Outpatient follow-up visits and readmission in medically complex children enrolled in Medicaid

A multicenter randomized trial to compare automatic versus as-needed follow-up for children hospitalized with common infections: The FAAN-C trial protocol

INTRODUCTION

Physicians commonly recommend automatic primary care follow-up visits to children being discharged from the hospital. While automatic follow-up provides an opportunity to address postdischarge needs, the alternative is as-needed follow-up. With this strategy, families monitor their child's symptoms and decide if they need a follow-up visit in the days after discharge. In addition to being family centered, as-needed follow-up has the potential to reduce time and financial burdens on both families and the healthcare system. As-needed follow-up has been shown to be safe and effective for children hospitalized with bronchiolitis, but the extent to which hospitalized children with other common conditions might benefit from as-needed follow-up is unclear.

METHODS

The Follow-up Automatically versus As-Needed Comparison (FAAN-C, or "fancy") trial is a multicenter randomized controlled trial. Children who are hospitalized for pneumonia, urinary tract infection, skin and soft tissue infection, or acute gastroenteritis are eligible to participate. Participants are randomized to an as-needed versus automatic posthospitalization follow-up recommendation. The sample size estimate is 2674 participants and the primary outcome is all-cause hospital readmission within 14 days of discharge. Secondary outcomes are medical interventions and child health-related quality of life. Analyses will be conducted in an intention-to-treat manner, testing noninferiority of as-needed follow-up compared with automatic follow-up.

DISCUSSION

FAAN-C will elucidate the relative benefits of an as-needed versus automatic follow-up recommendation, informing one of the most common decisions faced by families of hospitalized children and their medical providers. Findings from FAAN-C will also have implications for national quality metrics and guidelines.

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.

An examination of characteristics, social supports, caregiver resilience and hospital readmissions of children with medical complexity

BACKGROUND

Children with medical complexity (CMC) account for 1% of children in the United States. These children experience frequent hospital readmissions, high healthcare costs and poor health outcomes. A link between CMC caregiver social support, resilience and hospital readmissions has never been fully investigated. This study examines the feasibility of a prospective, descriptive, repeated measures research design to characterize CMC and their caregivers, social supports, caregiver resilience and hospital readmissions to inform a larger prospective investigation.

METHODS

Caregivers of CMC with unplanned hospitalizations completed surveys at the index hospitalization and 30 and 60 days after discharge. CMC caregiver and child characteristics, social supports and hospital readmissions were examined using an investigator-developed survey. Resilience was measured using the Resilience Scale-14© (7-Point Likert Scale, score range 14-98), and feasibility was measured by calculating enrolment, attrition, survey completion and item response. Analysis included descriptive statistics and qualitative data visualization.

RESULTS

Of caregivers who were approached for participation, 81.1% consented  and completed 76 surveys. Attrition was 31%. Item response rates were ≥ 90% for all but one item. A total of 62.1% of children had hospital readmissions within 90 days and 37.9% within 30 days. Additionally, 70% of caregivers had home care nursing, but the approved hours were only partially filled. More than 70% of caregiver resilience scores were moderate to high (score range 74-98) and were stable across repeated measures and hospital readmissions. Open-ended question responses revealed the following five categories: All-consuming, Family Reliance, Impact of Covid, Taking Action and Broken System.

CONCLUSIONS

Studying CMC caregiver social supports and resilience using repeated measures is feasible. CMC caregivers reported stressors including coordinating their child's substantial healthcare needs and managing partially filled home care nursing hours. Caregiver resilience remained stable over time, amidst frequent CMC hospital readmissions. Findings can inform future research priorities and power analyses for CMC caregiver resilience.

Simulation training of caregivers at hospital discharge of patients with chronic diseases: an integrative review

OBJECTIVE

to identify evidence about the use and effects of clinical simulation for preparing caregivers for discharging patients with chronic conditions.

METHODS

an integrative peer review in the Scopus, PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect and Virtual Health Library databases, from July to September 2022.

RESULTS

3,218 studies were identified, with a final sample consisting of four national and two international articles. Using simulation as an educational technology contributed to caregiver preparation in home care. In most studies, using clinical simulation included using other strategies to complement training: expository dialogued class, conversation circle and audiovisual resources.

FINAL CONSIDERATIONS

simulation proved to be efficient for training caregivers, with the active participation of family members and nurses in health education actions.

Seventy-Two-Hour Reutilization After Telemedicine Visits in Academic Pediatric Primary Care

Telemedicine has expanded due to the COVID-19 pandemic. However, the health care usage after telemedicine visits compared with similar in-person visits is not known. This study compared the 72-hour health care reutilization after telemedicine visits and in-person acute encounters in a pediatric primary care office. A retrospective cohort analysis was performed in a single quaternary pediatric health care system between March 1, 2020, and November 30, 2020. Reutilization information was collected for 72 hours following the index visit and included subsequent encounters within the health care system. The 72-hour reutilization rate for telemedicine encounters was 4.1% compared with 3.9% for in-person acute visits. Of revisits, patients who had a telemedicine visit most often sought additional care at the medical home, and patients with an in-person visit most often sought additional care to the emergency department or urgent care. Telemedicine does not result in higher total health care reutilization.

How are children with medical complexity being identified in epidemiological studies? A systematic review

BACKGROUND

There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies.

METHODS

PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths.

RESULTS

Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles).

CONCLUSIONS

CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.

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.

Risk factors for hospital readmission among infants with prolonged neonatal intensive care stays

OBJECTIVE

To assess risk factors associated with 30-day hospital readmission after a prolonged neonatal intensive care stay.

STUDY DESIGN

Retrospective analysis of 57,035 infants discharged >14 days from the NICU between 2013 and 2016. Primary outcome was 30-day, all-cause hospital readmission. Adjusted likelihood of readmission accounting for demographic and clinical characteristics, including chronic conditions was also estimated.

RESULTS

The 30-day readmission rate was 10.7%. Respiratory problems accounted for most (31.0%) readmissions. In multivariable analysis, shunted hydrocephalus [OR 2.2 (95%CI 1.8-2.7)], gastrostomy tube [OR 2.0 (95%CI 1.8-2.3)], tracheostomy [OR 1.5 (95%CI 1.2-1.8)], and use of public insurance [OR 1.3 (95%CI 1.2-1.4)] had the highest likelihood of readmission. Adjusted hospital readmission rates varied significantly (p < 0.001) across hospitals.

CONCLUSIONS

The likelihood of hospital readmission was highest for infants with indwelling medical devices and public insurance. These findings will inform future initiatives to reduce readmission for high risk infants with medical and social complexity.

Outpatient Follow-up Care After Hospital Discharge of Children With Complex Chronic Conditions at a Rural Tertiary Care Hospital

OBJECTIVE

To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge.

METHODS

We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded.

RESULTS

Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up.

CONCLUSIONS

Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates

PURPOSE

The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients.

METHODS

A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed.

RESULTS

1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients.

CONCLUSIONS

Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

Level III.

Nurse Practitioner-Led Telehealth to Improve Outpatient Pediatric Tracheostomy Management in South Texas

INTRODUCTION

Pediatric tracheostomy patients are a medically complex population with increased incidence of emergency room use, hospital readmission, tracheostomy-associated complications, and caregiver anxiety, especially within 30 days after discharge.

METHOD

The specific aims of this quality improvement initiative include using a nurse-led, interprofessional care team to improve access to care with creation and implementation of a hospital-based discharge protocol and adoption of telehealth follow-up care for newly placed tracheostomy tubes.

RESULTS

Telehealth was accessible for patients living more than 150 miles from the primary clinical site. Caregiver knowledge, satisfaction, self-efficacy, and competence in tracheostomy skills increased after protocol implementation. Outcomes included no tracheostomy-associated complications, emergency room visits, or unnecessary hospitalizations.

DISCUSSION

Evaluation of this initiative showed promise telehealth was effective in supporting caregivers and refining proficiency caring for tracheostomy-dependent children. This facility's experience with nurse-led telehealth found it to be an accessible, affordable, and valuable health-care service .

Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study

OBJECTIVES

Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC.

METHODS

We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach.

RESULTS

Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions.

CONCLUSIONS

Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.

Readmission and reinjury patterns in pediatric assault victims

INTRODUCTION

Repeated pediatric assault should be a never event. The purpose of this study was to evaluate the readmission and reinjury patterns in pediatric victims of assault including readmissions to different hospitals across the US.

METHODS

The 2010-2014 Nationwide Readmissions Database was queried for all nonelective admissions for patients under the age of 18 years. Primary outcomes were readmission or reinjury within 1 year. Results were weighted for national estimates.

RESULTS

Assault-related injury occurred in 46,294 pediatric patients with 11.4% of patients being readmitted within 1 year. Of those readmitted, 35.2% presented to a different hospital. Reinjury within 1 year occurred in about 1% of patients, with 14.8% of those presenting to a different hospital. Age < 13 years, firearm-injury, ISS > 15, female gender, and leaving AMA were found to be independent prognostic indicators of readmission within 1 year among pediatric assault patients.

CONCLUSION

Care of children who are admitted and discharged for assault injuries is more fragmented that previously thought. Quality metrics fail to capture this previously hidden population. Our results identify treatable factors which could improve the care of children after assault.

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community

OBJECTIVES

Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited.

METHODS

In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population.

RESULTS

Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background.

CONCLUSIONS

Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.

Developing Prediction Models for 30-Day Unplanned Readmission Among Children With Medical Complexity

OBJECTIVES

To target interventions to prevent readmission, we sought to develop clinical prediction models for 30-day readmission among children with complex chronic conditions (CCCs).

METHODS

After extracting sociodemographic and clinical characteristics from electronic health records for children with CCCs admitted to an academic medical center, we constructed a multivariable logistic regression model to predict readmission from characteristics obtainable at admission and then a second model adding hospitalization and discharge variables to the first model. We assessed model performance using c-statistic and calibration curves and internal validation using bootstrapping. We then created readmission risk scoring systems from final model β-coefficients.

RESULTS

Of the 2296 index admissions involving children with CCCs, 188 (8.2%) had unplanned 30-day readmissions. The model with admission characteristics included previous admissions, previous emergency department visits, number of CCC categories, and medical versus surgical admission (c-statistic 0.65). The model with hospitalization and discharge factors added discharge disposition, length of stay, and weekday discharge to the admission variables (c-statistic 0.67). Bootstrap samples had similar c-statistics, and slopes did not suggest significant overfitting for either model. Readmission risk was 3.6% to 4.9% in the lowest risk quartile versus 15.9% to 17.6% in the highest risk quartile (or 3.6-4.5 times higher) for both models.

CONCLUSIONS

Clinical variables related to the degree of medical complexity and illness severity can stratify children with CCCs into groups with clinically meaningful differences in the risk of readmission. Future research will explore whether these models can be used to target interventions and resources aimed at decreasing readmissions.

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses

OBJECTIVE

Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses.

METHODS

This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors.

RESULTS

Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09).

CONCLUSIONS

Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

CONTEXT

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.

OBJECTIVE

In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.

DATA SOURCES

We searched 7 bibliographic databases and 5 pediatric journals.

STUDY SELECTION

Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.

DATA EXTRACTION

Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.

RESULTS

Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.

LIMITATIONS

Variability limited findings and reduced generalizability.

CONCLUSIONS

In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Parental Vaccine Hesitancy and Declination of Influenza Vaccination Among Hospitalized Children

OBJECTIVES

Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations.

METHODS

This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0-100 scale) were dichotomized into scores of ≥50 (hesitant) and <50 (nonhesitant). The primary outcome was parental declination of the influenza vaccine for their child during hospitalization. A secondary outcome was the declination reason documented during hospitalization. The main independent variable was parental vaccine hesitancy status, determined by the PACV score. Multivariable logistic regression was used to examine the association between vaccine hesitancy and influenza vaccine declination, adjusting for sociodemographic, visit, and clinical characteristics. The relationship between vaccine hesitancy and declination reason was also explored.

RESULTS

Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5-16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting "vaccine concern" or "vaccine unnecessary."

CONCLUSIONS

Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.

ENCONTRO EDUCATIVO DA ENFERMAGEM E DA FAMÍLIA DE CRIANÇAS COM NECESSIDADES ESPECIAIS DE SAÚDE

RESUMO Objetivo: conhecer as dúvidas dos familiares de crianças com necessidades especiais de saúde quanto aos cuidados domiciliares relacionados aos dispositivos tecnológicos; e analisar o uso da roda de conversa como estratégia de educação em saúde no preparo de alta hospitalar dos familiares de crianças com dispositivos tecnológicos. Método: pesquisa descritiva e exploratória, com abordagem qualitativa, realizada no setor de internação pediátrica de um hospital federal no Rio de Janeiro entre maio e junho de 2014. Seis familiares participaram de entrevistas semiestruturadas e rodas de conversa. Os dados foram submetidos à análise temática. Resultados: os familiares destacaram dúvidas no aprendizado e na adaptação à tecnologia durante a transição do hospital para o domicílio e em possíveis situações de emergência após a alta hospitalar. Essas dúvidas versaram, principalmente, sobre os cuidados procedimentais com a traqueostomia e a gastrostomia. Entretanto, a estratégia da roda de conversa com uso de um boneco com dispositivos tecnológicos acoplados foi bem aceita pelos familiares, pois favoreceu o diálogo e a troca de conhecimentos e experiências entre os participantes, além da promoção da segurança no cuidado. Conclusão: a roda de conversa é uma estratégia de educação em saúde, que pode ser utilizada pela Enfermagem no preparo de alta hospitalar de crianças com necessidades especiais de saúde, dependentes de tecnologia. Todavia, esse preparo deve acontecer de forma processual durante a hospitalização.

Outcomes of Follow-up Visits After Bronchiolitis Hospitalizations

This survey study of families of children younger than 2 years discharged after hospitalization for bronchiolitis assesses the usefulness of routine outpatient follow-up after hospitalization.

Repeated Critical Illness and Unplanned Readmissions Within 1 Year to PICUs

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.

INTERVENTIONS

None.

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.

Discharge Handoff Communication and Pediatric Readmissions

BACKGROUND

Improvement in hospital transitional care has become a major national priority, although the impact on children's postdischarge outcomes is unclear.

OBJECTIVE

To characterize common handoff practices between hospital and primary care providers (PCPs), and test the hypothesis that common handoff practices would be associated with fewer unplanned readmissions.

DESIGN, SETTING, AND PATIENTS

This prospective cohort study enrolled randomly selected pediatric patients during an acute hospitalization at a tertiary children's hospital in 2012-2014.

MEASUREMENTS

Primary care and patient data were abstracted from administrative, caregiver, and PCP questionnaires on admission through 30 days postdischarge. The primary outcome was 30-day unplanned readmission to any hospital. Logistic regression assessed relationships between readmissions and 11 handoff communication practices.

RESULTS

We enrolled 701 children, from which 685 identified PCPs. Complete data were collected from 84% of PCPs. Communication practices varied widely--verbal handoffs occurred rarely (10.7%); PCP notification of admission occurred for 50.8%. Caregiver experience scores, using an adapted Care Transitions Measure-3, were high but were unrelated to readmissions. Thirty-day unplanned readmissions to any hospital were unrelated to most handoff practices. Having PCP follow-up appointments scheduled prior to discharge was associated with more readmissions (adjusted odds ratio, 2.20; 95% confidence interval, 1.08-4.46).

CONCLUSION

Despite their presumed value, common handoff practices between hospital providers and PCPs may not lead to reductions in postdischarge utilization for children. Addressing broader constructs like caregiver self-efficacy or social determinants is likely necessary. Journal of Hospital Medicine 2017;12:29-35.

[Factors associated with involuntary hospital admissions in technology-dependent children]

OBJECTIVE

To identify the factors associated with involuntary hospital admissions of technology-dependent children, in the municipality of Ribeirão Preto, São Paulo State, Brazil.

METHOD

A cross-sectional study, with a quantitative approach. After an active search, 124 children who qualified under the inclusion criteria, that is to say, children from birth to age 12, were identified. Data was collected in home visits to mothers or the people responsible for the children, through the application of a questionnaire. Analysis of the data followed the assumptions of the Generalized Linear Models technique.

RESULTS

102 technology-dependent children aged between 6 months and 12 years participated in the study, of whom 57% were male. The average number of involuntary hospital admissions in the previous year among the children studied was 0.71 (±1.29). In the final model the following variables were significantly associated with the outcome: age (OR=0.991; CI95%=0.985-0.997), and the number of devices (OR=0.387; CI95%=0.219-0.684), which were characterized as factors of protection and quantity of medications (OR=1.532; CI95%=1.297-1.810), representing a risk factor for involuntary hospital admissions in technology-dependent children.

CONCLUSION

The results constitute input data for consideration of the process of care for technology-dependent children by supplying an explanatory model for involuntary hospital admissions for this client group.

Pediatric Inpatient Readmissions in an Accountable Care Organization

OBJECTIVE

To assess the association between the length of consistent primary care as part of an accountable care organization (attribution length) and population-level and same-hospital readmissions. Readmission studies are generally focused on same-hospital readmissions rather than readmissions to any hospital (population-level readmissions).

STUDY DESIGN

A retrospective study of Medicaid claims data for 28,794 unique pediatric patients attributed to a single children's hospital between September 2013 and May 2015. Study used logistic regression to estimate the impact of attribution length on readmissions and a zero-inflated Poisson model to assess the impact of attribution length on readmission cost and readmission days.

RESULTS

The study showed attribution length was associated with a significant reduction in the population-level 30-day readmission rate from 8.9%-6.2% (P = .010) primarily by reducing readmissions that occurred at hospitals other than the discharging hospital. There was no significant reduction in the same-hospital readmission rate. Readmissions to a different hospital occurred in 37% of readmissions. Although not significant at the P = .05 level, attribution length was associated with a 44% reduction (P = .100) in 30-day readmission costs or a 5.0% reduction in the cost of an inpatient episode of care and a 53% reduction (P = .019) in readmission days.

CONCLUSIONS

Consistent primary care (attribution length) may be able to reduce 30-day, pediatric Medicaid patients' readmissions at the population level. The decrease occurred primarily in readmissions to hospitals other than the discharging hospital. There was no decrease in the rate of same-hospital readmissions.