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Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance
Sunitha V Kaiser1, Regina Lam2, Gabby B Joseph2
1University of California, San Francisco, California, USA. Sunitha.Kaiser@ucsf.edu.
Insights
Pediatric readmission rates for lower respiratory illness (LRI) require broader definitions and multiple years of data to identify hospital performance variations. Modifying quality metrics is crucial for evaluating care at low-volume pediatric hospitals.
Area of Science:
- Pediatric healthcare quality assessment
- Hospital performance metrics
- Health services research
Background:
- Adult hospital readmission rates effectively identify performance variations.
- Pediatric condition-specific readmission rates are often limited by low patient volumes.
- Meaningful identification of hospital performance in pediatric care requires robust metrics.
Purpose of the Study:
- To assess if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmissions can identify high- and low-performing hospitals.
- To evaluate the effectiveness of the pediatric LRI readmission measure in detecting performance differences.
- To determine the suitability of current pediatric quality measures for low-volume hospitals.
Main Methods:
- Observational, retrospective cohort analysis of administrative claims data from California hospitals (2012-2014).
- Application of the pediatric LRI readmission measure and several variations to identify outlier hospitals.
- Hierarchical regression models adjusted for patient age, gender, and chronic conditions were used to analyze readmission rates and costs.
Main Results:
- No outlier hospitals were identified using the standard NQF-endorsed pediatric LRI readmission metric, nor with variations including primary asthma or secondary asthma exacerbation diagnoses, or 30-day emergency revisits.
- By broadening the metric to include asthma admissions, emergency revisits, and merging 3 years of data, 9 outlier hospitals (2 high-performing, 7 low-performing) were identified.
- No association was found between hospital readmission rates and healthcare costs.
Conclusions:
- A nationally-endorsed quality measure for inpatient pediatric care was insufficient to identify meaningful hospital performance variation without modifications.
- Broadening the metric definition and merging multiple years of data are necessary to evaluate pediatric quality at low-volume hospitals.
- Pediatric quality measure utilizers should consider modifying existing metrics for better evaluation of care quality, especially in hospitals with fewer patients.
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.
Funding:
Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.
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