Readmission Rate As a Quality Indicator: the Risk Factors for Readmission Among Patients

READMISSION RATE AS A QUALITY INDICATOR: THE RISK FACTORS FOR READMISSION AMONG PATIENTS WITH CHILDHOOD ASTHMA

Yanhua Li

MD, Peking University,China, 2012

MB, Peking University, China, 2010

Submitted to the Graduate Faculty of

Multidisciplinary Master of Public Health

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2014

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

Yanhua Li

December 5, 2014

and approved by

Essay Advisor:

David N. Finegold, MD ______

Director

Multidisciplinary Master of Public Health

Graduate School of Public Health

Professor

School of Medicine, Pediatrics

University of Pittsburgh

Essay Reader:

Steven M. Albert, PhD ______

Professor and Chair

Department of Behavioral and Community Health Sciences

Graduate School of Public Health

University of Pittsburgh

2014

David N. Finegold, MD

READMISSION RATE AS A QUALITY INDICATOR: THE RISK FACTORS FOR READMISSION AMONG PATIENTS WITH CHILDHOOD ASTHMA

Yanhua Li,MPH

University of Pittsburgh, 2014

Abstract

Background:Global management of childhood asthma is suboptimal. With the increasing prevalence of childhood asthma, the poor management of childhood asthma became a huge public health concern and called for urgent actions.To design evidence-based interventions on improving quality of care for patients with childhood asthma, a better understanding is needed of what are the risk factors for readmission among asthmatic patients.

Objective:To provide an overview about the justification of readmission rate as a quality indicator for chronic disease management. To review the recent research findings about risk factors for readmission among patients with childhood asthma.

Methods: To search PubMed database for articles published in English that contained key words of readmission or re-hospitalization, childhood asthma or asthma for children.

Results:Shorter time (within 30 days) readmissionrate has more strength of assessing the quality of care at hospitals. On the contrary, 3-month or 1-year readmission rates reflect the effectiveness of care outside of hospitals. The risk factors for readmission among patients with childhood asthma are illustrated at an individual level (i.e. young age, race, and psychosocial stress), interpersonal level (i.e. parents’ perception, parent’s knowledge, family structure, and smoking), community level (i.e. air pollutant, low-income neighborhood), and institutional level (inappropriate treatment at hospital, communication barrier, school regulation).

Conclusion:Readmission rates with different time frames have various utilization. More studies are needed to justify readmission within 30 days to assess the quality of care at hospitals. The risk factors for readmission among patients with childhood asthma are complex at an individual, interpersonal, community and institutional level. To gain fully comprehension of the risk factors, more studies are needed. The ideal condition is that all the health care professionals should share the accountability of the long-term care of patients.

ACKNOWLEDGEMENTS

Thanks to Steven M. Albert, Professor and Chair of Department of Behavioral and Community Health Sciences, for his valuable suggestions on the structure of this literature review. Thanks to David N. Finegold, my academic advisor, for his constructive comments that enabled me to improve this essay. I am grateful to Michael A. Yonas, Assistant Professor at the Department of Family Medicine, for giving insightful information about childhood asthma in Pittsburgh. In addition, thanks to Yan Xing, Xiaomei Tong, the pediatricians at Peking University Third Hospital, for providing the useful advice on the status of childhood asthma in China. Finally, I also send my sincere gratefulness to Christopher L. Stoessel, my friend, for his generous help for providing thoughtful suggestions on this essay.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS…………………………………………………………………….vi

1.0 INTRODUCTION………………………………………………………………….. 1

2.0 METHODS…………………………………………………………………………...3

3.0 READMISSION RATE……………………………………………………...... 4

4.0 RISK FACTORS……………………………………………………………………..6

4.1 INDIVIDUAL LEVEL………………………………………………………7

4.2 INTERPERSONAL LEVEL…………………………………………….…8

4.3 COMMUNITY LEVEL……………………………………………………..9

4.4 INSTITUTION LEVEL…………………………………………………….9

5.0 CONCLUSIONS…………………………………………………………………...11

BIBLIOGRAPHY………………………………………………………………...... 15

LIST OF TABLES

Table 1. Summary of recent studies…………………………………………………………….12

LIST OF FIGURES

Figure 1. Process of identifying articles related to readmission and childhood asthma………....4

1.0INTRODUCTION

Asthma has become one of the most common chronic diseasesthroughout the world,with an increasing prevalence among children over the past decade. In developed countries, such as the United States, the period prevalence of childhood asthma increased from8.7% in 2001 to 9.4% in 2010. (1)Meanwhile, China as a developing country also has worrisome issues around the ever increasing prevalence of childhood asthma. China’s Centers for Disease Control and Prevention (CDC) has conducted three nationwide epidemiologic surveys over the last three decades.The second and third surveys indicated that theprevalence of asthma among childrenhad been increasing by 50.6%, which was 1.54% in 2000 and 2.32% in 2010 separately. (2, 3) In large cities, the prevalenceis even higher. According to a cross-sectional study conducted by Zhao et al. in 2009, the prevalence rates of childhood asthma in Beijing and Chongqingwere 3.2% and 7.2%, respectively.(4)

Globally, the status of asthma control is suboptimal. The Asthma Insight and Reality (AIR) surveys conducted between 1998 and 2001 indicated that the level of overall control of childhood asthma was under the standard which Global Initiative for Asthma (GINA)guidelines required. (5)In Europe, only 5.3% of patients were considered to be properly under control for asthma, which met all the criteria that GINA listed. (6)Among countries surveyed for asthma control, those in Asia aroused awareness for scoring the lowest. In the year 2000, only 14.4% of respondents in Asian areas reported using preventative medication, while 36.5% of children had missed school because of asthma. (7)In 2006, the Phase 2 of the AIR in the Asia-Pacific survey set an urgent alarm off for the health professionals in these areas. The study revealed that only 2.5% of all children with asthma were under control.(8)In 2011, a multi-center survey conducted among 29 provinces in China indicated the poor management of asthma. This study showed that among children with asthma, 66% of them experienced asthma attacks in the past 12 months. (9)

In the United States, the use of appropriate asthma therapy is unsatisfactory. In 1998, Adams et al. conducted a national population survey in the United States. Among the patients who should have been using anti-inflammatory medicine, only 1/4 to 1/3 of them actually reported using this kind of medication, especially for children.(10)In 2008, another study indicated that only 34% of children with asthma reported receiving asthma action plans, while 12% of them took an asthma education class.(11)Some researchers concluded that inadequate treatment for childhood asthma existed as a result of discontinuities in the United States healthcare system. (12-14)Kripalaniet al. did a peer review and found that only 3% to 20% of United States hospital providers communicated directly to outpatient Primary Care Physicians (PCP).(12)The failure of transferring discharge information was associated with poor quality of care on follow-up. Moore et al. demonstrated that 50% of patients experienced medical errors during the follow-up period due to discontinuity of care. (15)Uncontrolled asthma may progress mild asthma into severe asthma and even lead to death. In 2011, 169 children under the age of 15 died from asthma. (16)Although asthma-related deaths are rare among children, the death rate for children has increased by nearly 80% since 1980 in the United States. (16)

Improper management of childhood asthma could result in unnecessary utilization of healthcare resources as well as expenditures. With Emergency Departments (ED) being the main source of medical service for children with asthma exacerbations in the United States, the ED visit rate was higher among children than adults. (17)Childhood asthma placed a heavy financial burden on the families of affected children. The annual per capita of direct healthcare cost for all school-age children with asthma in the United States was $401. (18)In Asian countries, patients with poorly controlled asthma spentan average of $861 on healthcare per year, which was almost 3.5 times as high as that of patients whose asthma were well controlled. (19)In China, some families spent up to 16% of their annual household income on asthma treatment if their child’s asthma was uncontrolled.(9)

In addition, childhood asthma may disturb the daily lives of patients and their families. Patients with poor management of asthma are likely to have repeated readmission to hospitals, which eventually may result in school absence. According to a worldwide survey conducted from 1998 through 2001, the percentage of schooldays lost due to asthma in the United States was 49%. (5)The value of caregiver’s productivity loss associated with the school absences of their children was estimated to be $983.8 million ($390 per child) per year. (18)Sleep disorders happen frequently among children with improper asthma treatment. Meltzeret al. conducted a study to evaluate the sleep status among adolescents with asthma and found that patients obtained insufficient sleep, and experienced clinically significant insomnia compared to children without asthma. (20)

In summary, with the increasing prevalence of childhood asthma, the poor management of childhood asthma place a heavy economic and medical burden. There is an alarming urgent that implementing effective public health interventions to improve the quality of care among asthmatic children. However, a better understanding of which quality measure can be used and what are the deeper reasons of the suboptimal asthma control is needed before developing interventions.In order to gain this comprehension, this essay will be included some of the studies related to the readmission and risk factors for readmission among asthmatic patients.

2.0METHODS

PubMed is the database from which all the articles were selected. First of all, search both subject headings and keywords related to readmission or re-hospitalization, childhood asthma, asthma and children since 2000. 83 articles were found. 11 articles were not relevant on basis of title or abstract. The number of full-text articles were 51. In addition, 11 articles were not conducted in the United States. As there were some social factors related to risk factor among asthmatic patients, different healthcare systems and demographic status will have different risk factors at social level. The 11 articled conducted outside of the U.S. were excluded. In addition, 7 articles published before 2000 were included in order to illustrate the history of realization of readmission rate. Search strategy was developed with the assistance of a former colleague. The following content was developed by 33 articles that were selected. (Figure 1)

3.0READMISSION RATE

According to statistics, the 30-day readmission rate for childhood asthma was reported to go up from 2% to 11.3%. (21-23)The probability of readmission over time increased with each subsequent admission and finally reached 30% over a 10-year study interval. (24)According to a study conducted in New Jersey, the readmission of childhood asthma took place in almost 1/3 of all hospital admissions from 1994 to 2000.(25)

In the 1950’s, some psychiatrists found that psychiatric patients were readmitted to hospitals quite often. They began to realize that readmission rate could be an indicator to differentiate the high-risk patients.(26, 27)Over the last few decades, chronic disease has become a heavy burden for developed countries, as well as developing countries.Some researchers have drawn their attention to the management of long-term care for patients with chronic disease. Sincethe 1980’s, more and more clinicians have investigated the association between readmission and quality of long-term care.

The understanding of readmission hasdeveloped more comprehensively over the same period of time. In 1988, the Health Care Financing Administration encouraged peer review organizations to investigate the relationship between inpatient quality and readmissions within 31 days of discharge. Holloway et al. published a research article the following year, illustrating that the same-condition with risk-adjusted readmission could be a quality indicator for inpatient care.(28)Benbassatet al.suggested that global readmission rate may not be a good quality indicator because of its low specificity and low sensitivity, which was consistent with the study result that Holloway did. (29)A more accurate readmission rate was needed, one that would becondition-specific as well as carefully risk stratified. (30)

After the landmark report “To Err is Human: Building a Safer Health System” was released by the Institute of Medicine, federal government and some non-government organizations made significant investments in patient safety and quality improvement. The Center for Medicare Medicaid Services(CMS) mandated hospitals to report readmissions for chronic heart failure, acute myocardial infarction, and pneumonia from June 2009. (31)The United States government also initiated readmission reduction programs and gave financial incentives to encourage hospitals to pay attention to this quality measure among the adult population. (32)

When it comes to whether readmission rate of childhood asthmashould be included in the reduction program, there is still debate around the justification of readmission as a quality measurefor assessing hospital performance. Some researches indicated that not all readmissions were avoidable and the median proportion of avoidable readmissions was 27.1%. (30, 33)Most researchers believed that 3-month or 1-year readmission rates were associated with the quality of care outside of hospitals. A study conducted by Kenyon et al.also put forward this concern. This study illustrated that the 30-day readmission rate in most of children’s hospitals was less than 2% and that it would reach to 10.9% at day 365. (21) This increasing trend indicated the difficulties in long-term asthma control, although most hospitals performed adequately on reduction in 30-day readmission rate.

Most studies assessed the quality of care at hospitals according to the 30-day readmission rate. (34, 35)However, Joynt and Jhademonstrated that the 30-day readmission rate had limited utilization in improving quality of care because readmissions were affected by hospitals’ patient composition and the resources of the community in which it was located. (36)In addition, Dr. Bardach and his colleagues found that condition-specific, risk-adjusted pediatric 30-day readmission rate can hardly differentiate high-performance hospitals and low-performance hospitals because of low patient volumes. (37)In order to get accurate assessment of healthcare quality, some researchers suggested thatthe time window of readmission should be limited to a shorter period of time, such as 3-day readmission or 7-day readmission. (36)

Although healthcare professionals would argue that it is not the right time to consider readmission rate for childhood asthmaas an indicator for reimbursement policy, its effectiveness in assessing quality of care should be noted. Stephen Jencks, a former senior clinical adviser once said that readmissions were not only due to mistakes made in the hospital, but also because of inefficiency in transitions. (38)Kripalani and Moore et al. also illustrated the poor quality of care on follow up due to the lack of communication between hospital based physicians and outpatient doctors. (12, 15)The advice from these experts pointed out that the quality of management for chronic disease could not be improved by simply providing financial incentives to hospitals. In order to improve the quality of care, all healthcare professionals in the medical delivery system should share accountability.

4.0RISK FACTORS

Now that readmission rate is considered as an indicator assess the quality of healthcare there is of great value to have a fully comprehension of risk factor for readmissions among asthmatic patients.To elucidate the risk factors, the social ecological model will be used to summarize all the predictors. Therefore, the risk factors will be illustrated at the individual, interpersonal, community and institutional level.

4.1INDIVIDUAL LEVEL

Children were at high risk of being admitted to all health care settings compared to adults.(17)A cross sectional study indicated that adolescents and toddlers were less likely to report using anti-inflammatory medication. (10)Another study indicated that there was a significantly higher risk of subsequent hospitalization among patients between 3 to 5 years old. (39)Furthermore, adolescent children are characterized by a period of risk-taking behavior and are less likely to comply with their treatment protocol. A study found that only 14% of children aged 13 to 14 years old used inhalers, and a significant number of these inhaler users smoked.(40)

In 1994, Mitchell et al. found the severity of asthma to be associated with increased risk of readmission. (41)A study conducted by Minkovitzet al.also got a result consistent with Mitchell et al., finding that children with severe asthma were more likely to be readmitted to hospitals.In addition, this study also indicated that disease severity had a larger impact on readmission rather than proper treatment or follow-up care. (42)

Racial disparities were found among asthma patients.Studies indicated that African-American children with Medicaid or no insurance coverage were at higher risk of readmission.(24, 43)Consistent with this study, Beck et al. also found that African Americans were more likely to be admitted compared to white children and were readmitted at a significantly shorter time. (44)The reason behind racial disparity is complex and a lot of factors are intervolved with each other. Socioeconomic disadvantage could not stand alone to predict high risk of readmission. Beck et al.failed to find a significant association between socioeconomic determinants and readmission difference, but indicated that 49% of racial disparities could be explained by socioeconomic hardship variables. (44)

These studies may raise awareness with regards to children who live in economically disadvantaged families. Some studies went a little further in exploring the reason behind this. Yonas et al did a literature review on psychosocial stress and childhood asthma, finding that psychological factors such as stress were significantly associated with poorer asthma control. (45)Based on these study results, a way to explain why ethnicity and socioeconomic status are related to readmission for asthma patients was discovered. Patients who live in economic disadvantaged communities are more likely to experience violence and suffer from psychological stress, which will result in improper management of asthma.

4.2INTERPERSONAL LEVEL

Parents have the responsibility of caring for children with asthma. However, whether they have the ability to properly take care of asthma patients remains unclear. A study conducted by some researchers at Boston Children’s hospital investigated the relationship between parent’s perception and children’s readmission. They found that parents’ pessimistic opinion toward their child’s health at discharge was associated with readmission within 30 days. (22)Caregivers who did not graduate high school proved to be associated with their child’s readmission. (46)Of note, these studies demonstrated that caregiverswho were unconfident with their ability and at low level of education had less knowledge about asthma(10, 28)If caregivers cannot get in contact with their child’s Primary Care Physician (PCP), their child is more likely to be readmitted to hospitals. Another study proved this statement and found that patients with low access to medical homes had significantly increased risk of readmission when compared to those with good access.(47)This result is consistent with the study at Boston Children’s hospital.