Repeat Visitors Account for High Costs at Children's Hospitals

A new study finds that a small percentage of patients with chronic conditions accounts for a large percentage of admissions and costs at children's hospitals.

Nearly 20% of admissions and one-quarter of inpatient expenditures for a group of children’s hospitals were accounted for by a small percentage of patients who have frequent recurrent admissions, according to a study published in the Journal of the American Medical Association.

Hospital readmission is increasingly considered an indicator of quality of care. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data regarding the impact of their rehospitalizations, according to background information in the article.

Although children with chronic conditions may require multiple, unavoidable, and necessary hospitalizations to improve their health status, “repeat admissions felt to be amenable to high-quality outpatient care (asthma- and seizure-related admissions, for example) or related to the same medical problem may be considered potentially avoidable,” wrote the authors.

In the study, Jay G. Berry, MD, MPH, of Children's Hospital and Harvard Medical School, Boston, and colleagues examined the inpatient resource usage of children experiencing recurrent hospital readmissions and evaluated the clinical and demographic characteristics of patients and the reasons for readmission. The analysis included 317,643 patients admitted to 37 US children's hospitals in 2003 with follow-up through 2008. Outcomes measured included the maximum number of readmissions experienced by each child within any one-year interval during the five-year follow-up period.

Among the sample, 69,294 patients (21.8%) experienced one or more readmission within 365 days of a prior admission. Of those patients, 9,237 (2.9%) experienced four or more readmissions within a 365-day interval with a median of 37 days between their admissions. Despite comprising only 2.9% of patients in the group, these patients accounted for 18.8% (109,155) of admissions, 23.4% (491,815) of bed-days, and 23.2% ($3.42 billion) of total inpatient charges for the study group during the entire follow-up period.

As readmission frequency increased from zero to four or more, there was an increase in the percentage of children ages 13 to 18 years, adult patients older than 18 years, patients who had public insurance, non-Hispanic black patients, and patients with one or more complex chronic conditions (CCC). Also, as readmission frequency increased from zero of four or more, the percentage of technology assistance increased and the percentage of hospitalizations associated with an ambulatory care-sensitive condition (ACSC) decreased.

Among patients with four or more readmissions within a 365-day interval, 28.5% were hospitalized for a problem in the same organ system during the interval.

Neuromuscular CCCs were the most prevalent disease group among patients frequently readmitted; asthma was the most common ACSC and a respiratory problem was one of the most common major diagnostic categories encountered repeatedly across patients' multiple readmissions.

“Those patients with multiple CCCs and technology assistance may require communication, proactive care planning, and follow-up appointments with multiple outpatient specialty providers, equipment specialists, and home nurses at discharge,” they wrote. “High-quality discharge care planning, including timely communication with outpatient providers regarding hospitalization course and post-discharge care instructions, may be an important mitigating factor to minimize readmission. However, this planning may not prevent multiple future readmissions in children at risk for them if the outpatient providers and health system are underequipped to meet their health care needs, optimally manage their acute illnesses, and minimize their chronic illness exacerbations."