Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance
BACKGROUND: Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes.
OBJECTIVE: To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals.
DESIGN: Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences.
SETTING: Administrative claims from all hospital admissions in California (2012-2014). PATIENTS: Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma).
MEASUREMENTS: Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used.
RESULTS: Across all California hospitals admitting children (n = 239), using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs.
CONCLUSIONS: Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals.
© 2018 Society of Hospital Medicine
Respiratory illnesses are the leading causes of pediatric hospitalizations in the United States.1 The 30-day hospital readmission rate for respiratory illnesses is being considered for implementation as a national hospital performance measure, as it may be an indicator of lower quality care (eg, poor hospital management of disease, inadequate patient/caretaker education prior to discharge). In adult populations, readmissions can be used to reliably identify variation in hospital performance and successfully drive efforts to improve the value of care.2, 3 In contrast, there are persistent concerns about using pediatric readmissions to identify variation in hospital performance, largely due to lower patient volumes.4-7 To increase the value of pediatric hospital care, it is important to develop ways to meaningfully measure quality of care and further, to better understand the relationship between measures of quality and healthcare costs.
In December 2016, the National Quality Forum (NQF) endorsed a Pediatric Lower Respiratory Infection (LRI) Readmission Measure.8 This measure was developed by the Pediatric Quality Measurement Program, through the Agency for Healthcare Research and Quality. The goal of this program was to “increase the portfolio of evidence-based, consensus pediatric quality measures available to public and private purchasers of children’s healthcare services, providers, and consumers.”9
In anticipation of the national implementation of pediatric readmission measures, we examined whether the Pediatric LRI Readmission Measure could meaningfully identify high and low performers across all types of hospitals admitting children (general hospitals and children’s hospitals) using an all-payer claims database. A recent analysis by Nakamura et al. identified high and low performers using this measure10 but limited the analysis to hospitals with >50 pediatric LRI admissions per year, an approach that excludes many general hospitals. Since general hospitals provide the majority of care for children hospitalized with respiratory infections,11 we aimed to evaluate the measure in a broadly inclusive analysis that included all hospital types. Because low patient volumes might limit use of the measure,4,6 we tested several broadened variations of the measure. We also examined the relationship between hospital performance in pediatric LRI readmissions and healthcare costs.
Our analysis is intended to inform utilizers of pediatric quality metrics and policy makers about the feasibility of using these metrics to publicly report hospital performance and/or identify exceptional hospitals for understanding best practices in pediatric inpatient care.12
METHODS
Study Design and Data Source
We conducted an observational, retrospective cohort analysis using the 2012-2014 California Office of Statewide Health Planning and Development (OSHPD) nonpublic inpatient and emergency department databases.13 The OSHPD databases are compiled annually through mandatory reporting by all licensed nonfederal hospitals in California. The databases contain demographic (eg, age, gender) and utilization data (eg, charges) and can track readmissions to hospitals other than the index hospital. The databases capture administrative claims from approximately 450 hospitals, composed of 16 million inpatients, emergency department patients, and ambulatory surgery patients annually. Data quality is monitored through the California OSHPD.
