Using Length of Stay to Understand Patient Flow for Pediatric Inpatients.

2018

e050

2018 Jan-Feb

2472-0054

<p><strong>Objectives: </strong>Develop and test a new metric to assess meaningful variability in inpatient flow.</p>

<p><strong>Methods: </strong>Using the pediatric administrative dataset, Pediatric Health Information System, that quantifies the length of stay (LOS) in hours, all inpatient and observation encounters with 21 common diagnoses were included from the calendar year 2013 in 38 pediatric hospitals. Two mutually exclusive composite groups based on diagnosis and presence or absence of an ICU hospitalization termed Acute Care Composite (ACC) and ICU Composite (ICUC), respectively, were created. These composites consisted of an observed-to-expected (O/E) LOS as well as an excess LOS percentage (ie, the percent of day beyond expected). Seven-day all-cause risk-adjusted rehospitalizations was used as a balancing measure. The combination of the ACC, the ICUC, and the rehospitalization measures forms this new metric.</p>

<p><strong>Results: </strong>The diagnosis groups in the ACC and the ICUC included 113,768 and 38,400 hospitalizations, respectively. The ACC had a median O/E LOS of 1.0, a median excess LOS percentage of 23.9% and a rehospitalization rate of 1.7%. The ICUC had a median O/E LOS of 1.1, a median excess LOS percentage of 32.3%, and rehospitalization rate of 4.9%. There was no relationship of O/E LOS and rehospitalization for either ACC or ICUC.</p>

<p><strong>Conclusions: </strong>This metric shows variation among hospitals and could allow a pediatric hospital to assess the performance of inpatient flow.</p>

10.1097/pq9.0000000000000050

Pediatr Qual Saf

30229186

Children's Hospital Characteristics and Readmission Metrics.

2017

2017 Jan 25

1098-4275

<p><strong>BACKGROUND AND OBJECTIVE: </strong>Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves.</p>

<p><strong>METHODS: </strong>We performed a cross-sectional analysis of 64 children's hospitals from the Children's Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression.</p>

<p><strong>RESULTS: </strong>We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%-19.6%); the mean PPR rate was 4.9% (range 2.9%-6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63-1.23), compared with 0.95 (range 0.65-1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR.</p>

<p><strong>CONCLUSIONS: </strong>High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.</p>

10.1542/peds.2016-1720

Pediatrics

28123044

Pediatric severe sepsis in U.S. children's hospitals.

2014

798-805

11/2014

1529-7535

<p><strong>OBJECTIVES: </strong>To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies.</p>

<p><strong>DESIGN: </strong>Observational cohort study from 2004 to 2012.</p>

<p><strong>SETTING: </strong>Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database.</p>

<p><strong>PATIENTS: </strong>Children 18 years old or younger.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9th edition, Clinical Modification-based coding strategies: 1) combinations of International Classification of Diseases, 9th edition, Clinical Modification codes for infection plus organ dysfunction (combination code cohort); 2) International Classification of Diseases, 9th edition, Clinical Modification codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and ICU length of stay, and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified 176,124 hospitalizations (3.1% of all hospitalizations), whereas the sepsis code cohort identified 25,236 hospitalizations (0.45%), a seven-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p &lt; 0.001 for trend in each cohort). Length of stay (hospital and ICU) and costs decreased in both cohorts over the study period (p &lt; 0.001). Overall, hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2% [95% CI, 20.7-21.8] vs 8.2% [95% CI, 8.0-8.3]). Over the 9-year study period, there was an absolute reduction in mortality of 10.9% (p &lt; 0.001) in the sepsis code cohort and 3.8% (p &lt; 0.001) in the combination code cohort.</p>

<p><strong>CONCLUSIONS: </strong>Prevalence of pediatric severe sepsis increased in the studied U.S. children's hospitals over the past 9 years, whereas resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to seven-fold depending on the strategy used for case ascertainment.</p>

10.1097/PCC.0000000000000225

Pediatr Crit Care Med

25162514

Rates and impact of potentially preventable readmissions at children's hospitals.

2015

613-9.e5

03/2015

1097-6833

<p><strong>OBJECTIVE: </strong>To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals.</p>

<p><strong>STUDY DESIGN: </strong>A total of 1 719 617 hospitalizations for 1 531 828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions.</p>

<p><strong>RESULTS: </strong>The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year).</p>

<p><strong>CONCLUSIONS: </strong>Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs.</p>

10.1016/j.jpeds.2014.10.052

J. Pediatr.

25477164