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Original Investigation | Journal Club

Pediatric Hospital Discharges to Home Health and Postacute Facility Care A National Study

Jay G. Berry, MD, MPH1 ,2; Matt Hall, PhD3; Helene Dumas, PT, MS2; Edwin Simpser, MD4; Kathleen Whitford, PNP5; Karen M. Wilson, MD, MPH6; Margaret O’Neill, BS1 ; Vineeta Mittal, MD7; Rishi Agrawal, MD, MPH8; Michael Dribbon, PhD9; Christopher J. Haines, DO, MBA9; Christine Traul, MD5; Michelle Marks, DO5; Jane O'Brien, MD2
[+] Author Affiliations
1 Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
2Franciscan Hospital for Children, Boston, Massachusetts
3Children's Hospital Association, Overland Park, Kansas
4St Mary's Healthcare System for Children, Bayside, New York
5Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
6Children's Hospital Colorado, University of Colorado, Aurora
7University of Texas Southwestern Medical Center and Children’s Medical Center Dallas
8Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
9Children's Specialized Hospital, New Brunswick, New Jersey
JAMA Pediatr. 2016;170(4):326-333. doi:10.1001/jamapediatrics.2015.4836.
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Importance  Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children.

Objective  To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children.

Design, Setting, and Participants  Retrospective analysis of 2 423 031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids’ Inpatient Database.

Main Outcomes and Measures  Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children’s characteristics (eg, race/ethnicity and number of chronic conditions) by discharge type using generalized linear regression.

Results  The median age of participants was 3 years (interquartile range, 0-13 years), and 45.6% were female. Of 2 423 031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years, 122 673 discharges (5.1%) were to HHC and 26 282 (1.1%) were to PAC facilities. Neonatal care was the most common reason (44.5%, n = 54 589) for acute care hospitalization with discharge to HHC. Nonneonatal respiratory, musculoskeletal, and trauma-related problems, collectively, were the most common reasons for discharge to PAC (42.9%, n = 11 275). When compared with PAC, more discharges to HHC had no chronic condition (34.4% vs 18.0%, P < .001) and fewer discharges to HHC had 4 or more chronic conditions (22.5% vs 37.7%, P < .001). In multivariable analysis, Hispanic children were less likely to use PAC (0.8% vs 1.1%; odds ratio [OR], 0.9 [95% CI, 0.8-0.9]) or HHC (3.3% vs 5.5%; OR, 0.8 [95% CI, 0.7-0.8]) compared with other children. Children with 4 or more chronic conditions compared with no chronic conditions had a higher likelihood of HHC use (11.0% vs 4.4%; OR, 2.9 [95% CI, 2.8-3.0]) and PAC (3.9% vs 0.8%; OR, 4.5 [95% CI, 4.3-4.9]). After case-mix adjustment, there was significant (P < .001) variation across states in HHC (range, 0.4%-24.5%) and PAC (range, 0.4%-4.9%) use.

Conclusions and Relevance  Home health care and PAC use after discharge for hospitalized children is infrequent, even for children with multiple chronic conditions. It varies significantly by race/ethnicity and across states. Further investigation is needed to assess reasons for this variation and to determine for which children HHC and PAC are most effective.

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Figure 1.
Multivariable Analysis of the Likelihood of Hospital Discharge to Home Health Care or Postacute Facility Care in Children

Shown are the adjusted odds ratios and 95% CIs of postacute facility care and home health care use after hospital discharge in children from the Kids’ Inpatient Database 2009. Reference groups were the following: (1) no chronic condition for the number of chronic conditions; (2) less than 1 year for age; (3) private insurance for payer; (4) Non-Hispanic white for race/ethnicity; (5) West for region; and (6) nonchildren’s hospital for freestanding children’s hospital.

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Figure 2.
Variation Across States in the Use of Home Health Care After Acute Care Hospitalization in Children

Shown are the point estimates and 95% CIs by state for the predicted/expected ratios of home health care use after acute hospitalization in children from the Kids’ Inpatient Database 2009. The Kids’ Inpatient Database includes 44 states. The estimates are adjusted for each state’s case mix of hospitalized children’s age, race/ethnicity, payer, and type and number of chronic conditions. The dotted line indicates a predicted/expected ratio of 1.0. States with significantly more or less predicted/expected use are labeled.

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Figure 3.
Variation Across States in the Use of Facility-Based Postacute Care After Acute Care Hospitalization in Children

Shown are the point estimates and 95% confidence intervals by state for the predicted/expected ratios of postacute facility care use after acute hospitalization in children from the Kids’ Inpatient Database 2009. The Kids’ Inpatient Database includes 44 states. The estimates are adjusted for each state’s case mix of hospitalized children’s age, race/ethnicity, payer, and type and number of chronic conditions. The dotted line indicates a predicted/expected ratio of 1.0. States with significantly more or less predicted/expected use are labeled.

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