Discharge Medical Complexity, Change in Medical Complexity and Pediatric 30-day Readmission
BACKGROUND: While medical complexity is associated with pediatric readmission risk, less is known about how increases in medical complexity during hospitalization affect readmission risk.
METHODS: We conducted a five-year retrospective, case-control study of pediatric hospitalizations at a tertiary care children’s hospital. Cases with a 30-day unplanned readmission were matched to controls based on admission seasonality and distance from the hospital. Complexity variables included the number of medications prescribed at discharge, medical technology, and the need for home healthcare services. Change in medical complexity variables included new complex chronic conditions and new medical technology. We estimated odds of 30-day unplanned readmission using adjusted conditional logistic regression.
RESULTS: Of 41,422 eligible index hospitalizations, we included 595 case and 595 control hospitalizations. Complexity: Polypharmacy after discharge was common. In adjusted analyses, being discharged with ≥2 medications was associated with higher odds of readmission compared with being discharged without medication; children with ≥5 discharge medications had a greater than four-fold higher odds of readmission. Children assisted by technology had higher odds of readmission compared with children without technology assistance. Change in complexity: New diagnosis of a complex chronic condition (Adjusted Odds Ratio (AOR) = 1.75; 1.11-2.75) and new technology (AOR = 1.84; 1.09-3.10) were associated with higher risk of readmission when adjusting for patient characteristics. However, these associations were not statistically significant when adjusting for length of stay.
CONCLUSION: Polypharmacy and use of technology at discharge pose a substantial readmission risk for children. However, added technology and new complex chronic conditions do not increase risk when accounting for length of stay.
© 2019 Society of Hospital Medicine
Hospitalizations are disruptive, stressful, and costly for patients and families.1-5 Hospital readmissions subject families to the additional morbidity inherent to hospitalization and place patients at additional risk of hospital-acquired conditions or other harm.6-9 In pediatrics, hospital readmissions are common for specific conditions;10 with rates varying across institutions;10,11 and as many as one-third of unplanned pediatric readmissions are potentially preventable.12
Reducing pediatric readmissions requires a deeper understanding of the mechanisms through which readmissions occur. Medical complexity—specifically chronic conditions and use of medical technology—is associated with increased risk of readmission.13,14 Polypharmacy at discharge has also been associated with readmission.15,16 However, prior studies on polypharmacy and readmission risk examined the count of total medications and did not consider the nuances of scheduled versus as-needed medications, or the frequency of doses. These nuances may be critical to caregivers as discharge medical complexity can be overwhelming, even in diagnoses which are not traditionally considered complex.17 Finally, of potentially greater importance than medical complexity at discharge is a change in medical complexity during a hospitalization—for example, new diagnoses or new technologies that require additional education in hospital and management at home.
We sought to further understand the relationship between discharge medical complexity and readmission risk with regards to polypharmacy and home healthcare referrals at discharge. Specifically, we hypothesized that a change in medical complexity during an admission—ie, a new chronic diagnosis or new technology—would be a more prominent risk factor for readmission than discharge complexity alone. We examined these factors in the context of length of stay (LOS) since this is a marker of in-hospital severity of illness and a potentially modifiable function of time allowed for in-hospital teaching and discharge preparation.
METHODS
We conducted a retrospective, case-control study of pediatric hospitalizations at one tertiary care children’s hospital. Children <18 years were eligible for inclusion. Normal birth hospitalizations were excluded. We randomly selected one hospitalization from each child as the index visit. We identified cases, hospitalizations at C.S. Mott Children’s Hospital between 2008 and 2012 with a subsequent unplanned 30-day readmission,18 and matched them one to one with hospitalizations at the same hospital during the same period without subsequent readmission. We matched cases to controls based on the month of admission to account for seasonality of certain illnesses. We also matched on distance and direction from the hospital to the patient’s home to account for the potential to have readmissions to other institutions. We utilized both distance and direction recognizing that a family living 30 miles in one direction would be closer to an urban area with access to more facilities, as opposed to 30 miles in another direction in a rural area without additional access. We subsequently performed medical record review to abstract relevant covariates.
