First name
James
Middle name
C
Last name
Gay

Title

Trends in Length of Stay and Readmissions in Children's Hospitals.

Year of Publication

2021

Date Published

2021 May 04

ISSN Number

2154-1671

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix.</p>

<p><strong>RESULTS: </strong>Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased ( &lt; .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, &lt; .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.</p>

DOI

10.1542/hpeds.2020-004044

Alternate Title

Hosp Pediatr

PMID

33947746

Title

Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity.

Year of Publication

2021

Number of Pages

134-141

Date Published

2021 Mar

ISSN Number

1553-5606

Abstract

<p><strong>OBJECTIVE: </strong>To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC).</p>

<p><strong>RESULTS: </strong>The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC.</p>

<p><strong>CONCLUSION: </strong>Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).</p>

DOI

10.12788/jhm.3505

Alternate Title

J Hosp Med

PMID

33617439

Title

Hospitals' Diversity of Diagnosis Groups and Associated Costs of Care.

Year of Publication

2021

Date Published

2021 Feb 24

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Hospitals treating patients with greater diagnosis diversity may have higher fixed and overhead costs. We assessed the relationship between hospitals' diagnosis diversity and cost per hospitalization for children.</p>

<p><strong>METHODS: </strong>Retrospective analysis of 1 654 869 all-condition hospitalizations for children ages 0 to 21 years from 2816 hospitals in the Kids' Inpatient Database 2016. Mean hospital cost per hospitalization, Winsorized and log-transformed, was assessed for freestanding children's hospitals (FCHs), nonfreestanding children's hospitals (NFCHs), and nonchildren's hospitals (NCHs). Hospital diagnosis diversity index (HDDI) was calculated by using the D-measure of diversity in Shannon-Wiener entropy index from 1254 diagnosis and severity-of-illness groups distinguished with 3M Health's All Patient Refined Diagnosis Related Groups. Log-normal multivariable models were derived to regress hospital type on cost per hospitalization, adjusting for hospital-level HDDI in addition to patient-level demographic (eg, age, race and ethnicity) and clinical (eg, chronic conditions) characteristics and hospital teaching status.</p>

<p><strong>RESULTS: </strong>Admission counts were 383 789 (23.2%) in FCHs, 588 463 (35.6%) in NFCHs, and 682 617 (41.2%) in NCHs. Unadjusted mean cost per hospitalization was $10 757 (95% confidence interval [CI]: $9451 to $12 243) in FCHs, $6264 (95% CI: $5830 to $6729) in NFCHs, and $4192 (95% CI: $4121 to $4265) in NCHs. HDDI was significantly ( &lt; .001) higher in FCHs and NFCHs (median 9.2 and 6.4 times higher, respectively) than NCHs. Across all hospitals, greater HDDI was associated ( = .002) with increased cost. Adjusting for HDDI resulted in a nonsignificant ( = .1) difference in cost across hospital types.</p>

<p><strong>CONCLUSIONS: </strong>Greater diagnosis diversity was associated with increased cost per hospitalization and should be considered when assessing associated costs of inpatient care for pediatric patients.</p>

DOI

10.1542/peds.2020-018101

Alternate Title

Pediatrics

PMID

33627373

Title

Observation Encounters and Length of Stay Benchmarking in Children's Hospitals.

Year of Publication

2020

Date Published

2020 Oct 06

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Length of stay (LOS) is a common benchmarking measure for hospital resource use and quality. Observation status (OBS) is considered an outpatient service despite the use of the same facilities as inpatient status (IP) in most children's hospitals, and LOS calculations often exclude OBS stays. Variability in the use of OBS by hospitals may significantly impact calculated LOS. We sought to determine the impact of including OBS in calculating LOS across children's hospitals.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of hospitalized children (age &lt;19 years) in 2017 from the Pediatric Health Information System (Children's Hospital Association, Lenexa, KS). Normal newborns, transfers, deaths, and hospitals not reporting LOS in hours were excluded. Risk-adjusted geometric mean length of stay (RA-LOS) for IP-only and IP plus OBS was calculated and each hospital was ranked by quintile.</p>

<p><strong>RESULTS: </strong>In 2017, 45 hospitals and 625 032 hospitalizations met inclusion criteria (IP = 410 731 [65.7%], OBS = 214 301 [34.3%]). Across hospitals, OBS represented 0.0% to 60.3% of total discharges. The RA-LOS (SD) in hours for IP and IP plus OBS was 75.2 (2.6) and 54.3 (2.7), respectively ( &lt; .001). For hospitals reporting OBS, the addition of OBS to IP RA-LOS calculations resulted in a decrease in RA-LOS compared with IP encounters alone. Three-fourths of hospitals changed ≥1 quintile in LOS ranking with the inclusion of OBS.</p>

<p><strong>CONCLUSIONS: </strong>Children's hospitals exhibit significant variability in the assignment of OBS to hospitalized patients and inclusion of OBS significantly impacts RA-LOS calculations. Careful consideration should be given to the inclusion of OBS when determining RA-LOS for benchmarking, quality and resource use measurements.</p>

DOI

10.1542/peds.2020-0120

Alternate Title

Pediatrics

PMID

33023992

Title

Hospitalization Outcomes for Rural Children with Mental Health Conditions.

Year of Publication

2020

Date Published

2020 Sep 30

ISSN Number

1097-6833

Abstract

<p><strong>OBJECTIVE: </strong>To identify where rural children with mental health conditions are hospitalized and to determine differences in outcomes based upon location of hospitalization.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort analysis of US rural children aged 0-18 years with a mental health hospitalization between January 1, 2014, and November 30, 2014, using the 2014 Agency for Healthcare Research and Quality's Nationwide Readmissions Database. Hospitalizations for rural children were categorized to children's hospitals, metropolitan non-children's hospitals, or rural hospitals. Associations between hospital location and outcomes were assessed with logistic (readmission) and negative binomial regression (length of stay (LOS)) models. Classification and regression trees (CART) describe characteristics of most common hospitalizations at a rural hospital.</p>

<p><strong>RESULTS: </strong>Of 21,666 mental health hospitalizations of rural children, 20.6% were at rural hospitals. After adjustment for clinical and demographic characteristics, LOS was higher at metropolitan non-children's and children's hospitals compared with rural hospitals [LOS: adjusted rate ratio (aRR) 1.35 (95% CI 1.29, 1.41) and aRR 1.33 (95% CI 1.25, 1.41); all P &lt; .01]. 30-day readmission was lower at metropolitan non-children's and children's hospitals compared with rural hospitals [adjusted odds ratio (aOR) 0.73 (95% CI 0.63, 0.84) and aOR 0.59 (95% CI 0.48, 0.71); all p&lt;0.001]. Adolescent males living in poverty with externalizing behavior disorder had the highest percentage (69.4%) of hospitalization at rural hospitals.</p>

<p><strong>CONCLUSIONS: </strong>Although hospitalizations at children's and metropolitan non-children's hospitals were longer, patient outcomes were more favorable.</p>

DOI

10.1016/j.jpeds.2020.09.067

PMID

33010261

Title

ED Visits and Readmissions After Follow-up for Mental Health Hospitalization.

Year of Publication

2020

Date Published

2020 Jun

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition.</p>

<p><strong>METHODS: </strong>We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome.</p>

<p><strong>RESULTS: </strong>Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators.</p>

<p><strong>CONCLUSIONS: </strong>Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.</p>

DOI

10.1542/peds.2019-2872

Alternate Title

Pediatrics

PMID

32404433

Title

Costs and Reimbursements for Mental Health Hospitalizations at Children's Hospitals.

Year of Publication

2020

Date Published

2020 May 21

ISSN Number

1553-5606

Abstract

<p>The financial impact of the rising number of pediatric mental health hospitalizations is unknown. Therefore, this study assessed costs, reimbursements, and net profits or losses for 111,705 mental health and non-mental health medical hospitalizations in children's hospitals with use of the Pediatric Health Information System and Revenue Management Program. Average financial margins were calculated as (reimbursement per day) - (cost per day), and they were lowest for mental health hospitalizations ($136/day), next lowest for suicide attempt ($518/day), and highest for other medical hospitalizations ($611/day). For 10 of 17 hospitals, margin per day for mental health hospitalizations was lower than margin per day for other medical hospitalizations. For these 10 hospitals, the total net loss for inpatient and observation status mental health hospitalizations, compared with other medical hospitalizations, was $27 million (median, $2.2 million per hospital). Financial margins were usually lower for mental health vs non-mental health medical hospitalizations.</p>

DOI

10.12788/jhm.3411

Alternate Title

J Hosp Med

PMID

32496188

Title

Classification System for International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision Pediatric Mental Health Disorders.

Year of Publication

2020

Date Published

2020 Mar 23

ISSN Number

2168-6211

Abstract

<p>Effective October 2015, all US health care institutions and practitioners transitioned to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding system, raising concerns about the validity of examining trends over time in clinical care, costs, and quality. For child mental health disorders, alignment with psychiatric diagnosis groups in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) is also required to consistently examine trends. This is because the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes differ for individual disorders, and child mental health disorders are reclassified under new psychiatric diagnosis groups. We thus developed the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS), which classifies child mental health disorders across coding systems and aligns with DSM-5 psychiatric diagnosis groups. To examine our system’s performance, we compared detection of these disorders in a Medicaid claims database against the Clinical Classification Software (CCS) groups and then examined identification of the disorders across ICD-9-CM and ICD-10-CM coding systems using a national pediatric hospitalization database.</p>

DOI

10.1001/jamapediatrics.2020.0037

Alternate Title

JAMA Pediatr

PMID

32202603

Title

Healthcare Utilization and Spending for Children with Mental Health Conditions in Medicaid.

Year of Publication

2020

Date Published

2020 Feb 01

ISSN Number

1876-2867

Abstract

<p><strong>OBJECTIVE: </strong>To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.</p>

<p><strong>METHODS: </strong>This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3-17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total healthcare spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.</p>

<p><strong>RESULTS: </strong>Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year-olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (p&lt;0.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total healthcare spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.</p>

<p><strong>CONCLUSIONS: </strong>Among children with MH conditions, mental and physical health comorbidities were common and spending for general healthcare outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical healthcare services and investigate whether current spending on MH services supports high-quality MH care.</p>

DOI

10.1016/j.acap.2020.01.013

Alternate Title

Acad Pediatr

PMID

32017995

Title

Outpatient Prescription Opioid Use in Pediatric Medicaid Enrollees With Special Health Care Needs.

Year of Publication

2019

Date Published

2019 May 28

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN.</p>

<p><strong>METHODS: </strong>This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with ≥1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE.</p>

<p><strong>RESULTS: </strong>Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions (≥3 conditions: 49.1% vs 30.6%), and had more polypharmacy (≥5 other medication classes: 54.7% vs 31.2%), &lt; .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively.</p>

<p><strong>CONCLUSIONS: </strong>OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up.</p>

DOI

10.1542/peds.2018-2199

Alternate Title

Pediatrics

PMID

31138667

WATCH THIS PAGE

Subscription is not available for this page.