Association of Extending Hospital Length of Stay With Reduced Pediatric Hospital Readmissions

Hospital readmission rates are widely used as a quality measure for hospitalized patients. Hospital readmission gained attention largely from concerns about the quality of discharge care, including those patients discharged before they were adequately prepared to leave the hospital.¹ In adult patients, shorter index hospitalization length of stay (LOS) is associated with a higher risk of hospital readmission for some conditions.² This association has not been shown in children,³ and it remains unknown whether specific pediatric conditions might benefit from increasing LOS. Therefore, this study explored the association between index hospitalization LOS and pediatric readmissions by capitalizing on the natural variation in LOS across patients and hospitals.

This was a retrospective cohort study of hospitalized children (aged 0-18 years) using data from 2015 to 2016 from the Pediatric Health Information System database (Children’s Hospital Association), which includes clinical and billing data from 49 children’s hospitals, representing approximately 20% of all US discharges for children. This study was considered non–human subjects research by the institutional review board at Vanderbilt University Medical Center, Nashville, Tennessee, which waived the need for approval as well as patient informed consent. Reasons for condition-specific admissions were determined using the All-Patient Refined Diagnosis Related Groups (APR-DRGs) (version 32.0) classification scheme.⁴ Low frequency APR-DRGs (ie, APR-DRGs with <10 patients per year per hospital or APR-DRGs reported from <30 hospitals) were excluded. To ensure that patients within an APR-DRG had similar severity and complexity, discharges with high APR-DRG severity-of-illness levels (level 3 or 4), complex chronic conditions,⁵ intensive care unit services, or death were also excluded. To assess the association between index hospitalization LOS and readmissions, an ecological analysis was performed in which (1) the mean LOS (in bed-days) and associated 15-day and 30-day readmission rates for each APR-DRG were calculated; (2) the association between hospital-level adjusted mean LOS and hospital-level adjusted readmission rates using a linear regression model were estimated to identify which reasons for the index hospital admission had a statistically significant inverse association between LOS and readmission; and (3) the number of additional hospital bed-days and costs (estimated from charges using each hospital’s cost to charge ratio) required to prevent a single readmission were estimated. Statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc), with a 2-sided P value less than .05 for significance.

There were 956 507 pediatric hospitalizations included. Of 314 possible reasons for admission, only 6 distinct APR-DRGs for the index hospitalization (1.9%) had higher readmission rates with shorter hospital LOS. Of these 6 APR-DRGs, asthma, cellulitis and other bacterial skin infections, and nephritis and nephrosis had decreased 15-day readmissions and dorsal and lumbar spinal fusion (for scoliosis), cellulitis and other bacterial skin infections, all normal newborns, and the subset of newborns with hyperbilirubinemia had decreased 30-day readmissions (Table). To prevent a single readmission, the estimated number of additional hospital bed-days ranged from 18 days (for nephritis and nephrosis; 15-day readmission) to 148 days (for newborns; 30-day readmission). Accompanying costs for these additional hospital bed-days ranged from $41 000 (for nephritis and nephrosis) to $1.4 million (for dorsal and lumbar spinal fusion) (Figure). Among newborns, a longer hospital LOS for those with hyperbilirubinemia was associated with reduced readmissions; however, 134 additional hospital bed-days and $104 000 were required to prevent 1 readmission.

These findings do not suggest a robust association between index hospitalization LOS and hospital readmission among children. Few specific reasons for the index hospitalization admission had an inverse association between LOS and readmission. For those diagnoses, the number of additional hospital bed-days and costs needed to avoid 1 readmission may neither be reasonable nor cost-effective to pursue. Because the study findings are most applicable to children’s hospitals, future studies should assess the association between hospital LOS and readmission in other types of hospitals. In children’s hospitals, the majority of children may already be staying in the hospital for the appropriate amount of time. As a result, efforts to avoid readmissions should focus on other aspects of hospital discharge care.

Accepted for Publication: August 27, 2018.

Corresponding Author: James C. Gay, MD, MMHC, Division of General Pediatrics, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, 11204 Doctor’s Office Tower, Nashville, TN 37232-9225 (james.gay@vumc.org).

Published Online: December 28, 2018. doi:10.1001/jamapediatrics.2018.3815

Author Contributions: Drs Gay and Hall had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gay, Hall, Markham, Bettenhausen, Berry.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Gay, Hall, Berry.

Critical revision of the manuscript for important intellectual content: Gay, Markham, Bettenhausen, Doupnik, Berry.

Statistical analysis: Hall, Markham, Bettenhausen.

Obtained funding: Berry.

Administrative, technical, or material support: Gay, Berry.

Supervision: Gay, Berry.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant 1P30HS024453-01 from the Agency for Healthcare Research and Quality (Dr Berry).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Julia Simmons, MD, MBA (Children’s Mercy Kansas City), and James A. Feinstein, MD, MPH (Colorado Children’s Hospital), for their valuable contributions to discussions of this work. They did not receive compensation for their contributions.