Thirty-days readmissions in pediatric surgery: The first U.K. experience

Sinha, Chandni; Decker, E; Rex, DK; Mukhtar, Zulfikri; Murphy, Feilim; Nicholls, Eric A.; Okoye, Bruce; Giuliani, Stefano

doi:10.1016/j.jpedsurg.2016.06.015

Cited by 16 publications

(10 citation statements)

References 21 publications

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“…While the return rate to the ED after pediatric surgery varies widely in the literature from 2.3% to 18.9% with a readmission rate of 0.78–16.5% [4–11], our findings were similar to the findings of Arlen et al [12], who reported a 2.59% return rate, 0.54% readmission rate, and 0.12% reoperative rate. Other studies found race and insurance status to predict return to the ED or readmission, but this was not true of our population [5,13–15].…”

Section: Discussionsupporting

confidence: 89%

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery

Shepard

Wan

2017

Journal of Pediatric Urology

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Summary Introduction More pediatric patients seem to present to the emergency department (ED) for non-urgent matters after urologic procedures than adult patients. Under new and expanding healthcare reform, pediatric urologists may be penalized for these visits. We compare our 30-day postoperative bounceback rates to the ED and the acuity of the concerns in these populations. Materials and methods All urology consults at our institution are maintained on a prospectively tracked database. We identified all patients who presented to our adult or pediatric ED between July 2013 and June 2015 within 30 days of a urologic procedure. We investigated the patient demographics including age, race, insurance, distance from the home zip code to the ED, procedures performed, chief complaint in the ED, diagnosis, and treatment required. Results In our pediatric group, there were 67 visits for 56 patients (19 female, 37 male, mean age 6.8 years), which represents an overall bounceback incidence of 2.7%. Of those, 19% required admission (0.60% overall readmission rate), 10% underwent a procedure (0.32% reoperative rate, 18% required catheter manipulation/placement, 13% were given a prescription (most commonly for constipation), 6% required local wound care, and 33% were reassured only. Most pediatric patients had private insurance (62.5%) and those with private insurance or who were uninsured tended to require only reassurance compared to those with Medicare/Medicaid (p = 0.053). In the adult population, there were 369 visits in 310 patients (111 female, 199 male, mean age 55.4 years) for an incidence of 4.4%. Of those, 42% were admitted (2.2% overall readmission rate), 14% underwent a procedure (0.74% reoperative rate), 11% required catheter manipulation/placement, 14% were given medication (most commonly antibiotics and narcotics), 4% were given local wound care, and 12% were reassured. Most adult patients had Medicare/Medicaid (48.7%), but insurance type was not related to treatment required (p = 0.382). On multivariable analysis, pediatric patients, closer proximity to the hospital, and earlier postoperative day at presentation to the ED were predictive of requiring only reassurance. Conclusions Compared to adults, pediatric patients are less likely to return to the ED postoperatively (p < 0.001), but they are significantly more likely to require only reassurance (p < 0.001) while adults are significantly more likely to require hospital admission (p < 0.001). In both groups, nearly one-third of patients required only catheter care or medication. This difference could have significant implications for new healthcare policy.

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Section: Discussionsupporting

confidence: 89%

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery

Shepard

Wan

2017

Journal of Pediatric Urology

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“…Although there is no established evidence that this is the case, there may be a theoretical tipping point in which expediency of discharge negatively affects readmission rates. Appendicitis already represents the most common reason for unplanned 30‐day readmissions in paediatric surgery . Reduction in resource utilization and hospital cost should not come at the expense of patient safety.…”

Section: Discussionmentioning

confidence: 99%

“…Appendicitis already represents the most common reason for unplanned 30-day readmissions in paediatric surgery. 49 Reduction in resource utilization and hospital cost should not come at the expense of patient safety. Reassuringly, few studies reported increased rates of representation, readmission, or complication.…”

Section: Discussionmentioning

confidence: 99%

Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care

Do‐Wyeld

Rogerson

Court‐Kowalski

et al. 2019

ANZ Journal of Surgery

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Background ‘Fast‐track’ surgery protocols aim to standardize and rationalize post‐operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post‐operative monitoring and patient selection. Methods A systematic review of the literature was performed to evaluate the current evidence underpinning fast‐track protocols for childhood appendicitis and identify areas of consensus and controversy. Results About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case–control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post‐operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive. Conclusion Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.

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“…It is reasonable to assume that patients at greater risk for short-term readmission may also be at increased risk for hospitalization over a longer time frame [22]. The type and extent of surgery is known to affect readmission rate [5, 7], as is length of stay during a hospitalization [14, 23]. Auger and Davis found that patients admitted on a weekend were more likely to be readmitted within 30 days [10].…”

Section: Discussionmentioning

confidence: 99%

“…Outpatient visits are one indicator of children who are sicker or otherwise more prone to hospitalization. Another is emergency visits, which have been seen as a factor in hospitalization [25] and readmission [5] rates. These are examples of additional predictors that could be added to our model.…”

Section: Discussionmentioning

confidence: 99%

Prediction of 30-day pediatric unplanned hospitalizations using the Johns Hopkins Adjusted Clinical Groups risk adjustment system

2019

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Background The Johns Hopkins ACG System is widely used to predict patient healthcare service use and costs. Most applications have focused on adult populations. In this study, we evaluated the use of the ACG software to predict pediatric unplanned hospital admission in a given month, based on the past year’s clinical information captured by electronic health records (EHRs). Methods and findings EHR data from a multi-state pediatric integrated delivery system were obtained for 920,051 patients with at least one physician visit during January 2009 to December 2016. Over this interval an average of 0.36% of patients each month had an unplanned hospitalization. In a 70% training sample, we used the generalized linear mixed model (GLMM) to generate regression coefficients for demographic, clinical predictors derived from the ACG system, and prior year hospitalizations. Applying these coefficients to a 30% test sample to generate risk scores, we found that the area under the receiver operator characteristic curve (AUC) was 0.82. Omitting prior hospitalizations decreased the AUC from 0.82 to 0.80, and increased under-estimation of hospitalizations at the greater risk levels. Patients in the top 5% of risk scores accounted for 43% and the top 1% of risk scores accounted for 20% of all unplanned hospitalizations. Conclusions A predictive model based on 12-months of demographic and clinical data using the ACG system has excellent predictive performance for 30-day pediatric unplanned hospitalization. This model may be useful in population health and care management applications targeting patients likely to be hospitalized. External validation at other institutions should be done to confirm our results.

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Thirty-days readmissions in pediatric surgery: The first U.K. experience

Cited by 16 publications

References 21 publications

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery

Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery

Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care

Prediction of 30-day pediatric unplanned hospitalizations using the Johns Hopkins Adjusted Clinical Groups risk adjustment system

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