Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness

Hospitalization Characteristics

Acute-care RI hospitalization median LOS was longer for discharges to PAC vs non-PAC (10 days [IQR 4-27] vs 2 days [IQR 1-4], P < 0.001; Table 1). A greater percentage of discharges to PAC were administered medications from multiple classes during the acute-care RI admission (eg, 54.8% vs 13.4% used medications from ≥7 classes, P < 0.001). A greater percentage of discharges to PAC used intensive care services during the acute-care admission (65.6% vs 22.4%, P < 0.001). A greater percentage of discharges to PAC received CPAP (10.6 vs 5.0%), BiPAP (19.8% vs 11.4%), or mechanical ventilation (52.7% vs 9.1%) during the acute-care RI hospitalization (P < 0.001 for all; Table 1).

Multivariable Analysis of the Likelihood of Post-Acute Care Use Following Discharge

In multivariable analysis, the patient characteristics associated with the highest likelihood of discharge to PAC included ≥11 vs no chronic conditions (odds ratio [OR] 11.8 , 95% CI, 8.0-17.2), ≥9 classes vs no classes of medications administered during the acute-care hospitalization (OR 4.8 , 95% CI, 1.8-13.0), and existing tracheostomy (OR 3.0, [95% CI, 2.6-3.5; Figure 2 and eTable). Patient characteristics associated with a more modest likelihood of discharge to PAC included public vs private insurance (OR 1.8, 95% CI, 1.6-2.0), neuromuscular complex chronic condition (OR 1.6, 95% CI, 1.5-1.8), new tracheostomy (OR 1.9, 95% CI, 1.7-2.2), and use of any enhanced respiratory support (ie, CPAP/BiPAP/mechanical ventilation) during the acute-care hospitalization (OR 1.4, 95% CI, 1.3-1.6; Figure 2 and Supplementary Table).

Classification and Regression Tree Analysis

In the CART analysis, the highest percentage (6.3%) of children hospitalized with RI who were discharged to PAC had the following combination of characteristics: ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Median (IQR) length of acute-care LOS for children with these attributes who were transferred to PAC was 19 (IQR 8-56; range 1-1005) days; LOS remained long (median 13 days [IQR 6-41, range 1-1413]) for children with the same attributes not transferred to PAC (n = 9448). Between these children transferred vs not to PAC, 79.3% vs 65.9% received ICU services; 74.4% vs 73.5% received CPAP, BiPAP, or mechanical ventilation; and 31.0% vs 22.7% underwent tracheotomy during the acute-care hospitalization. Of these children who were not transferred to PAC, 18.9% were discharged to home nursing services.

The findings from the present study suggest that patients with RI hospitalization in children’s hospitals who use PAC are medically complex, with high rates of multiple chronic conditions—including cerebral palsy, asthma, chronic respiratory insufficiency, dysphagia, epilepsy, and gastroesophageal reflux—and high rates of technology assistance including enterostomy and tracheostomy. The characteristics of patients most likely to use PAC include long LOS, a large number of chronic conditions, many types of medications administered during the acute-care hospitalization, respiratory technology use, and an underlying neuromuscular condition. Specifically, the highest percentage of children hospitalized with RI who were discharged to PAC had ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Our analysis suggests that there may be a large population of children with these same characteristics who experienced a prolonged LOS but were not transferred to PAC.

There are several reasons to explain why children hospitalized with RI who rely on medical technology, such as existing tracheostomy, are more likely to use PAC. Tracheostomy often indicates the presence of life-limiting impairment in oxygenation or ventilation, thereby representing a high degree of medical fragility. Tracheostomy, in some cases, offers enhanced ability to assist with RI treatment, including establishment of airway clearance of secretions (ie, suctioning and chest physiotherapy), administration of antimicrobials (eg, nebulized antibiotics), and optimization of ventilation (eg, non-invasive positive airway pressure). However, not all acute-care inpatient clinicians have experience and clinical proficiencies in the care of children with pediatric tracheostomy.²³ As a result, a more cautious approach, with prolonged LOS and gradual arrival to hospital discharge, is often taken in the acute-care hospital setting for children with tracheostomy. Tracheostomy care delivered during recovery from RI by trained and experienced teams of providers in the PAC setting may be best positioned to help optimize respiratory health and ensure proper family education and readiness to continue care at home.⁶

Further investigation is needed of the long LOS in children not transferred to PAC who had similar characteristics to those who were transferred. In hospitalized adult patients with RI, PAC is routinely introduced early in the admission process, with anticipated transfer within a few days into the hospitalization. In the current study, LOS was nearly 2 weeks or longer in many children not transferred to PAC who had similar characteristics to those who were transferred. Perhaps some of the children not transferred experienced long LOS in the acute-care hospital because of a limited number of pediatric PAC beds in their local area. Some families of these children may have been offered but declined use of PAC. PAC may not have been offered to some because illness acuity was too high or there was lack of PAC awareness as a possible setting for recovery.

There are several limitations to this study. PHIS does not contain non-freestanding children’s hospitals; therefore, the study results may generalize best to children’s hospitals. PHIS does not contain information on the amount (eg, number of days used), cost, or treatments provided in PAC. Therefore, we were unable to determine the true reasons why children used PAC services following RI hospitalization (eg, for respiratory rehabilitation vs other reasons, such as epilepsy or nutrition/hydration management). Moreover, we could not assess which children truly used PAC for short-term recovery vs longer-term care because they were unable to reside at home (eg, they were too medically complex). We were unable to assess PAC availability (eg, number of beds) in the surrounding areas of the acute-care hospitals in the PHIS database. Although we assessed use of medical technology, PHIS does not contain data on functional status or activities of daily living, which correlate with the use of PAC in adults. We could not distinguish whether children receiving BiPAP, CPAP, or mechanical ventilation during hospitalization were using it chronically. Although higher PAC use was associated with public insurance, due to absent information on the children’s home, family, and social environment, we were unable to assess whether PAC use was influenced by limited caregiving support or resources.

Data on the type and number of chronic conditions are limited by the ICD-9-CM codes available to distinguish them. Although several patient demographic and clinical characteristics were significantly associated with the use of PAC, significance may have occurred because of the large sample size and consequent robust statistical power. This is why we elected to highlight and discuss the characteristics with the strongest and most clinically meaningful associations (eg, multiple chronic conditions). There may be additional characteristics, including social, familial, and community resources, that are not available to assess in PHIS that could have affected PAC use.

Despite these limitations, the current study suggests that the characteristics of children hospitalized with RI who use PAC for recovery are evident and that there is a large population of children with these characteristics who experienced a prolonged LOS that did not result in transfer to PAC. These findings could be used in subsequent studies to help create the base of a matched cohort of children with similar clinical, demographic, and hospitalization characteristics who used vs didn’t use PAC. Comparison of the functional status, health trajectory, and family and/or social attributes of these 2 groups of children, as well as their post-discharge outcomes and utilization (eg, length of PAC stay, emergency department revisits, and acute-care hospital readmissions), could occur with chart review, clinician and parent interview, and other methods. This body of work might ultimately lead to an assessment of value in PAC and potentially help us understand the need for PAC capacity in various communities. In the meantime, clinicians may find it useful to consider the results of the current study when contemplating PAC use in their hospitalized children with RI, including exploration of health system opportunities of clinical collaboration between acute-care children’s hospitals and PAC facilities. Ultimately, all of this work will generate meaningful knowledge regarding the most appropriate, safe, and cost-effective settings for hospitalized children with RI to regain their health.