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Variation in Case-Mix Adjusted Unplanned Pediatric Cardiac ICU Readmission Rates
Andrew H Smith1, Vijay Anand2, Mousumi Banerjee3
1Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN.
Insights
Identifying modifiable factors for unplanned readmissions in pediatric cardiac intensive care units (ICUs) is crucial. Shorter time from therapy discontinuation to transfer and nighttime discharge impact readmission risk, with some hospitals showing better performance.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Health Services Research
Background:
- Unplanned readmissions after pediatric cardiac intensive care unit (ICU) discharge pose a significant challenge.
- Identifying modifiable factors and hospital-specific variations in readmission rates is essential for improving patient outcomes.
Purpose of the Study:
- To identify modifiable factors associated with unplanned readmissions in pediatric cardiac ICU patients.
- To characterize differences in adjusted unplanned readmission rates among hospitals.
Main Methods:
- Retrospective cohort study utilizing data from the Pediatric Cardiac Critical Care Consortium clinical registry (October 2013 - March 2016).
- Analysis of 11,301 pediatric cardiac ICU encounters across 16 hospitals.
- Generalized logit models were used to identify predictors of early (<48 hours) and late (2-7 days) unplanned readmissions.
Main Results:
- The study identified 1.6% early and 2.7% late unplanned readmissions, primarily for respiratory and cardiac indications.
- Shorter time from vasoactive infusion discontinuation to ICU transfer was linked to early readmission.
- Nighttime discharge independently increased the likelihood of late readmission.
Conclusions:
- The time from critical care therapy discontinuation to pediatric cardiac ICU transfer is a significant, modifiable predictor of unplanned readmission.
- Two hospitals demonstrated significantly lower-than-expected readmission rates, indicating effective systems for prevention.
- These findings suggest opportunities for disseminating best practices through collaborative learning to reduce pediatric cardiac ICU readmissions.
Objectives:
To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals.
Design:
Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry.
Patients:
Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals.
Interventions:
None.
Measurements And Main Results:
We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both.
Conclusions:
This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.
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