This study suggests that a small cohort of recurrently readmitted pediatric patients is a major contributor to inpatient utilization and expenditures within a group of children’s hospitals: nearly one-fourth of all inpatient bed-days and charges were attributable to 3% of admitted patients who experienced 4 or more readmissions within a 1-year period. Some of the readmissions may have been potentially avoidable: nearly one-third of patients readmitted 4 or more times were rehospitalized for a problem in the same organ system during the interval they were most frequently readmitted. If these patients were prospectively identified and received effective readmission prevention services before they accumulated multiple readmissions, there would be potential for substantial inpatient expenditure reduction.
The study findings support the importance of monitoring the number of times individual pediatric patients are readmitted. With a median of 37 days between readmissions, the majority of rehospitalizations experienced by patients with the highest readmission frequency would not have been recorded or reviewed using traditional 30-day hospital readmission metrics.
25,26 The readmissions may be underrecognized by primary care clinicians if they are not actively involved in the patients’ hospital or immediate postdischarge care. High rates of absent postdischarge primary care follow-up are reported among adults experiencing readmission.
27The attributes of pediatric patients at risk for recurrent readmissions observed in this study suggest that heightened complexity of discharge care planning may be needed to ensure their safe transition from the hospital.
28 Those patients with multiple CCCs and technology assistance may require communication, proactive care planning, and follow-up appointments with multiple outpatient specialty providers, equipment specialists, and home nurses at discharge.
29 High-quality discharge care planning, including timely communication with outpatient providers regarding hospitalization course and postdischarge care instructions, may be an important mitigating factor to minimize readmission.
30 However, this planning may not prevent multiple future readmissions in children at risk for them if the outpatient providers and health system are underequipped to meet their health care needs, optimally manage their acute illnesses, and minimize their chronic illness exacerbations.
Further investigation is needed to determine whether there is a greater opportunity to break the readmission cycle of patients recurrently readmitted or target patients at risk for a single readmission. In the present study, one-fourth of patients experienced a single readmission within 6 weeks of a prior admission. Although these patients accounted for less hospital resource use than patients with recurrent readmissions, it may be easier to mitigate their readmissions because they have a higher prevalence of ACSC hospitalizations and a lower prevalence of CCCs.
Neuromuscular CCCs were the most prevalent disease group among patients frequently readmitted. Children with these conditions are at risk for uncoordinated care and unmet health care needs.
31–33 This care could be contributing to their high rates of emergency department use and subsequent hospitalization.
34,35 Young adults with pediatric neuromuscular conditions may be particularly vulnerable for unmet health care needs and overuse of inpatient health services when attempting to transfer their care from pediatric to adult providers.
36 This may help explain the rising prevalence of adults 18 years and older with increasing readmission frequency.
Even if the highest care quality is delivered throughout inpatient and outpatient care to children at risk for recurrent readmissions, further investigation is needed to determine which readmissions may be truly avoided. Readmissions for ACSCs and for the same major diagnostic category are currently under discussion for being potentially avoidable.
13,37 In the present study, asthma was the most common ACSC and a respiratory problem was one of the most common major diagnostic categories encountered repeatedly across patients’ multiple readmissions. Ambulatory action plans that mitigate worsening respiratory illnesses have been successful in decreasing respiratory-related hospitalizations for asthma and other chronic lung diseases.
22,38,39There may be additional respiratory problems among children with CCCs that could be considered ambulatory care–sensitive but are not included within the current ACSC set. Multiple readmissions for aspiration pneumonia in a child with cerebral palsy may be considered care-sensitive if clinicians feel the readmissions are potentially reducible with optimized surgical and ambulatory reflux, digestive motility, and oromotor dysfunction management.
40 Establishing a complementary set of ACSCs for children with CCCs that account for this (and other related) clinical situations and designate care management responsibilities between a child’s family and ambulatory health care providers may help inform strategies to identify and reduce potentially avoidable pediatric readmissions.
Our study has several limitations related to PHIS inpatient administrative data. Clinical data are preferable to uncover the true reasons for readmission and identify hospitalizations that are potentially avoidable. Although the diagnosis codes used to exclude planned chemotherapy admissions may have reputable accuracy,
41 it is possible that some were unplanned and incorrectly excluded. Outpatient data were unavailable, including access to a medical home, long-term care facility, home nursing, case management, and respite care. Psychosocial factors were unavailable, including home environment stability and family empowerment of chronic illness self-management. Advanced directives with a do-not-hospitalize attribute were not available. We were unable to identify hospitalized children who died in settings beyond a PHIS hospital, such as at home. We could not identify situations where a patient was admitted to a non-PHIS hospital or to a different PHIS hospital, and therefore readmission frequency may be underestimated for some children.
A small number of patients with Medicaid-managed care may have been assigned to the commercial insurance category, underestimating the prevalence of Medicaid users. PHIS data contain hospital charge data that may not reflect the true cost of a hospitalization. The generalizability of the results may be limited to freestanding children’s hospitals. Our sample contains data from 37 of approximately 50 freestanding US children’s hospitals.
42 Nationally, it is estimated that 25% of children’s hospitalizations occur within children’s hospitals.
43 Children treated at children’s hospitals have a higher prevalence of single and multiple CCCs than children treated at other hospitals.
44 Variation was present in the prevalence of patients experiencing recurrent readmissions among the hospitals. Individual hospitals may have their own distinctive discharge care planning and care coordination policies that influence readmission prevalence.
Despite these limitations, this study suggests that a small group of children is accounting for a substantial proportion of inpatient expenditures because they are experiencing recurrent readmissions. There is a need to monitor the number of times individual pediatric patients are readmitted over time so that children’s hospitals and outpatient providers within their local health care environments may understand the true reasons why many of these children are recurrently readmitted, which reasons are associated with contributory illness and health system problems that are ameliorable, and how to identify and help the children who are the most likely to experience future recurrent readmissions given the readmission frequency variation they may experience over time.
It is important to approach the entire continuum of care to best understand and optimally support children at risk for recurrent readmissions. Health care reform initiatives are underway to evaluate the shared accountability for patient outcomes and inpatient utilization among integrated community- and hospital-based clinician teams.
45,46 Episode-of-care experiments with a bundled payment for inpatient surgical and outpatient posthospitalization care have been associated with improved patient outcomes, reduced hospital readmission up to 90 days after discharge, and reduced costs.
47 Longer-term case management interventions within pediatric medical homes have lowered hospitalization rates in medically complex cases of children with neuromuscular CCCs and technology assistance.
48 Further investigation of these strategies among pediatric patients at risk for recurrent readmissions may yield important insight on how to optimize the health and well-being of these children, reduce their readmissions, and keep them safe in their home and community environments.
The publisher's final edited version of this article is available at 
