The most important finding of this study is the impact of outpatient follow-up on readmission rate in children with SCD. The care of children with SCD is best provided by physicians experienced in the treatment of SCD. Children with SCD seen at least once in a pediatric SCD or hematology clinic have fewer ED visits, decreased hospital length of stay and cost[7
]. More recently, children with SCD and pneumococcal sepsis who were not followed by a hematologist demonstrated increased mortality [8
]. The importance of regular follow-up with a hematologist was reinforced in this study.
Post-discharge hospital follow-up has been shown to be important in other chronic conditions such as asthma. Schmaling, et al. found that patients who did not keep post-discharge follow-up appointments demonstrated poor adherence to asthma therapy[9
]. Lack of outpatient follow-up after hospitalization has also been found to be an independent risk factor for death in Angolan children with SCD[10
]. Strategies aimed at arranging timely follow-up shortly after discharge is necessary to decrease the 30-day readmission rate. Additional effort will need to be focused on ensuring patients are able to keep their appointments such as providing transportation and/or alternative clinic hours.
The contribution of disease severity to 30-day readmission rate is not surprising. Previous research has reported an increase in mortality in adults with frequent SCD pain episodes[5
]. Although no uniform consensus exists regarding the definition of disease severity in SCD, ≥ 3 hospitalizations for SCD-related morbidity in a one-year period remains one of the most commonly used definitions in both observational studies[5
] and treatment studies[6
]. Children with severe disease have more disease-related complications which increases the number of possible admissions eligible for a readmission within 30-days. The modification of disease severity is not as easily accomplished as a hospital follow-up appointment. Interventions to improve 30-day readmission rate should include methods to recognize patients eligible for disease-modifying agents.
Previous research has established asthma as a risk factor for pain, acute chest syndrome and early mortality [11
]. The fact that children with asthma and SCD were more likely to be readmitted is consistent with these findings. The quality measure, 30-day readmission rate, has also been applied to asthma suggesting that it is a disease process at risk for hospital readmission. A higher readmission rate was seen in patients receiving dexamethasone than in patients who did not for acute chest syndrome[13
] and was confirmed by a second study reporting 23 episodes of readmission within 14 days for children who received dexamethasone for acute chest syndrome[14
]. Although steroid administration was not predictive of readmission in our cohort, these results may be biased by the low rate of glucocorticoid administration for an asthma exacerbation in this cohort.
The application of quality measures in pediatrics is unclear, particularly when used in complex chronic disease states where multiple factors, independent of the disease process or medical care, may influence the designated measure. The specific measure, readmission within 30-days for patients with Sickle Cell Anemia (SCA) was originally developed as an Oryx non-core measure by JCAHO and NACHRI[15
]. It was recently published in a compendium of quality measures by the Centers for Medicaid and Medicare and has been endorsed by an increasing number of hospital administrations and insurance agencies[1
] prior to the publication of any studies assessing the validity of the measure in SCD. In this study, we have published the first study identifying potentially modifiable risk factors that were associated with 30-day hospital readmission for children with SCD.
Risk factors that were not well characterized in this study included access to transportation, ability to obtain medications, adherence to complicated dosing regimens and other psycho-social stressors such as loss of employment or housing. Some of these factors likely contributed to poor post-discharge follow-up. We identified anecdotal evidence to suggest that lack of medications at home resulted in some of the hospital readmissions. Due to the retrospective nature of this study, we did not accurately report these issues. Even in a prospective study, many of these issues do not lend themselves to easy quantification. Any intervention aimed at reducing the 30-day readmission rate for children with SCD will need to address these psychosocial variables as well. Additionally, the risk factors identified may be institution-specific and may not be generalizable to other medical centers.
We have identified several risk factors for hospital readmission in children with SCD. Some of these factors are potentially modifiable such as developing strategies to improve post-discharge follow-up. Some factors, such as disease activity, may be partially modified.