Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs. (Chaudhary)

Edwards JD, Lucas AR, Boscardin WJ, Dudley RA. Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs. Crit Care Med. 2017 Aug;45(8):1276-1284.

OBJECTIVES: To determine the occurrence rate of unplanned readmissions to PICUs within 1 year and examine risk factors associated with repeated readmission.

DESIGN: Retrospective cohort analysis.

SETTING: Seventy-six North American PICUs that participated in the Virtual Pediatric Systems, LLC (VPS, LLC, Los Angeles, CA).

PATIENTS: Ninety-three thousand three hundred seventy-nine PICU patients discharged between 2009 and 2010.


MEASUREMENTS AND MAIN RESULTS: Index admissions and unplanned readmissions were characterized and their outcomes compared. Time-to-event analyses were performed to examine factors associated with readmission within 1 year. Eleven percent (10,233) of patients had 15,625 unplanned readmissions within 1 year to the same PICU; 3.4% had two or more readmissions. Readmissions had significantly higher PICU mortality and longer PICU length of stay, compared with index admissions (4.0% vs 2.5% and 2.5 vs 1.6 d; all p < 0.001). Median time to readmission was 30 days for all readmissions, 3.5 days for readmissions during the same hospitalization, and 66 days for different hospitalizations. Having more complex chronic conditions was associated with earlier readmission (adjusted hazard ratio, 2.9 for one complex chronic condition; hazard ratio, 4.8 for two complex chronic conditions; hazard ratio, 9.6 for three or more complex chronic conditions; all p < 0.001 compared no complex chronic condition). Most specific complex chronic condition conferred a greater risk of readmission, and some had considerably higher risk than others.

CONCLUSIONS: Unplanned readmissions occurred in a sizable minority of PICU patients. Patients with complex chronic conditions and particular conditions were at much higher risk for readmission.

Measuring hospital quality using pediatric readmission and revisit rates. (Vats)

Bardach NS, Vittinghoff E, Asteria-Peñaloza R, et al. Measuring hospital quality using pediatric readmission and revisit rates. Pediatrics. 2013 Sep;132(3):429-36.

OBJECTIVE: To assess variation among hospitals on pediatric readmission and revisit rates and to determine the number of high- and low-performing hospitals.

METHODS: In a retrospective analysis using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project with revisit linkages available, we identified pediatric (ages 1-20 years) visits with 1 of 7 common inpatient pediatric conditions (asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy). For each condition, we calculated rates of all-cause readmissions and rates of revisits (readmission or presentation to the emergency department) within 30 and 60 days of discharge. We used mixed logistic models to estimate hospital-level risk-standardized 30-day revisit rates and to identify hospitals that had performance statistically different from the group mean.

RESULTS: Thirty-day readmission rates were low (<10.0%) for all conditions. Thirty-day rates of revisit to the inpatient or emergency department setting ranged from 6.2% (appendicitis) to 11.0% (mood disorders). Study hospitals (n = 958) had low condition-specific visit volumes (37.0%-82.8% of hospitals had <25 visits). The only condition with >1% of hospitals labeled as different from the mean on 30-day risk-standardized revisit rates was mood disorders (4.2% of hospitals [n = 15], range of hospital performance 6.3%-15.9%).

CONCLUSIONS: We found that when comparing hospitals’ performances to the average, few hospitals that care for children are identified as high- or low-performers for revisits, even for common pediatric diagnoses, likely due to low hospital volumes. This limits the usefulness of condition-specific readmission or revisit measures in pediatric quality measurement.

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Unscheduled readmissions to the PICU: epidemiology, risk factors, and variation among centers. (Carmean)

Pediatr Crit Care Med. 2013 Jul;14(6):571-9. PMID: 23823192

OBJECTIVES: To determine the rate of, and potential risk factors for, unscheduled PICU readmission and assess for variability among PICUs within the United States.

DESIGN AND DATA SOURCE: This retrospective cohort study used 2005-2008 data from 73 PICUs in the Virtual PICU Systems database.

METHODS AND MEASUREMENTS: Early (within 48 hr of PICU discharge) and late (later than 48 hr) unscheduled readmission rates were calculated. Hierarchical logistic regression, with a random intercept for site, was used to identify factors independently associated with early readmission. Significant random effects identified sites with an outlying risk of readmission, adjusting for patient and admission characteristics.

MAIN RESULTS: For 117,923 children meeting inclusion criteria, the unscheduled readmission rate was 3.7% with 38% (1.4%) occurring early. Half of early readmissions had the same primary diagnosis as the first admission. Patients with late readmissions had a higher mortality (6.6% vs 3.3%, p < 0.001) and longer median total PICU length of stay (11 d vs 6 d, p < 0.0001) than those with early readmission. Patient characteristics strongly associated with increased risk of early readmission included the following: age < 6 months, acute respiratory and renal disease, and several underlying chronic conditions such as liver disease, bone marrow transplant, airway stenosis, and abnormal antidiuretic hormone balances. An initial PICU admission that was unscheduled, originated from the general floor, or with a discharge time between 4 PM and 8 AM was associated with higher risk of readmission. A quarter of sites were identified as potential high (16%) or low (8%) outliers.

CONCLUSIONS: The rate of unscheduled PICU readmission was low but associated with worse outcomes. Patient and admission/discharge characteristics associated with increased risk of readmissions could be used to target high-risk populations or modifiable factors to improve outcome. Variation of risk among centers suggests room for improvement.

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