Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance
BACKGROUND: Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes.
OBJECTIVE: To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals.
DESIGN: Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences.
SETTING: Administrative claims from all hospital admissions in California (2012-2014). PATIENTS: Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma).
MEASUREMENTS: Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used.
RESULTS: Across all California hospitals admitting children (n = 239), using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs.
CONCLUSIONS: Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals.
© 2018 Society of Hospital Medicine
CONCLUSION
The ability of a nationally-endorsed pediatric respiratory readmissions measure to meaningfully identify variation in hospital performance is limited. General hospitals, which provide the majority of pediatric care for common conditions such as LRI, likely cannot be accurately evaluated using national pediatric quality metrics as they are currently designed. Modifying measures in order to increase hospital-level pediatric patient volumes may facilitate more meaningful evaluation of the quality of pediatric care in general hospitals and identification of exceptional hospitals for understanding best practices in pediatric inpatient care.
Disclosures
Regina Lam consulted for Proximity Health doing market research during the course of developing this manuscript, but this work did not involve any content related to quality metrics, and this entity did not play any role in the development of this manuscript. The remaining authors have no conflicts of interest relevant to this article to disclose.
Funding
Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.
