It is frankly unbelievable that we know so little about preventing hospital readmissions in children despite (1) 60 years of readmission study and discussion across the world1; (2) national endorsement of measurement and reduction of readmissions by esteemed entities such as the National Quality Forum, the Centers for Medicare and Medicare Services, and the Agency for Healthcare Research and Quality2–4; (3) computer software designed to measure preventable readmissions5; and (4) financial penalties to hospitals (including children’s hospitals) with too many readmissions.6–8 There has been tremendous fervor about readmissions in adult patients, but this fervor does not sizzle at the same amplitude in children. To begin with, children (in general) have lower readmission rates than adults.9–12 Furthermore, in children, there is neither a wealth of data correlating quality of discharge care with readmission nor a clear understanding of best practices to prevent readmissions.13–15
So what’s the big deal with readmissions in children? Should we even care about them? Of course we should. First, many children do have a problem with discharge care (eg, incorrect dosing of a medication) that negatively affects their health after discharge. The burden placed on a family (and the accompanying stress) to remedy problems and issues regarding a child’s health after discharge can be devastating. The experience of worsening health after discharge and returning for another hospitalization is always an unwelcome occurrence in the life of a child. Readmissions, like all hospitalizations, are expensive, and they expose children to the dangers of the hospital environment (eg, nosocomial pathogens, adverse events). Finally, some children, especially those with medical complexity, have readmission rates that are as high as or higher than those for adult patients.10
Central to the issue of readmissions is the supposition that something could have been done to prevent them. Although “preventable” readmissions are assumed to be common in children, their true prevalence remains unknown. Both acute and chronic pediatric illnesses that require hospital treatment may have unpredictable courses, and readmissions can and do occur despite receipt of the best transitional care. So it is imperative that we distinguish which pediatric readmissions are preventable to understand how we might avoid them. In this issue of Hospital Pediatrics, articles by Wallace et al and Brittan et al address the preventability of hospital readmissions in children.
The study by Wallace et al16 used chart review by 3 physicians to examine the reasons for and preventability of 204 readmissions to a pediatric hospital medicine service at a large academic medical center. Using a 4-tiered readmission classification scheme, they found that most (87%) 30-day readmissions were related to the same disease processes as the index admission. The authors concluded that 20% of these readmissions were the most preventable because they were related to factors under the influence of physicians (16%) and caretakers/families (4%). Interestingly, and similar to a previous study of readmission preventability, the agreement between physician reviewers was moderate at best.17 This finding emphasizes the difficulties of deciding whether a readmission is preventable. The authors also noted that preventable readmissions occurred significantly earlier after hospital discharge than unpreventable ones. Their main conclusion was that “pediatric readmissions are questionable indicators of quality,” but certain subsets of readmissions, such as those which occur within 7 days of discharge, may serve as appropriate targets for further study and interventions.
The study by Brittan et al18 assessed physician and family perceptions of the preventability of 30 seven-day readmissions. Perhaps not surprisingly, these perceptions differed between physicians and parents, with a tendency for each party to assign responsibility for the readmission to the other. The authors concluded that a “lack of shared perspective or understanding” between physicians and parents often led to readmissions. Parents of readmitted children frequently focused on (1) not being ready, in retrospect, to leave the hospital; (2) their child experiencing lingering symptoms after discharge; (3) insufficient evaluation or treatment of their child’s illness during the prior hospitalization; and (4) difficulty coping with the uncertainty of their child’s health. The authors suggest that these parent perceptions could be powerful indicators of the likelihood of their child’s hospital readmission.
The most valuable contribution of the Brittan study is the illustrative quotes from families and physicians. These quotes provide nuanced perceptions on hospital discharge care and readmissions that are not obtainable from administrative data or information in the electronic health record. Reading the quotes led us to question whether some of the factors commonly prioritized as contributing to readmission (eg, problem with medications and follow-up appointments, clarity of discharge instructions, etc) may matter less than the issues raised by the families. Families often felt that their children were not ready for discharge despite the assurances of the medical team; they perceived that their child’s clinical condition had insufficiently improved or that the etiology of their child’s symptoms was inadequately distinguished.
What stands out extraordinarily in the Brittan study is the discordance between the parents’ and physicians’ views of a child’s condition at the time of discharge and the necessity for continued hospitalization. These findings are reminiscent of a previous study19 reporting that parents who did not believe that their child was healthy enough to leave the hospital had a significantly higher 30-day readmission rate compared with those who did (11% vs 4%). The findings also complement the large body of work by Weiss and colleagues that underscores the importance of assessing discharge readiness.20,21 The major lesson here may be that clear communication and agreement between hospital clinicians and families on the discharge goals, the shared feelings about the child’s readiness for discharge, and a mutual understanding about the postdischarge environment could be important adjuncts in the prevention of readmissions.
The findings from the Wallace and Brittan articles must be taken in the context of the studies’ limitations. Both are from single institutions, and both have a small sample size. These attributes question the generalizability and strength of the findings. The study by Wallace et al was also restricted to a general hospital medicine service, further limiting the patient population to one with more acute illnesses who might be less prone to hospital readmission than children with a higher degree of medical complexity. This might help explain the 3.1% 30-day readmission rate, which is half the rate that is reported across children’s hospitals.11,12 Neither study included nurses or other hospital personnel (eg, social work, case management). Weiss and colleagues’ findings suggest that nurses have a more accurate assessment of discharge readiness than families and physicians.21 Neither study included a control group. Therefore, absent is a group of patients who were not readmitted but whose parents were asked questions about their discharge and postdischarge care. If the perceptions between readmitted and nonreadmitted children were similar, then efforts focused on improving communication between physicians and families, although beneficial in their own right, may have little impact on readmissions.
When assessing the results from the Brittan and Wallace studies in the context of existing literature, it seems reasonable to conclude, unless subsequent research suggests otherwise, that most readmissions in children soon after discharge may not be preventable. This finding, in conjunction with the low readmission rates for most hospitalized children, may lead many to question the merit of using pediatric readmissions for measurement, policies, and financial penalties. Has all of the attention to readmissions in children already served its purpose? Are most preventable readmissions in children being avoided already?
After reading the Brittan and Wallace papers, we are inspired to move beyond readmissions and to focus our attention clinically on how to improve the readiness of children and their families for discharge. As pediatric hospitalists, we feel that we could do a better job to (1) set discharge goals with our patients and families early on during admission, (2) explore family discharge readiness ahead of the actual discharge, and (3) identify and address the problems and issues that preclude families from being ready to leave the hospital. We need to do a better job working with families to determine how healthy a child needs to be to safely leave the hospital; this is especially true for children with medical complexity who are unlikely to return to a normative baseline level of health. We also need to do a better job counseling and helping families when the end of their child’s admission is not reassuring, such as when a definitive cause was not found for the symptoms that led to the admission in the first place.
Although we might not be able to make all hospitalized children and families 100% ready to leave, it certainly seems that the efforts described here might foster a more collaborative spirit between hospital clinicians and families that results in a more cohesive team—with the child and family at the center. These efforts might prevent readmissions too. Regardless, aren’t they the right thing do to for our hospitalized children and their families anyway?
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.
- ↵National Quality Forum (NQF) Report: All-Cause Admissions and Readmissions Measures—Final Report. Available at: http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx. Accessed July 20, 2015
- CMS Readmissions Reduction Program. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed July 20, 2015
- ↵Agency for Healthcare Research and Quality. Hospital Guide to Reducing Medicaid Readmissions. Available at: http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide. Accessed 7/20/2015
- ↵Potentially Preventable Readmissions in the Texas Medicaid Population, State Fiscal Year 2011. Texas Health and Human Services Commission. Public Report: November 2012. Available at: http://www.hhsc.state.tx.us/reports/2012/PPR-Readmissions-FY2012.pdf. Accessed March 4, 2013
- Department of Healthcare and Family Services. Potentially Preventable Readmissions Policy. Available at: https://www2.illinois.gov/hfs/SiteCollectionDocuments/PPR_Overview.pdf. Accessed March 3, 2014
- ↵NYS Health Foundation. Reducing Hospital Readmissions in New York State: A Simulation Analysis of Alternative Payment Incentives. Available at: http://nyshealthfoundation.org/uploads/resources/reducing-hospital-readmissions-payment-incentives-september-2011.pdf. Accessed March 28, 2014
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