Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management

Grass pollen exposure is associated with higher readmission rates for pediatric asthma

BACKGROUND

Pediatric asthma hospital readmission is a burden on the individual and costly for Australian hospitals. Grass pollen's role, a known trigger for asthma admissions, is unexamined in readmissions. We examined the association between grass pollen and pediatric asthma readmission.

METHODS

The Victorian Admitted Episodes Dataset was used to identify all primary admissions with a principal diagnosis of asthma in children aged 2-18 years between 1997 and 2009. Readmissions were defined as subsequent admissions within 28 days of index admission discharge. Generalized additive models were used to assess associations between readmission, grass pollen season, and daily grass pollen counts, lagged and cumulative. Models were further stratified by sex and age group.

RESULTS

Mean daily readmission was higher during grass pollen season than other times of the year, incidence rate ratio (IRR) 1.44 (95% CI, 1.03, 2.02) and for children aged 2-5 years, IRR 1.99 (1.26, 3.14). Same day grass pollen was nonlinearly associated with daily readmission for the 13-18 age group between 110 and 256 grains/m³ , p < .01. Lag 2 grass pollen was nonlinearly associated with daily readmissions overall (p = .03), boys (p = .01), and younger age groups 2-5 (p = .02) and 6-12 (p < .001).

CONCLUSIONS

Grass pollen exposure was associated with higher readmission rates for pediatric asthma. Treatment plans prior to discharge could be implemented to reduce the likelihood of readmission by younger children during the pollen season.

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.

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.

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

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

Process for improving the integration of care across the primary and acute care settings in rural South Australia: asthma as a case study

OBJECTIVE

To develop a process for improving the integration of care across the rural acute and primary care settings using asthma as a case study.

METHODS

Development of the process on the analysis of case note audit, survey, interviews and a workshop.

SETTING

A rural region of South Australia.

RESULTS

A work plan for improving general practitioner (GP)-hospital integration was developed that resulted from analysis of the defined problem, GPs and stakeholder involvement, communication between all stakeholders, provision of an incentive to bring all the stakeholders together, and identification of evidence-based solutions.

CONCLUSIONS

Managing chronic disease in a community requires the integration of care across the primary and acute care setting. To be successful, GP-hospital integration initiatives require stakeholder involvement, locally developed solutions, engagement of GPs, communication and a well-developed plan. This project provides a process for achieving this.

Are elderly patients with obstructive airway disease being prematurely discharged?

Despite the temporal trend toward decreasing length of hospital stay for all medical conditions in North America, the effect of different lengths of hospitalization on short-term outcomes such as readmission or mortality has not been well studied. However, there is growing concern that very short stays in hospital may result in premature discharges, which may lead to worse outcomes for patients. We conducted a population-based study of elderly patients with obstructive airway disease in Ontario, Canada to test the hypothesis that very short initial hospital stays increase the short-term risk for readmission and mortality. Using a cohort of 32,384 elderly patients 65 yr of age or older, we compared 15-d rates of readmission and mortality among patients with different lengths of stay. Although patients with hospital stays of less than 4 d were younger and had fewer comorbidities, they were 39% (95% confidence interval [CI], 20% to 61%) more likely to be readmitted and 45% (95% CI, 9% to 92%) more likely to die within 15 d postdischarge compared with those who stayed 4 to 6 d. The risk was highest among patients whose stay was less than or equal to 1 hospital day; they had a 69% (95% CI, 32% to 117%) excess risk of readmission and a 2.08 (95% CI, 1.23 to 3.45) -fold increase in mortality compared with those who stayed in hospital for 2 d. This suggests that some elderly patients with obstructive airway disease may be being prematurely discharged.

Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice

BACKGROUND

Discharge planning is becoming an important part of the management of childhood asthma in hospital. Readmission to hospital, although often inevitable, might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital.

AIM

To examine the impact of a structured, nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital, reattendance at the accident and emergency (A&E) department, and general practitioner consultations for asthma.

METHODS

A structured nurse-led discharge package, consisting of a 20 minute patient education programme and self management plan for children with asthma was developed on the wards of a busy children's hospital. A randomised controlled trial was conducted involving 160 children aged 2-16 years admitted for asthma over a 12 month period. Readmission and A&E reattendance's over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records.

RESULTS

Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group (12 of 80 v 30 of 80 patients), and significantly less likely to attend the A&E department (6 of 80 v 31 of 80). Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma (31 of 78 v 72 of 77 for whom data were available).

CONCLUSION

By delivering the simplest form of education and support during a child's stay in hospital, readmissions over a six month period were reduced. The programme was designed to be suitable for administration by nursing staff on the children's wards after a brief period of training.

Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study

OBJECTIVE

To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty.

DESIGN AND SETTING

Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital.

PARTICIPANTS

163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients).

MAIN OUTCOME MEASURES

Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay.

RESULTS

Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients.

CONCLUSION

Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty.

Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987-1995

OBJECTIVE

To describe changes in admission patterns, bed resources and hospital use in acute public hospitals and their relationship with early readmissions and interhospital transfers in Victoria between 1987 and 1995.

DESIGN

Descriptive study of longitudinal trends using data from the Victorian inpatient Minimum Database and the Acute Health Services Branch of the Department of Human Services, Victoria.

SETTING

State of Victoria.

MAIN OUTCOME MEASURES

Acute public hospital beds and hospital separations per 1000 population; separation type (same-day or longer); mean length of stay; interhospital transfers; and readmissions to the same hospital within 28 days.

RESULTS

Between 1987-88 and 1994-95, public hospital beds in Victoria decreased from 3.2 to 2.8/1000 population, and mean length of hospital stay decreased from 6.4 to 4.2 days. There was a significant direct correlation between number of beds/1000 and length of stay (r = 0.90; 95% confidence interval [CI], 0.52-0.98). Bed occupancy remained constant at 80%. Over the same period, same-day admissions increased from 22% to 42% of hospital separations, interhospital transfers increased from 2.7% to 4% of separations, and readmissions to the same hospital within 28 days for any reason increased from 12.4% to 15% of separations (21% increase). Beds/1000 were inversely correlated with interhospital transfers (r = -0.83; 95% CI, -0.31 to -0.97), while readmission rates were inversely correlated with beds/1000 (r = -0.89; 95% CI, -0.98 to -0.50) and length of hospital stay (r = -0.95; 95% CI, -0.99 to -0.74).

CONCLUSIONS

There were significant changes in the patterns of use of public hospitals between 1987 and 1995, possibly reflecting technological advances and changes in clinical practice, as well as policy to improve efficiency. Early readmission rates may be a useful proxy measure of potentially avoidable adverse outcomes.