Discharge Medical Complexity, Change in Medical Complexity and Pediatric 30-day Readmission

Discharge against medical advice in pediatrics: a 10-year retrospective analysis in a tertiary care center

BACKGROUND

There is still limited data on Discharge Against Medical Advice (DAMA) in the pediatric population. Most research comes from low-and middle-income countries, where the financial burden associated with medical care is often an important reason to leave a healthcare facility prematurely. Discharge against medical advice in the children's population is considered a significant issue that may lead to an increased risk of morbidity and mortality.

OBJECTIVES

Describe the characteristics and predictors of DAMA in children over ten years in in Riyadh, Saudi Arabia.

DESIGN

Retrospective.

SETTING

Tertiary care center.

PATIENTS AND METHODS

This study included all patients aged <14 years who had DAMA during all admissions between 1 January 2012, and 31 December 2022.

MAIN OUTCOME MEASURES

Data was retrieved from medical records and included 1) sociodemographic data, 2) medical history and clinical characteristics, 3) utilization of services during the admission leading to DAMA, and 4) interventions provided to prevent departure.

SAMPLE SIZE

355 DAMA episodes.

RESULTS

Males accounted for 45.4%, and the average age was 4.4 years. The overall DAMA prevalence of was 0.4%. At baseline, 277 children (78%) had at least a chronic illness or severe baseline condition; 59% had a potential life-limiting or life-threatening condition. Reasons for DAMA included disagreement about the treatment plan (14.9%), social reasons (12.6%), and perception that the child's condition improved (5.6%). An increased risk of DAMA recurrence was associated with pre-existing severe or chronic medical conditions (OR: 8.2, P=.004) and a discharge during the treatment phase (OR: 1.9, P=.040).

CONCLUSIONS

Despite inconsistent documentation, preventive measures included the involvement of healthcare providers, social services, and patient relations. The study highlights the need for standardized protocols and improved documentation practices to effectively address discharge against medical advice.

LIMITATIONS

Needs to moderate documentation quality of DAMA episodes. The study was limited to a single center, which may affect the generalizability. Children might also have presented to receive care in another facility post-DAMA.

Unplanned Readmissions in Children with Medical Complexity in Saudi Arabia: A Large Multicenter Study

Background

Children with medical complexity (CMC) account for a substantial proportion of healthcare spending, and one-third of their expenditures are due to readmissions. However, knowledge regarding the healthcare-resource utilization and characteristics of CMC in Saudi Arabia is limited.

Objectives

To describe hospitalization patterns and characteristics of Saudi CMC with an unplanned 30-day readmission.

Methodology

This retrospective study included Saudi CMC (aged 0-14 years) who had an unplanned 30-day readmission at six tertiary centers in Riyadh, Jeddah, Dammam, Alahsa, and Almadina between January 2016 and December 2020. Hospital-based inclusion criteria focused on CMC with multiple complex chronic conditions (CCCs) and technology assistance (TA) device use. CMC were compared across demographics, clinical characteristics, and hospital-resource utilization.

Results

A total of 9139 pediatric patients had unplanned 30-day readmission during the study period, of which 680 (7.4%) met the inclusion criteria. Genetic conditions were the most predominant primary pathology (66.3%), with one-third of cases (33.7%) involving the neuromuscular system. During the index admission, pneumonia was the most common diagnosis (33.1%). Approximately 35.1% of the readmissions were after 2 weeks. Pneumonia accounted for 32.5% of the readmissions. After readmission, 16.9% of patients were diagnosed with another CCC or received a new TA device, and the in-hospital mortality rate was 6.6%.

Conclusion

The rate of unplanned 30-day readmissions in children with medical complexity in Saudi Arabia is 7.4%, which is lower than those reported from developed countries. Saudi children with CCCs and TA devices were readmitted approximately within similar post-discharge time and showed distinct hospitalization patterns associated with specific diagnoses. To effectively reduce the risk of 30-day readmissions, targeted measures must be introduced both during the hospitalization period and after discharge.

Thirty-day readmissions in children with complex chronic conditions

INTRODUCTION

The rate of hospital readmission within 30 days of discharge is a quality indicator in health care. Paediatric patients with complex chronic conditions have high readmission rates. Failure in the transition between hospital and home care could explain this phenomenon.

OBJECTIVES

To estimate the incidence rate of 30-day hospital readmission in paediatric patients with complex chronic conditions, estimate how many are potentially preventable and explore factors associated with readmission.

MATERIALS AND METHOD

Cohort study including hospitalised patients with complex chronic conditions aged 1 month to 18 years. Patients with cancer or with congenital heart disease requiring surgical correction were excluded. The outcomes assessed were 30-day readmission rate and potentially preventable readmissions. We analysed sociodemographic, geographic, clinical and transition to home care characteristics as factors potentially associated with readmission.

RESULTS

The study included 171 hospitalizations, and 28 patients were readmitted within 30 days (16.4%; 95% CI, 11.6%-22.7%). Of the 28 readmissions, 23 were potentially preventable (82.1%; 95% CI, 64.4%-92.1%). Respiratory disease was associated with a higher probability of readmission. There was no association between 30-day readmission and the characteristics of the transition to home care.

CONCLUSIONS

The 30-day readmission rate in patients with complex chronic disease was 16.4%, and 82.1% of readmissions were potentially preventable. Respiratory disease was the only identified risk factor for 30-day readmission.

Readmission Rates After Acute Respiratory Distress Syndrome in Children

Importance

An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown.

Objective

To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission.

Design, Setting, and Participants

This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023.

Exposures

Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS.

Main Outcomes and Measures

The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission.

Results

One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47).

Conclusions and Relevance

In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.

Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample

Objective

The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs.

Methods

We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes.

Results

Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%).

Conclusions and Relevance

The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.

The Impact of Non-English Language Preference on Pediatric Hospital Outcomes

OBJECTIVES

To characterize the relationship between non-English language preference (NELP) and hospital outcomes including length of stay (LOS), time of discharge, emergency department return visits, readmissions, and cost for pediatric general medicine inpatients.

METHODS

We conducted a retrospective analysis at an urban, quaternary care, free-standing children's hospital. Patients ages 0 to 18 admitted to any general medicine service between January 1, 2017, and December 31, 2019 were included. Patients were divided into 3 language preference categories: English, Spanish, and non-Spanish NELP. Single and multifactor regression analysis was used to model differences in outcome measures by language preference adjusted for technology dependence.

RESULTS

A total of 4820 patients met criteria. In adjusted models, the average LOS for English-speaking patients was 126 hours; LOS for patients who preferred Spanish was not significantly different, whereas LOS for patients with non-Spanish NELP was 50% longer (P < .001). English-speaking patients were discharged earliest in the day (mean 3:08 pm), with patients who preferred Spanish discharged 0.5 hours later and patients with non-Spanish NELP discharged 1.1 hours later than English-speaking patients (P < .001). Patients with NELP were found to be technology-dependent more frequently (P < .001) than the English preference group. Emergency department return visits, readmissions, and cost were not significantly different between groups.

CONCLUSIONS

NELP was associated with longer length of stay and discharges later in the day. The most pronounced differences occurred in patients with non-Spanish NELP who also had more frequent technology dependence and more limited access to interpreters.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes

OBJECTIVES

To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization.

METHODS

Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement.

RESULTS

We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year.

CONCLUSIONS

Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

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.

Performance Characteristics of a Machine-Learning Tool to Predict 7-Day Hospital Readmissions

OBJECTIVES

To develop an institutional machine-learning (ML) tool that utilizes demographic, socioeconomic, and medical information to stratify risk for 7-day readmission after hospital discharge; assess the validity and reliability of the tool; and demonstrate its discriminatory capacity to predict readmissions.

PATIENTS AND METHODS

We performed a combined single-center, cross-sectional, and prospective study of pediatric hospitalists assessing the face and content validity of the developed readmission ML tool. The cross-sectional analyses used data from questionnaire Likert scale responses regarding face and content validity. Prospectively, we compared the discriminatory capacity of provider readmission risk versus the ML tool to predict 7-day readmissions assessed via area under the receiver operating characteristic curve analyses.

RESULTS

Overall, 80% (15 of 20) of hospitalists reported being somewhat to very confident with their ability to accurately predict readmission risk; 53% reported that an ML tool would influence clinical decision-making (face validity). The ML tool variable exhibiting the highest content validity was history of previous 7-day readmission. Prospective provider assessment of risk of 413 discharges showed minimal agreement with the ML tool (κ = 0.104 [95% confidence interval 0.028-0.179]). Both provider gestalt and ML calculations poorly predicted 7-day readmissions (area under the receiver operating characteristic curve: 0.67 vs 0.52; P = .11).

CONCLUSIONS

An ML tool for predicting 7-day hospital readmissions after discharge from the general pediatric ward had limited face and content validity among pediatric hospitalists. Both provider and ML-based determinations of readmission risk were of limited discriminatory value. Before incorporating similar tools into real-time discharge planning, model calibration efforts are needed.

Allocation of Pediatric Home Care Nursing Hours: The Minnesota Experience

Despite an increasing demand for pediatric home care nursing, there is no comprehensive or universal standard of care for prescribing pediatric home care nursing hours based on a child's medical complexity. Adoption of a qualification tool (QT) to allocate home care nursing hours based on the medical complexity of a child may mitigate inequality in access to care and improve the patient and family experience. A QT, developed in Minnesota, recommends home care nursing hours based on the level of medical complexity and need for skilled nursing interventions. Four hypothetical case studies demonstrate the use of the QT to calculate recommended nursing hours. To validate the tool, a survey of discharge planners found a percentage difference in calculated hours of 4.1, 5.7, 11.2, and 24.9 in the four case studies. Discharge planners rated the usability of the QT as favorable with a score of 3.6 on a Likert scale of 5. The recommended nursing hours prescribed for families, based on the QT, was perceived as meeting the needs of the child by 56% and 42% of surveyed parents and home care nurses (HCNs), respectively. The need for additional nursing hours was expressed by 33% and 50% of parents and nurses, respectively. In general, HCNs' assessment of allocated nursing hours paralleled that of parents. Further refinement and adoption of a standardized QT to allocate home care nursing hours may improve access and outcomes for children requiring home care nursing.

Resources and Costs Associated With Repeated Admissions to PICUs

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To determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge.