Readmission and Ambulatory Health Care Use After Asthma Hospitalization Among Urban Minority Children

Kaitlyn S. Philips; Daniel E. Reiss; Ellen J. Silver; Deepa Rastogi

doi:10.1542/hpeds.2019-0148

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TABLE 1

Bivariate Analysis of Variables Associated With 365-Day Readmission

Variables	Total (N = 613), n	1+ Readmission (N = 152; 24.8%), n (%)	OR (95% CI)	P
Attendance at ambulatory visits
Postdischarge visit			0.65 (0.44–0.95)	.03
No	197	60 (30.0)
Yes	416	92 (22.1)
Routine visit^a			1.44 (0.98–2.14)	.07
No	265	51 (19.3)
Yes	332	85 (25.6)
Both visits^a			0.95 (0.64–1.41)	.82
No	368	85 (23.1)
Yes	229	51 (22.3)
Demographics
Age, y			1.05 (0.63–1.73)	.86
2–12	519	128 (24.7)
12–18	94	24 (25.5)
Sex			0.89 (0.61–1.29)	.54
Female	261	68 (26.1)
Male	352	84 (23.9)
Race and/or ethnicity^b				.60
Hispanic	314	76 (24.2)	Reference
Non-Hispanic African American	226	62 (27.4)	1.18 (0.80–1.75)
Non-Hispanic other	66	13 (19.7)	0.77 (0.40–1.49)
Unavailable	7	1 (14.3)	0.52 (0.06–4.40)
Language			0.70 (0.37–1.34)	.28
Non-English	48	15 (31.2)
English	565	137 (24.2)
Measures of baseline asthma disease severity
Asthma hospitalization in previous year			3.59 (2.36–5.46)	<.001
None	490	95 (19.4)
1+	123	57 (46.3)
ED visit in previous year			1.88 (1.30–2.72)	.001
None	350	69 (19.7)
1+	263	83 (31.6)
Asthma sick visit in previous year			1.20 (0.83–1.73)	.34
None	351	82 (23.4)
1+	262	70 (26.7)
Asthma scheduled visit in previous year			1.94 (1.26–2.98)	.002
None	194	33 (17.0)
1+	419	119 (28.4)
Previous PICU admission			3.15 (1.91–5.18)	<.001
None	538	117 (21.7)
Any	75	35 (46.7)
Asthma severity				<.001
Mild intermittent	265	47 (17.7)	Reference
Mild persistent	173	45 (26.0)	1.63 (1.03–2.59)
Moderate persistent	130	41 (31.5)	2.14 (1.31–3.47)
Severe	45	19 (42.2)	3.39 (1.73–6.63)
Exposure to smoke, dogs and/or cats, mice, cockroaches, or mold			1.54 (1.05–2.27)	.03
None	427	95 (22.2)
Any	186	57 (30.6)
Visit with asthma specialist in previous year			1.82 (1.14–2.90)	.01
No	516	118 (22.9)
Yes	97	34 (35.1)
History of asthma comorbidity^c			1.22 (0.82–1.80)	.32
None	214	48 (22.4)
Any	399	104 (26.1)
Measures of severity of index hospitalization
PICU stay during index hospitalization			2.77 (1.74–4.42)	<.001
No	523	113 (21.6)
Yes	90	39 (43.3)
Controller medication prescribed at discharge			2.17 (1.41–3.33)	<.001
No	206	33 (16.0)
Yes	407	119 (29.2)
Postdischarge visit scheduled			1.29 (0.89–1.86)	.18
No	295	66 (22.4)
Yes	318	86 (27.0)
APR-DRG severity of illness				.049
Minor	359	85 (23.7)	Reference
Moderate	209	49 (23.4)	0.99 (0.66–1.48)
Major or extreme	45	18 (40.0)	2.15 (1.13–4.09)
Other measure: need for routine follow-up documented at postdischarge visit^d			0.88 (0.55–1.40)	.58
No	166	39 (23.5)
Yes	250	53 (21.2)

Unadjusted ORs are presented.
↵a Total n = 597 because 16 children were readmitted before they had a chance for routine follow-up.
↵b Fisher’s exact test.
↵c Asthma comorbidity was defined as a condition that leads to more complicated asthma, including the presence of obesity, allergic rhinitis, eczema, gastroesophageal reflux disease, and/or obstructive sleep apnea.¹⁸
↵d Includes only children who attended a postdischarge visit (n = 416; n = 92 for 1+ readmission).

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TABLE 2

Three Multivariable Logistic Regression Models Analyzing Variables Associated With 365-Day Readmission by Timing of Ambulatory Visit Attended (Variable of Interest)

	OR (95% CI)
Model 1^a (N = 613)
Attended postdischarge visit	0.65 (0.43–0.97)
1+ asthma hospitalization in previous year versus none	3.15 (2.03–4.87)
1+ ED visit in previous year versus none	1.56 (1.05–2.30)
PICU stay during index hospitalization versus none	2.78 (1.70–4.53)
Model 2^a (N = 597)
Attended routine visit	1.4 (0.91–2.08)
1+ asthma hospitalization in previous year versus none	3.43 (2.17–5.42)
Any previous PICU admission versus none	1.91 (1.08–3.36)
PICU stay during index hospitalization versus none	2.42 (1.45–4.05)
Model 3^a (N = 597)
Attended both visits	0.89 (0.58–1.36)
1+ asthma hospitalization in previous year versus none	3.47 (2.20–5.49)
Any previous PICU admission versus none	1.84 (1.05–3.25)
PICU stay during index hospitalization versus none	2.54 (1.52–4.26)

Manual backward selection procedure was used. Bivariate analyses performed with n = 597 led to the same conclusions for model inclusion as in the analysis presented in Table 1. Sixteen children were removed from routine visit and both visit models because they were readmitted before they had the chance for routine follow-up. Variables that are significant (α <0.05) in final model are presented.
↵a Variables included in full model included the following: type of visit attended (variable of interest); age; sex; race and/or ethnicity; asthma hospitalization in the previous year; ED visit in the previous year; asthma scheduled visit in the previous year; previous PICU admission; asthma severity; exposure to smoke, dogs and/or cats, mice, cockroaches, or mold; visit with an asthma specialist in the previous year; PICU stay during the index hospitalization; controller medication prescribed at discharge; postdischarge visit scheduled; and index hospitalization APR-DRG severity of illness.

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TABLE 3

Bivariate and Multivariable Analysis of Variables Associated With Attendance at Postdischarge Visit

Variables	Total (N = 613), n	Attended Visit (N = 416; 67.9%), n (%)	OR (95% CI)	aOR (95% CI)^a
Demographics
Age, y			0.72 (0.46–1.14)	—
2–12	519	358 (69.0)
12–18	94	58 (61.7)
Sex			0.97 (0.69–1.37)	—
Female	261	178 (68.2)
Male	352	238 (67.6)
Race and/or ethnicity^b
Hispanic	314	209 (66.6)	Reference
Non-Hispanic African American	226	154 (68.1)	1.07 (0.75–1.55)
Non-Hispanic other	66	48 (72.7)	1.34 (0.74–2.42)
Unavailable	7	5 (71.4)	1.26 (0.24–6.58)
Language			0.46 (0.22–0.98)	0.46 (0.22–1.00)
Non-English	48	39 (81.3)
English	565	377 (66.7)
Measures of baseline asthma disease severity
Asthma hospitalization in previous year			0.82 (0.54–1.23)	—
None	490	337 (68.8)
1+	123	79 (64.2)
ED visit in previous year			0.80 (0.57–1.12)	—
None	350	245 (70.0)
1+	263	171 (65.0)
Asthma sick visit in previous year			1.46 (1.03–2.07)	1.47 (1.02–2.14)
None	351	226 (64.4)
1+	262	190 (72.5)
Asthma scheduled visit in previous year			0.95 (0.66–1.38)	—
None	194	133 (68.6)
1+	419	283 (67.5)
Previous PICU admission			0.59 (0.36–0.97)	0.55 (0.32–0.93)
None	538	373 (69.3)
Any	75	43 (57.3)
Asthma severity
Mild intermittent	265	189 (71.3)	Reference
Mild persistent	173	111 (64.2)	0.72 (0.48–1.08)
Moderate persistent	130	87 (66.9)	0.81 (0.52–1.28)
Severe	45	29 (64.4)	0.73 (0.37–1.42)
Exposure to smoke, dogs and/or cats, mice, cockroaches, or mold			0.99 (0.69–1.43)	—
None	427	290 (67.9)
Any	186	126 (67.7)
Visit with asthma specialist in previous year			1.20 (0.75, 1.93)	—
No	516	347 (67.3)
Yes	97	69 (71.1)
History of asthma comorbidity^c			1.49 (1.05, 2.11)	1.79 (1.23–2.61)
None	214	133 (62.1)
Any	399	283 (70.9)
Measures of severity of index hospitalization
PICU stay during index hospitalization			1.12 (0.69–1.82)	—
No	523	353 (67.5)
Yes	90	63 (70.0)
Controller medication prescribed at discharge			0.66 (0.45–0.95)	0.55 (0.36–0.82)
No	206	152 (73.8)
Yes	407	264 (64.9)
Postdischarge visit scheduled			1.96 (1.39–2.76)	2.24 (1.56–3.23)
No	295	178 (60.3)
Yes	318	238 (74.8)
APR-DRG severity of illness
Minor	359	235 (65.5)	Reference	Reference
Moderate	209	143 (68.4)	1.14 (0.80–1.65)	1.07 (0.73–1.57)
Major or extreme	45	38 (84.4)	2.86 (1.24–6.60)	4.08 (1.69–9.83)

aOR, adjusted odds ratio; —, not applicable.
↵a Manual backward selection procedure was used. Variables included in full model were as follows: age; sex; race and/or ethnicity; language; ED visit in the previous year; asthma sick visit in the previous year; previous PICU admission; asthma severity; history of asthma comorbidity; controller medication prescribed at discharge; postdischarge visit scheduled; and index hospitalization APR-DRG severity of illness. Variables that were significant (α < .05) in the final model are presented. The model including language was a significantly better fit than the model excluding language when using the likelihood-ratio test.
↵b Fisher’s exact test.
↵c Asthma comorbidity was defined as a condition that leads to more complicated asthma, including the presence of obesity, allergic rhinitis, eczema, gastroesophageal reflux disease, and/or obstructive sleep apnea.¹⁸