Garrett Keim, MD

Credit: chop.edu

The elements linked to readmission for children with acute respiratory distress syndrome (ARDS) include an index hospitalization of 14 days or more, the existence/development of chronic medical issues at the index admission, and placement of tracheostomy during index admission, according to new findings.¹

These results indicate a high risk of ARDS patient readmission within the initial 2 months following discharge, and they were the results of a study assessing which elements are shown to be linked to readmission among pediatric survivors of this condition.

The issue was seen as necessary to examine further, given that over 100 000 pediatric ARDS patients per year in the US are known to need mechanical ventilation (MV) for management of their condition.² The new research was led by Garrett Keim, MD, from the Department of Anesthesiology and Critical Care Medicine at Children’s Hospital of Philadelphia in Pennsylvania.

“We hypothesized that readmission would occur in one-quarter of survivors and that the presence of a respiratory CCC, receipt of a tracheostomy during index admission, and longer LOS would be associated with increased hospital readmission after discharge,” Keim and colleagues wrote.

Background and Findings

The investigators used a retrospective cohort study design using pediatric patient data in the time frame between 2013 and 2018 through the use of the MarketScan databases representing 49 states, with comprehensive medical records for more than 43 million claimants being assessed.

For the purposes of ensuring data accuracy, the investigators excluded those without 30 days of insurance coverage prior to their index hospitalization, and the index admissions from 2013 - 2017 were considered by the team to allow for 1-year follow-up data through to the year 2018.

The research team put the participants into categories based upon the existence and the type of complex chronic conditions (CCCs) using Feudtner et al.'s criteria, and this was derived from prehospital ICD-9 and ICD-10 codes within around a month prior to admission and/or from discharge ICD-9 as well as ICD-10 codes.

The investigators created a 3-level CCC exposure classification (none, respiratory CCC, nonrespiratory CCC) for their primary hazard modeling, and ARDS cases identified by an algorithm were defined by the team as pediatric patients with the condition in need of mechanical ventilation from specific types of sources.

The main outcome assessed by the investigators was patients’ readmission to hospital facilities within a single year following their index hospitalization, and this was found by using a new record of hospitalization up to 365 days following index discharge, though same-day readmissions were excluded.

A Kaplan-Meier survival analysis was used for readmission probabilities at distinct points in time, and participants were censored at 366 days or at the time of the loss of their insurance coverage. The research team conducted sensitivity analyses for 30 and for 60-day readmissions, but days alive and days out of the hospital were calculated as cumulative days alive and not admitted within the initial year following their discharge.

The study ended up having 13,505 participants, and the investigators sought to detect a 5% difference in rates of readmission between respiratory and nonrespiratory CCCs with a 3:1 patient ratio as well as a significance level of P < .05.

Among the cohort of 13,505 children surviving ARDS-related mechanical ventilation, the investigators found that 3,748 were shown to have 1-year readmissions, and these mainly took place within 61 days following their discharge.

Factors which were shown to be linked to readmission included both respiratory and nonrespiratory complex chronic issues among patients, the placement of new tracheostomies, and stays in hospital facilities taking 14 days or more. Even after the team excluded the patients with chronic conditions, they still found that lengthy hospital stays of 14 days or more remained tied to readmission.

“Future studies are needed to evaluate whether such interventions as postdischarge telephonic contact, follow-up clinics, and home health care may reduce the readmission burden facing pediatric ARDS survivors,” they wrote.

References

1. ^{Keim G, Hsu JY, Pinto NP, et al. Readmission Rates After Acute Respiratory Distress Syndrome in Children. JAMA Netw Open. 2023;6(9):e2330774. doi:10.1001/jamanetworkopen.2023.30774.}
2. ^{Killien EY, Keller MR, Watson RS, Hartman ME. Epidemiology of intensive care admissions for children in the US from 2001 to 2019. JAMA Pediatr. 2023;177(5):506-515.}