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Preventing hospitalizations in children with medical complexity: a systematic review
Ryan J Coller1, Bergen B Nelson2, Daniel J Sklansky3
1Department of Pediatrics, University of Wisconsin, Madison School of Medicine and Public Health, Madison, Wisconsin; rcoller@pediatrics.wisc.edu.
Insights
Preventable hospitalizations for children with medical complexity (CMC) are linked to specific patient factors and care gaps. Interventions like care coordination and home visits can reduce hospital use in this population.
Area of Science:
- Pediatric Healthcare Research
- Health Services Research
- Complex Care Management
Background:
- Children with medical complexity (CMC) utilize hospital services disproportionately.
- The potential for preventing hospitalizations in CMC is not well understood.
- Evidence on factors contributing to and interventions for potentially preventable hospitalizations in CMC is limited.
Purpose of the Study:
- To systematically review studies characterizing potentially preventable hospitalizations in CMC.
- To evaluate interventions aimed at reducing hospitalizations in CMC.
Main Methods:
- A comprehensive literature search of major databases (Medline, Cochrane, Web of Science, CINAHL) was conducted.
- Included observational studies (n=13) characterizing preventable hospitalizations and experimental studies (n=4) evaluating interventions.
- Data extracted included patient/family characteristics, medical complexity, hospitalization indicators, rates, costs, and intervention effects on hospital use.
Main Results:
- Preventable hospitalizations were defined by ambulatory care sensitive conditions, readmissions, or investigator criteria.
- Higher rates were observed in postsurgical patients, those with neurologic disorders, medical devices, public insurance, and nonwhite race/ethnicity.
- Risk factors included passive smoke exposure, medication nonadherence, and poor post-discharge follow-up; however, home visits, care coordination, and continuity of care reduced hospitalizations.
Conclusions:
- Published evidence is limited, with heterogeneous measures for CMC and preventable hospitalizations.
- Moderate risk of bias exists due to few controlled experimental designs.
- Reductions in hospital use for CMC are achievable by targeting primary drivers of preventable hospitalizations.
Background And Objectives:
Children with medical complexity (CMC) account for disproportionately high hospital use, and it is unknown if hospitalizations may be prevented. Our objective was to summarize evidence from (1) studies characterizing potentially preventable hospitalizations in CMC and (2) interventions aiming to reduce such hospitalizations.
Methods:
Our data sources include Medline, Cochrane Central Register of Controlled Trials, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases from their originations, and hand search of article bibliographies. Observational studies (n = 13) characterized potentially preventable hospitalizations, and experimental studies (n = 4) evaluated the efficacy of interventions to reduce them. Data were extracted on patient and family characteristics, medical complexity and preventable hospitalization indicators, hospitalization rates, costs, and days. Results of interventions were summarized by their effect on changes in hospital use.
Results:
Preventable hospitalizations were measured in 3 ways: ambulatory care sensitive conditions, readmissions, or investigator-defined criteria. Postsurgical patients, those with neurologic disorders, and those with medical devices had higher preventable hospitalization rates, as did those with public insurance and nonwhite race/ethnicity. Passive smoke exposure, nonadherence to medications, and lack of follow-up after discharge were additional risks. Hospitalizations for ambulatory care sensitive conditions were less common in more complex patients. Patients receiving home visits, care coordination, chronic care-management, and continuity across settings had fewer preventable hospitalizations.
Conclusions:
There were a limited number of published studies. Measures for CMC and preventable hospitalizations were heterogeneous. Risk of bias was moderate due primarily to limited controlled experimental designs. Reductions in hospital use among CMC might be possible. Strategies should target primary drivers of preventable hospitalizations.
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