Hospital-level factors associated with pediatric emergency department return visits
BACKGROUND
Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied.
OBJECTIVE
To identify what hospital-level factors correspond with high RV and RVA rates.
SETTING
Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates.
DATA SOURCE
Pediatric Health Information System with survey of emergency department directors.
MEASUREMENTS
Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis.
RESULTS
Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups.
CONCLUSION
RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care. Journal of Hospital Medicine 2017;12:536-543. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Return visit (RV) rate is a quality measure commonly used in the emergency department (ED) setting. This metric may represent suboptimal care at the index ED visit.1-5 Although patient- and visit-level factors affecting ED RVs have been evaluated,1,3,4,6-9 hospital-level factors and factors of a hospital’s patient population that may play roles in ED RV rates have not been examined. Identifying the factors associated with increased RVs may allow resources to be designated to areas that improve emergent care for children.10
Hospital readmission rates are a closely followed quality measure and are linked to reimbursement by the federal government, but a recent study found the influence a hospital can have on this marker may be mitigated by the impact of the social determinates of health (SDHs) of the hospital’s patient population.11 That study and others have prompted an ongoing debate about adjusting quality measures for SDHs.12,13 A clearer understanding of these interactions may permit us to focus on factors that can truly lead to improvement in care instead of penalizing practitioners or hospitals that provide care to those most in need.
Prior work has identified several SDHs associated with higher ED RV rates in patient- or visit-level analyses.3,11,14 We conducted a study of hospital-level characteristics and characteristics of a hospital’s patient population to identify potentially mutable factors associated with increased ED RV rates that, once recognized, may allow for improvement in this quality measure.
PATIENTS AND METHODS
This study was not considered human subjects research in accordance with Common Rule 45 CFR§46.104(f) and was evaluated by the Ann and Robert H. Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine Institutional Review Boards and deemed exempt from review.
Study Population and Protocol
Our study had 2 data sources (to be described in detail): the Pediatric Health Information System (PHIS) and a survey of ED medical directors of the hospitals represented within PHIS. Hospitals were eligible for inclusion in the study if their data (1) met PHIS quality control standards for ED patient visits as determined by internal data assurance processes incorporated in PHIS,3,14,15 (2) included data only from an identifiable single main ED, and (3) completed the ED medical director’s survey.
