Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness
BACKGROUND: Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity.
OBJECTIVE: We assessed which children hospitalized with RI are the most likely to use post-acute facility care (PAC) for recovery.
METHODS: Retrospective analysis of 609,800 hospitalizations for patients in 43 US children’s hospitals between 2010-2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations.
RESULTS: There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), P < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio [OR] 11.7 [95% CI, 8.0-17.2]), ≥9 vs no therapeutic medication classes (OR 4.8 [95% CI, 1.8-13.0]), and existing tracheostomy (OR 3.0, 95% confidence interval [CI], 2.6-3.5). Median (interquartile range [IQR]) acute-care length of stay (LOS) for children most likely to use PAC was 19 (8-56) days; LOS remained long (median 13 [6-41] days) for children with the same attributes (n = 9448) not transferred to PAC.
CONCLUSIONS: Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it. Journal of Hospital Medicine 2017;12:626-631. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Respiratory illness (RI) is one of the most common reasons for pediatric hospitalization.1 Examples of RI include acute illness, such as bronchiolitis, bacterial pneumonia, and asthma, as well as chronic conditions, such as obstructive sleep apnea and chronic respiratory insufficiency. Hospital care for RI includes monitoring and treatment to optimize oxygenation, ventilation, hydration, and other body functions. Most previously healthy children hospitalized with RI stay in the hospital for a limited duration (eg, a few days) because the severity of their illness is short lived and they quickly return to their previous healthy status.2 However, hospital care is increasing for children with fragile and tenuous health due to complex medical conditions.3 RI is a common reason for hospitalization among these children as well and recovery of respiratory health and function can be slow and protracted for some of them.4 Weeks, months, or longer periods of time may be necessary for the children to return to their previous respiratory baseline health and function after hospital discharge; other children may not return to their baseline.5,6
Hospitalized older adults with high-severity RI are routinely streamlined for transfer to post-acute facility care (PAC) shortly (eg, a few days) after acute-care hospitalization. Nearly 70% of elderly Medicare beneficiaries use PAC following a brief length of stay (LOS) in the acute-care hospital.7 It is believed that PAC helps optimize the patients’ health and functional status and relieves the family caregiving burden that would have occurred at home.8-10 PAC use also helps to shorten acute-care hospitalization for RI while avoiding readmission.8-10 In contrast with adult patients, use of PAC for hospitalized children is not routine.11 While PAC use in children is infrequent, RI is one of the most common reasons for acute admission among children who use it.12
For some children with RI, PAC might be positioned to offer a safe, therapeutic, and high-value setting for pulmonary rehabilitation, as well as related medical, nutritional, functional, and family cares.6 PAC, by design, could possibly help some of the children transition back into their homes and communities. As studies continue to emerge that assess the value of PAC in children, it is important to learn more about the use of PAC in children hospitalized with RI. The objectives were to (1) assess which children admitted with RI are the most likely to use PAC services for recovery and (2) estimate how many hospitalized children not using PAC had the same characteristics as those who did.
METHODS
Study Design, Setting, and Population
We conducted a retrospective cohort analysis of 609,800 hospitalizations for RI occurring from January 1, 2010 to December 31, 2015, in 43 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. All hospitals participating in PHIS are members of the Children’s Hospital Association.13 The Boston Children’s Hospital Institutional Review Board approved this study with a waiver for informed consent.
RI was identified using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS).14 Using diagnosis CCS category 8 (“Diseases of the Respiratory System”) and the procedure CCS category 6 (“Operations on the Respiratory System”), we identified all hospitalizations from the participating hospitals with a principal diagnosis or procedure International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for an RI.
Main Outcome Measure
Discharge disposition following the acute-care hospitalization for RI was the main outcome measure. We used PHIS uniform disposition coding to classify the discharge disposition as transfer to PAC (ie, rehabilitation facility, skilled nursing facility, etc.) vs all other dispositions (ie, routine to home, against medical advice, etc.).12 The PAC disposition category was derived from the Centers for Medicare & Medicaid Services Patient Discharge Status Codes and Hospital Transfer Policies as informed by the National Uniform Billing Committee Official UB-04 Data Specifications Manual, 2008. PAC transfer included disposition to external PAC facilities, as well as to internal, embedded PAC units residing in a few of the acute-care children’s hospitals included in the cohort.
