Hospital-level factors associated with pediatric emergency department return visits
BACKGROUND
Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied.
OBJECTIVE
To identify what hospital-level factors correspond with high RV and RVA rates.
SETTING
Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates.
DATA SOURCE
Pediatric Health Information System with survey of emergency department directors.
MEASUREMENTS
Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis.
RESULTS
Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups.
CONCLUSION
RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care. Journal of Hospital Medicine 2017;12:536-543. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Study Limitations
This study had several limitations. The PHIS dataset tracks only patients within each institution and does not include RVs to other EDs, which may account for a proportion of RVs.39 Our survey response rate was 68% among medical directors, excluding 11 hospitals from analysis, which decreased the study’s power to detect differences that may be present between groups. In addition, the generalizability of our findings may be limited to tertiary-care children’s hospitals, as the PHIS dataset included only these types of healthcare facilities. We also included data only from the sites’ main EDs, and therefore cannot know if our results are applicable to satellite EDs. ED staffing of PEM physicians was analyzed using FTEs. However, number of clinical hours in 1 FTE may vary among sites, leading to imprecision in this hospital characteristic.
CONCLUSION
Hospitals with the highest RV rates served populations with a larger proportion of patients with government insurance and lower household income, and these hospitals had fewer PEM trained physicians. Variation in RV rates among hospitals may be indicative of the SDHs of their unique patient populations. ED revisit rates should be used cautiously in determining the quality of care of hospitals providing care to differing populations.
Disclosure
Nothing to report.
