Variation in Case-Mix Adjusted Unplanned Pediatric Cardiac ICU Readmission Rates

Abstract

Objectives: To identify modifiable factors leading to unplanned readmission and characterize differences in adjusted unplanned readmission rates across hospitals.

Design: Retrospective cohort study using prospectively collected clinical registry data SETTING:: Pediatric Cardiac Critical Care Consortium clinical registry.

Patients: Patients admitted to a pediatric cardiac ICU at Pediatric Cardiac Critical Care Consortium hospitals.

Interventions: None.

Measurements and main results: We examined pediatric cardiac ICU encounters in the Pediatric Cardiac Critical Care Consortium registry from October 2013 to March 2016. The primary outcomes were early (< 48 hr from pediatric cardiac ICU transfer) and late (2-7 d) unplanned readmission. Generalized logit models identified independent predictors of unplanned readmission. We then calculated observed-to-expected ratios of unplanned readmission and identified higher-than or lower-than-expected unplanned readmission rates for those with an observed-to-expected ratios greater than or less than 1, respectively, and a 95% CI that did not cross 1. Of 11,301 pediatric cardiac ICU encounters (16 hospitals), 62% were surgical, and 18% were neonates. There were 175 (1.6%) early unplanned readmission, and 300 (2.7%) late unplanned readmission, most commonly for respiratory (31%), or cardiac (28%) indications. In multivariable analysis, unique modifiable factors were associated with unplanned readmission. Although shorter time between discontinuation of vasoactive infusions and pediatric cardiac ICU transfer was associated with early unplanned readmission, nighttime discharge was independently associated with a greater likelihood of late unplanned readmission. Two hospitals had lower-than-expected unplanned readmission in both the early and late categories, whereas two other hospitals were higher-than-expected in both.

Conclusions: This analysis demonstrated time from discontinuation of critical care therapies to pediatric cardiac ICU transfer as a significant, modifiable predictor of unplanned readmission. We identified two hospitals with lower-than-expected adjusted rates of both early and late unplanned readmission, suggesting that their systems are well designed to prevent unplanned readmission. This offers the possibility of disseminating best practices to other hospitals through collaborative learning.

Figure 1.

Scatterplot relating early (vertical axis) and late (horizontal axis) case-mix adjusted unplanned readmission rates with respect to PC⁴ participating center. Centers are considered lower or higher-than-expected if both lower and upper 95% confidence intervals do not cross a case-mix adjusted observed-to-expected (O/E) ratio of 1. Centers I and M demonstrate lower-than-expected case-mix adjusted rates of both early and late UR, while centers P and N demonstrate higher-than expected case-mix adjusted rates of both early and late UR.