33% of readmissions could be prevented

Roughly a third of pediatric hospital readmissions may be preventable, according to a new report that stresses the importance of communication, education, and follow-up care after discharge.

Sara Toomey, MD, MPhil, MPH, MSc, assistant professor of pediatrics at Harvard Medical School and a physician in the division of general pediatrics at Boston Children’s Hospital in Massachusetts, led the study and says she hopes it will raise awareness about pediatric readmissions. Pediatric care involves both patients and their families, and adequate postdischarge care can be difficult.

“Recognize that new equipment, new medications, or coming home with new treatment can often be a place for which problems can arise for patients and families,” Toomey says. “Try and support them at home with doing the care they need to provide for their children.”

Hospital readmissions are costly to the healthcare system; disruptive to the lives of patients and their families; and-most importantly-are preventable in some cases. Numerous adult studies show that readmissions can result from poor discharge planning and inadequate follow-up care or coordination among providers. The Centers for Medicare and Medicaid Services (CMS) and state Medicaid agencies have started issuing penalties to hospitals with high adult readmission rates, and more states are looking at doing the same with pediatric readmissions.

This is the first study to try and determine through medical record review and structured interviews what factors contribute to unplanned 30-day readmissions in the pediatric population.

The study involved 305 patients aged younger than 18 years readmitted within 30 days from their initial hospitalization. The overall readmission rate was 6.5%, and 29.5% of those were determined to be potentially preventable. Of that 29.5%, 11.8% were deemed very likely to be preventable; 17.7% were somewhat preventable; 16.1% were somewhat unlikely to be preventable; and 54.4% were very unlikely to be preventable. Researchers found no variation in readmission rates based on age, sex, language, or race/ethnicity. There was also no significant link between the presence of chronic conditions and readmission rates with the exception of 2 of the 18 chronic condition categories, neoplasms and diseases of blood or blood-forming organs. In those cases, readmission rates were deemed less likely to have been prevented, according to the data. Congenital problems, however, were associated with an increased rate of readmission prevention.

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Most often, potentially preventable readmissions were associated with hospital factors (36.2%), primary care physician factors (4.6%), and patient factors (18.1%). Hospital factors most often included patient assessment issues (37.4%) and postoperative or hospital-acquired conditions (28%). Primary care physician (PCP) factors were often related to patient assessment (58.3%) and “handover” communication (25%). Patient factors were frequently related to “following discharge from the hospital” (60.4%).

Potentially preventable readmissions often occurred sooner than non–potentially preventable readmissions, according to the report, at 4 days to readmission compared with 9 days, respectively. Readmission times were significantly longer when underlying chronic conditions were a factor, the researchers note.

In more than a third of the cases studied, new information was learned from the interview about the readmission. New information obtained in these interviews came mostly from parents (21.6%), PCPs (11.1%), and inpatient nurses (7.2%), and a majority of the information was associated with the hospital (19%), parents (15.1%), patients (7.9%), and PCPs (4.6%).

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Information collected during readmission interviews resulted in a change of status for many of the readmissions-with 47.2% of cases revised from potentially nonpreventable to potentially preventable after the interview, and 8.3% changed from potentially preventable to nonpreventable.

“Although they are not the majority of readmissions, potentially preventable readmissions are prevalent enough to warrant monitoring readmission rates and to provide targets for quality improvement,” the report states. “Interviews led to a change in the assessment of the potential preventability and provided important information regarding the reasons for and contributing factors to readmissions in a substantial proportion of cases.”

Most of the readmissions were causally related to the index admission, with the addition of a contributing factor-most often a hospital or patient factor.

Toomey says the readmission rates identified in the study weren’t that far off from those found in adults-excluding seniors. “I think people often look at the readmission rates in pediatrics and say they are so low, but they really aren’t that different [from] young adults and into the 50s,” she says.

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Education and support are key to preventing readmissions, Toomey explains, but there are a host of factors in pediatric care that can complicate success after discharge. Discharge instructions can be overwhelming and confusing for parents, particularly when new treatments or medications are initiated.

“Even when we’re doing it well, it can sometimes be overwhelming,” Toomey says. “Caregivers have started to do more teach-back and read-back methods to try to not only reinforce but also to make sure people are clear about the instructions being given. With pediatrics, you are really dealing with a whole family. It’s not only that you make the patient as aware as possible about what [he/she needs] to do, but you also have to educate and support the family.”

For example, something like a painful dressing change can be difficult enough for an adult patient, but when it is a parent performing such an intervention on their child, it becomes more complicated.

Children can also experience complications quicker, and they are often unable to verbalize early changes in their condition that could lead to early intervention. Pediatricians can work to head off complications by working closely with patients and families that have recently been in an acute care situation.

“Think about identifying patients whom you think might be at risk for being admitted-patients who have complicated social situations or that are medically complex-and be really diligent about close follow-up after discharge,” Toomey says. “We’re really hoping that studies like ours will help to increase awareness that readmissions are preventable in pediatrics.”

Pediatricians should increase their focus on better communication, not just with families and patients, but with PCPs and specialists whenever possible. “The more that we can be working as a team to provide care, in particular for our medically and socially complex kids, the more successful the kids will be in terms of their medical outcomes,” Toomey says.

Primary care and hospital providers should scrutinize their readmissions, she adds, and see if they can find some target areas for improvement.