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Cut Readmissions After Pediatric Heart Surgery by Fact Finding


 

EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE WESTERN THORACIC SURGICAL ASSOCIATION

COLORADO SPRINGS – Physicians at Emory University Hospital now have a firmer grip on what they’re dealing with in reducing 30-day readmissions.

The knowledge that there are three major risk factors – preoperative failure to thrive, an initial length of stay greater than 10 days, and Hispanic ethnicity – for readmission following pediatric congenital heart disease surgery is a tool for improvement, said Dr. Brian E. Kogon of Emory University, Atlanta.

"These data are obviously our data and are very specific to our hospital, our location, and our patient population. I would think that it’s going to be very different throughout the country based on whether you’re at an academic center or private center, urban versus rural setting, and even in adult cardiac, general thoracic, and pediatric practices," Dr. Kogon said in presenting the study findings at the annual meeting of the Western Thoracic Surgical Association.

The important thing is for physicians and surgeons to analyze their own hospital’s readmission experience, identify the risk factors, and then address the potentially modifiable ones in an effort to drive that readmission rate down, added Dr. Kogon, director of the congenital cardiac surgery fellowship program at Emory.

Studying Readmissions Following Pediatric Surgery

Readmissions within 30 days are increasingly viewed by third-party payers as preventable complications warranting stiff payment penalties. The focus thus far has been on the adult world, but at some point pediatric care will come under scrutiny as well. This realization led Dr. Kogon and his coworkers to analyze their institutional experience via a retrospective cohort study.

During 2002-2009, the annual 30-day readmission rates following pediatric surgery for congenital heart disease were 5.9%-10.4%, with a median of 8.7%. Those rates are relatively low; other centers typically report readmission rates of 10%-20%, he noted.

In 2009, 685 patients were discharged after pediatric congenital heart disease surgery; 70 of them had 74 readmissions. Among the key findings: only 15% of readmissions were for cardiac reasons. Indeed, the top three reasons for readmission were pleural or pericardial effusions, accounting for 26% of all readmissions; gastrointestinal problems, 24%; and infection, 19%.

Readmissions were costly. A total of 69% of patients were readmitted to a ward, 31% to the ICU. Upon readmission these patients spent a total of 653 additional days – almost 22 months – in the hospital.

The investigators scrutinized numerous potential demographic, preoperative, operative, and postoperative risk factors for readmission. Only three proved significant in a multivariate analysis: an initial length of stay greater than 10 days was associated with a 4.4-fold increased risk of readmission; a preoperative diagnosis of failure to thrive was associated with a 2.7-fold risk; and Hispanic ethnicity was associated with a 1.87-fold increased risk.

These readmissions occurred despite an intense discharge process and close follow-up. All families at the pediatric heart surgery unit attend a discharge class and a CPR training class. A pharmacist is on hand at the discharge class to review medications. Shunt recipients and newborns receive additional education. All case-management issues, such as formula supplies and home health equipment, are resolved before discharge. Patients meet with a cardiothoracic surgeon during their first week out of hospital, a cardiologist the second week, and thereafter with their primary care provider.

The median time to the first scheduled outpatient appointment was 4.5 days postdischarge. The median time to readmission was 8 days. Thirty-one percent of patients were readmitted prior to their first clinic appointment, 10% directly from the clinic, and 50% after their first clinic visit. The rest were readmitted after being no-shows for their clinic visit.

Dr. Kogon said he suspects that Hispanics were at increased risk for readmission because of educational and language barriers. Although a Spanish-language interpreter is present at the discharge class as needed, Dr. Kogon and his colleagues have observed that many Hispanic families nonetheless return unclear about medication and feeding regimens.

"I think there’s still a gap in our education of those patients," he said.

Discussant Dr. David R. Clarke said it might be argued that if a hospital doesn’t have a certain number of readmissions, then patients are being kept in the hospital too long.

"On a practical level, how much do we spend during the initial admission to ensure no readmissions? Do we automatically keep patients identified as high risk, such as Hispanics, 2, 3, or 4 extra days to minimize their readmission rate? And even if we do that and other things, is it really possible to prevent readmissions?" wondered Dr. Clarke of Children’s Hospital Colorado, Denver.

Dr. Kogon replied that this is the key question his colleagues raised when he shared the study findings. The group has decided to modify the discharge process for their high-risk patients, keeping them in the hospital a day or so longer while continuing to collect data in order to see if this pays off in fewer readmissions.

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