logistic regression analyses showed that the predictors of readmission included eczema history (odds ratio (OR) 3.122, p = 0.003) and mycoplasma pneumoniae (MP) antibody immunoglobulin M(IgM) (OR 2.386, p = 0.037).

CONCLUSIONS

Among the children admitted to a hospital in south China with acute asthma attacks, 5.29% were readmitted within the following year. Patients with history of eczema and positive MP antibody IgM had significantly increased the chances of one-year readmission, underlining the importance of targeted long-term postdischarge follow-up of these children.

Bilevel Positive Airway Pressure ventilation efficiently improves respiratory distress in initial hours treating children with severe asthma exacerbation

OBJECTIVE

Treatment of severe asthma exacerbation could be challenging, especially in the initial hours of acute attack when systemic corticosteroid is yet to take effect. In spite of using inhaled agents, the role of non-invasive ventilation (NIV), including Bilevel Positive Airway Pressure (BiPAP), had been addressed recently.

METHODS

We reviewed 5-year experience in our hospital for records of patients who were admitted to pediatric intensive care unit because of severe asthma attack. The included admission records from 2012 to 2017 were grouped according to BiPAP use (Yes/No). Clinical parameters (heart rate (HR), respiratory rate (RR), SpO2 and serum pCO2) at selected time intervals of treatment were collected for both groups and analyzed.

RESULTS

We included data of 46 admissions from 33 different patients (24 with BiPAP and 21 without BiPAP.) The BiPAP group had significantly higher initial RR as well as higher severity scores compared with the other group (p < 0.001). The RR improved significantly in the following time intervals in BiPAP group. There was no significant difference in HR between groups in any of the time intervals. The serum pCO2 levels decreased significantly after initiation of ventilation support in the BiPAP group, and SpO2 levels improved significantly for both groups.

CONCLUSION

BiPAP seemed efficient in improving respiratory rate and oxygenation in our study. It does not seem to cause additional irritation regarding that HR was not increased in BiPAP group compared with non-BiPAP group. Overall, BiPAP ventilation is safe and efficient in treating children with severe asthma attack.

Contextual Factors Influencing Implementation of Evidence-Based Care for Children Hospitalized With Asthma

BACKGROUND AND OBJECTIVES

The translation of research findings into routine care remains slow and challenging. We previously reported successful implementation of an asthma evidence-based care process model (EB-CPM) at 8 (1 tertiary care and 7 community) hospitals, leading to a high health care provider (HCP) adherence with the EB-CPM and improved outcomes. In this study, we explore contextual factors perceived by HCPs to facilitate successful EB-CPM implementation.

METHODS

Structured and open-ended questions were used to survey HCPs (n = 260) including physicians, nurses, and respiratory therapists, about contextual factors perceived to facilitate EB-CPM implementation. Quantitative analysis was used to identify significant factors (correlation coefficient ≥0.5; P ≤ .05) and qualitative analysis to assess additional facilitators.

RESULTS

Factors perceived by HCPs to facilitate EB-CPM implementation were related to (1) inner setting (leadership support, adequate resources, communication and/or collaboration, culture, and previous experience with guideline implementation), (2) intervention characteristics (relevant and applicable to the HCP's practice), (3) individuals (HCPs) targeted (agreement with the EB-CPM and knowledge of supporting evidence), and (4) implementation process (participation of HCPs in implementation activities, teamwork, implementation team with a mix of expertise and professional's input, and data feedback). Additional facilitators included (1) having appropriate preparation and (2) providing education and training.

CONCLUSIONS

Multiple factors were associated with successful EB-CPM implementation and may be used by others as a guide to facilitate implementation and dissemination of evidence-based interventions for pediatric asthma and other chronic diseases in the hospital setting.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

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.

Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry

Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.

Validation of Asthma Control Assessment Among Urban Adolescents Using the Asthma Control and Communication Instrument

BACKGROUND

The National Institutes of Health guidelines recommend questionnaires to assess asthma control, but there are few self-reported asthma morbidity surveys validated among urban, African American, Hispanic, and/or poor adolescents. The Asthma Control and Communication Instrument (ACCI) is a 12-item self-reported questionnaire previously validated among a diverse adult population, but not among adolescents.

OBJECTIVE

To assess the ability of the ACCI to accurately describe asthma control in an urban adolescent population.

METHODS

Between November 13, 2014, and March 2, 2017, we collected information using the ACCI, the Asthma Control Test, the Pediatric Asthma Quality of Life Questionnaire, and lung function among adolescents enrolled in a school-based asthma intervention study. The ACCI measure of asthma control was validated by evaluating accuracy (on the basis of receiver operating characteristic curve), internal reliability, and concurrent and discriminative validity.

RESULTS

We collected information on 280 adolescents (mean age, 13.4 years; 56% males; and 51% African American). ACCI control showed good internal reliability and strong concurrent and discriminative validity with the Asthma Control Test and the Pediatric Asthma Quality of Life Questionnaire. The accuracy of the ACCI in classifying adolescents with uncontrolled asthma was good (area under the curve, 0.83; 95% CI, 0.79-0.88).

CONCLUSION

The ACCI, a clinical tool developed to assist communication about asthma control, has demonstrated strong construct validity as a self-reported questionnaire within an urban, African American, and Hispanic sample of adolescents. It has the potential to assist in the assessment of asthma control in urban, minority, and/or poor adolescents.

Development of the Pediatric Social Risk Instrument Using a Structured Panel Approach

BACKGROUND

Social determinants of health impact child illness. Currently, no instrument exists to identify social need during hospital admission.

METHODS

Using the UCLA (University of California Los Angeles)-RAND appropriateness method, consensus was reached for an instrument to identify social need in hospitalized children. A panel of 11 experts reviewed candidate indicators through 3 rounds to reach consensus. The instrument then underwent usability testing.

RESULTS

Three hundred and forty-seven indicators from the literature were sorted into 18 social risk themes. After 3 rounds, consensus was reached on 82 indicators. Six additional social risk themes were recommended by the panel, resulting in consensus for 18 additional indicators. Final refinement resulted in an instrument containing 86 indicators representing 11 social risk themes. Usability testing identified that the tool was well received by families. Final feedback was incorporated into a post-usability instrument.

CONCLUSIONS

Using the UCLA-RAND appropriateness method, a new pediatric social risk instrument was created to identify social need for hospitalized children.

Risk Factors for Return to the Emergency Department for Asthma: A Population-Based Study

BACKGROUND

A substantial proportion of patients with asthma return after being discharged from the emergency department (ED). Given the high economic burden of acute care claims, and the impact on productivity and quality of life, a better understanding of risk factors for ED return is of interest.

OBJECTIVE

To quantify the rate and determine factors associated with return to the ED for asthma within 1 year of an initial ED visit for asthma.

METHODS

Individuals aged 5 to 99 years living in Ontario, Canada, with an ED visit for asthma in the period 2008 to 2014 were included. Descriptive statistics were used to compare those with an ED return with those without an ED return. An adjusted modified Poisson regression model was used to estimate the relative risk of ED return for asthma within 1 year after the initial discharge.

RESULTS

In total, 58,366 individuals met the inclusion criteria. At 1-year follow-up, 12.1% returned to the ED at least once. Younger age, being materially deprived, and having chronic obstructive pulmonary disease were significantly associated with increased risk of ED return within 1 year after the initial visit.

CONCLUSIONS

Nearly 1 in 8 individuals with a first ED visit for asthma returned to the ED within a year of the initial ED discharge. Targeting those at risk for ED return may help improve health care costs, productivity, and quality of life.

Impact of pediatric obesity on acute asthma exacerbation in Japan

BACKGROUND

Asthma and obesity are common health problems in children. This study investigated the impact of obesity on children hospitalized with acute asthma exacerbation.

METHODS

We obtained the hospital discharge records of inpatients aged 3-8 years with a diagnosis of asthma using a national inpatient database in Japan. The patients were classified into underweight, normal weight, overweight, and obese groups using weight for height and body mass index for age provided by the World Health Organization. We compared 30-day re-admission, need for intensive care, mean total hospitalization costs, and length of hospital stay between the 4 groups using multivariable regression models.

RESULTS

Overall, 38 679 patients were identified, including 3177 underweight, 28 904 normal weight, 3334 overweight, and 3264 obese patients. The obese group showed significantly higher 30-day re-admission (adjusted odds ratio, 1.26; 95% confidence interval, 1.03-1.54) and longer length of stay (adjusted difference, 0.12 days; 95% confidence interval, 0.10-0.20 days) than the normal weight group. The threshold was a 91st percentile of weight for length or body mass index for the relationship with 30-day re-admission. No significant difference was observed between the 4 groups regarding the need for intensive care and total hospitalization costs.

CONCLUSION

These findings demonstrated that obesity was a risk factor for repeated admissions caused by asthma in children, indicating the importance for the prevention of pediatric obesity.

Improving Asthma-Related Outcomes Among Children Participating in the Head-Off Environmental Asthma in Louisiana (HEAL), Phase II Study

PURPOSE

Pediatric asthma disproportionately affects low-income and minority children. The HEAL (Head-Off Environmental Asthma in Louisiana), Phase II Project was a collaborative effort with a primary focus to improve pediatric asthma management in New Orleans, Louisiana. The purpose of this article is to report clinical outcomes captured at baseline and 12-month follow-up.

METHOD

HEAL (Head-off Environmental Asthma in Louisiana), Phase II was a pre-post intervention study that enrolled children ages 2 to 18 years of age with a diagnosis of asthma to receive asthma education within the clinic setting. Enrollees received an asthma education intervention, an environmental evaluation, and a 12-month follow-up session. Endpoints included symptom days, level of asthma control, asthma exacerbations, emergency room visits, hospitalizations, and missed school days.

RESULTS

The majority of participants were aged 5 years and older, male, Black, and persistent asthmatics. Emergency room visits decreased from 41% to 20% ( p < .001). Improvements in coughing (83% to 62%, p < .001), wheezing (50% to 26%, p < .001), and chest tightness (29% to 18%, p < .001) were also seen.

CONCLUSION

The novel intervention was associated with improved asthma outcomes among pediatric patients receiving care at the clinical sites in the Greater New Orleans area.

Association between pediatric home management plan of care compliance and asthma readmission

OBJECTIVES

In 2007, The Joint Commission implemented three children's asthma care (CAC) measures to help improve the quality of care for patients admitted with asthma. Due to lack of consistent evidence showing a relationship between home management plan of care (HMPC) compliance and readmission rates, CAC-3 was retired in 2016. We aimed to understand the relationship between HMPC compliance and revisits to the hospital, and investigate which components of the HMPC, if any, were driving the effect.

METHODS

This was a retrospective cohort study at a quaternary care freestanding children's hospital, including patients between 2 and 17 years of age admitted with a primary diagnosis of asthma between January 1, 2006, and July 1, 2013. Bivariate and multiple logistic regression analyses examined effects of HMPC provider compliance on hospital readmission and emergency department utilization for asthma within 180 days of initial discharge, controlling for admission to the intensive care unit, age, gender, ethnicity, insurance type, and whether inhaled corticosteroids were prescribed.

RESULTS

A total of 1,176 patients were included. Those discharged with an HMPC (n = 756, of which 84% were fully compliant) were found to have significantly lower readmission rates (7 vs. 11.9%; aOR = 0.63; 95% CI, 0.41-0.95) and ED revisit rates (aOR = 0.73; 95% CI, 0.56-0.96) within 180 days of discharge.

CONCLUSIONS

Providing an HMPC upon discharge was found to be associated with decreased asthma readmission and ED utilization rates. This suggests that although HMPC is no longer a required measure, there may still be utility in continuing this practice.

Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals

BACKGROUND AND OBJECTIVES

Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals.

METHODS

Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses.

RESULTS

At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths.

CONCLUSIONS

Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.