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Is Unplanned PICU Readmission a Proper Quality Indicator? A Systematic Review and Meta-analysis
Gabriela J Prutsky1,2, Dipti Padhya3, Ahmed T Ahmed4
1Department of Pediatrics, Mayo Clinic Health System, Mankato, Minnesota; prutskylopez.gabriela@mayo.edu.
Insights
Early unplanned readmissions to the pediatric intensive care unit (PICU) are linked to complex chronic diseases and moderate to severe disabilities in children. Many risk factors are not modifiable, questioning the quality metric's utility.
Area of Science:
- Pediatric critical care medicine
- Healthcare quality metrics
- Epidemiology of pediatric readmissions
Background:
- Unplanned readmissions to the pediatric intensive care unit (PICU) within 48 hours are a critical care quality indicator.
- Identifying factors predicting these readmissions is crucial for improving patient outcomes and healthcare efficiency.
Purpose of the Study:
- To identify specific risk factors associated with early, unplanned readmissions to the PICU in pediatric patients.
- To evaluate the impact of various patient characteristics and admission factors on readmission rates.
Main Methods:
- A systematic literature search was conducted across major databases (Medline, Embase, Cochrane, Scopus) up to July 2018.
- Eleven observational studies involving 128,974 children were included and analyzed using a random-effects meta-analysis model.
- Data extraction and study selection were performed independently by two reviewers.
Main Results:
- Complex chronic diseases (OR 2.42) and moderate to severe disability (OR 2.85) were significant risk factors for early unplanned PICU readmission.
- Other identified risks included unplanned index admission, initial general ward admission, spring season, respiratory diagnoses, and longer initial PICU stay.
- Conversely, trauma/surgery-related admissions, direct home admission, and summer season were associated with lower readmission likelihood.
Conclusions:
- The study identified several significant risk factors for early unplanned PICU readmissions, with complex chronic diseases and disabilities being prominent.
- A substantial portion of these identified risk factors are non-modifiable, raising questions about the appropriateness of using early unplanned PICU readmissions as a sole quality metric.
- Further research may be needed to refine quality measures considering the balance of modifiable and non-modifiable risk factors.
Context:
Unplanned PICU readmissions within 48 hours of discharge (to home or a different hospital setting) are considered a quality metric of critical care.
Objective:
We sought to determine identifiable risk factors associated with early unplanned PICU readmissions.
Data Sources:
A comprehensive search of Medline, Embase, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to July 16, 2018.
Study Selection:
Observational studies of early unplanned PICU readmissions (<48 hours) in children (<18 years of age) published in any language were included.
Data Extraction:
Two reviewers selected and appraised studies independently and abstracted data. A meta-analysis was performed by using the random-effects model.
Results:
We included 11 observational studies in which 128 974 children (mean age: 5 years) were evaluated. The presence of complex chronic diseases (odds ratio 2.42; 95% confidence interval 1.06 to 5.55; I 2 79.90%) and moderate to severe disability (odds ratio 2.85; 95% confidence interval 2.40 to 3.40; I 2 11.20%) had the highest odds of early unplanned PICU readmission. Other significant risk factors included an unplanned index admission, initial admission to a general medical ward, spring season, respiratory diagnoses, and longer initial PICU stay. Readmission was less likely after trauma- and surgery-related index admissions, after direct admission from home, or during the summer season. Modifiable risk factors, such as evening or weekend discharge, revealed no statistically significant association. Included studies were retrospective, which limited our ability to account for all potential confounders and establish causality.
Conclusions:
Many risk factors for early unplanned PICU readmission are not modifiable, which brings into question the usefulness of this quality measure.
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