READMISSION RATE AS A QUALITY INDICATOR: THE RISK FACTORS FOR
READMISSION AMONG PATIENTS WITH CHILDHOOD ASTHMA
by
Yanhua Li
MD, Peking University, China, 2012
MB, Peking University, China, 2010
Submitted to the Graduate Faculty of
Multidisciplinary Master of Public Health
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Yanhua Li
on
December 5, 2014
and approved by
Essay Advisor:
David N. Finegold, MD
Director
Multidisciplinary Master of Public Health
Graduate School of Public Health
Professor
School of Medicine, Pediatrics
University of Pittsburgh
______________________________________
Essay Reader:
Steven M. Albert, PhD
______________________________________
Professor and Chair
Department of Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
ii
Copyright © by Yanhua Li
2014
iii
David N. Finegold, MD
READMISSION RATE AS A QUALITY INDICATOR: THE RISK FACTORS FOR
READMISSION AMONG PATIENTS WITH CHILDHOOD ASTHMA
Yanhua Li, MPH
University of Pittsburgh, 2014
Abstract
Background: Global management of childhood asthma is suboptimal. With the increasing
prevalence of childhood asthma, the poor management of childhood asthma became a huge
public health concern and called for urgent actions. To design evidence-based interventions on
improving quality of care for patients with childhood asthma, a better understanding is needed of
what are the risk factors for readmission among asthmatic patients.
Objective: To provide an overview about the justification of readmission rate as a quality
indicator for chronic disease management. To review the recent research findings about risk
factors for readmission among patients with childhood asthma.
Methods: To search PubMed database for articles published in English that contained key words
of readmission or re-hospitalization, childhood asthma or asthma for children.
Results: Shorter time (within 30 days) readmission rate has more strength of assessing the
quality of care at hospitals. On the contrary, 3-month or 1-year readmission rates reflect the
effectiveness of care outside of hospitals. The risk factors for readmission among patients with
childhood asthma are illustrated at an individual level (i.e. young age, race, and psychosocial
stress), interpersonal level (i.e. parents’ perception, parent’s knowledge, family structure, and
smoking), community level (i.e. air pollutant, low-income neighborhood), and institutional level
(inappropriate treatment at hospital, communication barrier, school regulation).
Conclusion: Readmission rates with different time frames have various utilization. More studies
are needed to justify readmission within 30 days to assess the quality of care at hospitals. The
risk factors for readmission among patients with childhood asthma are complex at an individual,
interpersonal, community and institutional level. To gain fully comprehension of the risk factors,
iv
more studies are needed. The ideal condition is that all the health care professionals should share
the accountability of the long-term care of patients.
v
ACKNOWLEDGEMENTS
Thanks to Steven M. Albert, Professor and Chair of Department of Behavioral and
Community Health Sciences, for his valuable suggestions on the structure of this literature
review. Thanks to David N. Finegold, my academic advisor, for his constructive comments that
enabled me to improve this essay. I am grateful to Michael A. Yonas, Assistant Professor at the
Department of Family Medicine, for giving insightful information about childhood asthma in
Pittsburgh. In addition, thanks to Yan Xing, Xiaomei Tong, the pediatricians at Peking
University Third Hospital, for providing the useful advice on the status of childhood asthma in
China. Finally, I also send my sincere gratefulness to Christopher L. Stoessel, my friend, for his
generous help for providing thoughtful suggestions on this essay.
vi
TABLE OF CONTENTS
ACKNOWLEDGEMENTS…………………………………………………………………….vi
1.0
INTRODUCTION………………………………………………………………….. 1
2.0
METHODS…………………………………………………………………………...3
3.0
READMISSION RATE……………………………………………………...............4
4.0
RISK FACTORS……………………………………………………………………..6
5.0
4.1
INDIVIDUAL LEVEL………………………………………………………7
4.2
INTERPERSONAL LEVEL…………………………………………….…8
4.3
COMMUNITY LEVEL……………………………………………………..9
4.4
INSTITUTION LEVEL…………………………………………………….9
CONCLUSIONS…………………………………………………………………...11
BIBLIOGRAPHY………………………………………………………………........................15
vii
LIST OF TABLES
Table 1. Summary of recent studies…………………………………………………………….12
viii
LIST OF FIGURES
Figure 1. Process of identifying articles related to readmission and childhood asthma………....4
ix
1.0
INTRODUCTION
Asthma has become one of the most common chronic diseases throughout the world, with
an increasing prevalence among children over the past decade. In developed countries, such as
the United States, the period prevalence of childhood asthma increased from 8.7% in 2001 to
9.4% in 2010. (1) Meanwhile, China as a developing country also has worrisome issues around
the ever increasing prevalence of childhood asthma. China’s Centers for Disease Control and
Prevention (CDC) has conducted three nationwide epidemiologic surveys over the last three
decades. The second and third surveys indicated that the prevalence of asthma among children
had been increasing by 50.6%, which was 1.54% in 2000 and 2.32% in 2010 separately. (2, 3) In
large cities, the prevalence is even higher. According to a cross-sectional study conducted by
Zhao et al. in 2009, the prevalence rates of childhood asthma in Beijing and Chongqing were
3.2% and 7.2%, respectively. (4)
Globally, the status of asthma control is suboptimal. The Asthma Insight and Reality
(AIR) surveys conducted between 1998 and 2001 indicated that the level of overall control of
childhood asthma was under the standard which Global Initiative for Asthma (GINA) guidelines
required. (5) In Europe, only 5.3% of patients were considered to be properly under control for
asthma, which met all the criteria that GINA listed. (6) Among countries surveyed for asthma
control, those in Asia aroused awareness for scoring the lowest. In the year 2000, only 14.4% of
respondents in Asian areas reported using preventative medication, while 36.5% of children had
missed school because of asthma. (7) In 2006, the Phase 2 of the AIR in the Asia-Pacific survey
set an urgent alarm off for the health professionals in these areas. The study revealed that only
2.5% of all children with asthma were under control. (8) In 2011, a multi-center survey conducted
among 29 provinces in China indicated the poor management of asthma. This study showed that
among children with asthma, 66% of them experienced asthma attacks in the past 12 months. (9)
In the United States, the use of appropriate asthma therapy is unsatisfactory. In 1998,
Adams et al. conducted a national population survey in the United States. Among the patients
who should have been using anti-inflammatory medicine, only 1/4 to 1/3 of them actually
reported using this kind of medication, especially for children. (10) In 2008, another study
indicated that only 34% of children with asthma reported receiving asthma action plans, while
1
12% of them took an asthma education class. (11) Some researchers concluded that inadequate
treatment for childhood asthma existed as a result of discontinuities in the United States
healthcare system. (12-14) Kripalani et al. did a peer review and found that only 3% to 20% of
United States hospital providers communicated directly to outpatient Primary Care Physicians
(PCP). (12) The failure of transferring discharge information was associated with poor quality of
care on follow-up. Moore et al. demonstrated that 50% of patients experienced medical errors
during the follow-up period due to discontinuity of care. (15) Uncontrolled asthma may progress
mild asthma into severe asthma and even lead to death. In 2011, 169 children under the age of 15
died from asthma. (16) Although asthma-related deaths are rare among children, the death rate for
children has increased by nearly 80% since 1980 in the United States. (16)
Improper management of childhood asthma could result in unnecessary utilization of
healthcare resources as well as expenditures. With Emergency Departments (ED) being the main
source of medical service for children with asthma exacerbations in the United States, the ED
visit rate was higher among children than adults. (17) Childhood asthma placed a heavy financial
burden on the families of affected children. The annual per capita of direct healthcare cost for all
school-age children with asthma in the United States was $401. (18) In Asian countries, patients
with poorly controlled asthma spent an average of $861 on healthcare per year, which was
almost 3.5 times as high as that of patients whose asthma were well controlled. (19) In China,
some families spent up to 16% of their annual household income on asthma treatment if their
child’s asthma was uncontrolled. (9)
In addition, childhood asthma may disturb the daily lives of patients and their families.
Patients with poor management of asthma are likely to have repeated readmission to hospitals,
which eventually may result in school absence. According to a worldwide survey conducted
from 1998 through 2001, the percentage of school days lost due to asthma in the United States
was 49%. (5) The value of caregiver’s productivity loss associated with the school absences of
their children was estimated to be $983.8 million ($390 per child) per year. (18) Sleep disorders
happen frequently among children with improper asthma treatment. Meltzer et al. conducted a
study to evaluate the sleep status among adolescents with asthma and found that patients
obtained insufficient sleep, and experienced clinically significant insomnia compared to children
without asthma. (20)
2
In summary, with the increasing prevalence of childhood asthma, the poor management
of childhood asthma place a heavy economic and medical burden. There is an alarming urgent
that implementing effective public health interventions to improve the quality of care among
asthmatic children. However, a better understanding of which quality measure can be used and
what are the deeper reasons of the suboptimal asthma control is needed before developing
interventions. In order to gain this comprehension, this essay will be included some of the studies
related to the readmission and risk factors for readmission among asthmatic patients.
2.0
METHODS
PubMed is the database from which all the articles were selected. First of all, search both
subject headings and keywords related to readmission or re-hospitalization, childhood asthma,
asthma and children since 2000. 83 articles were found. 11 articles were not relevant on basis of
title or abstract. The number of full-text articles were 51. In addition, 11 articles were not
conducted in the United States. As there were some social factors related to risk factor among
asthmatic patients, different healthcare systems and demographic status will have different risk
factors at social level. The 11 articled conducted outside of the U.S. were excluded. In addition,
7 articles published before 2000 were included in order to illustrate the history of realization of
readmission rate. Search strategy was developed with the assistance of a former colleague. The
following content was developed by 33 articles that were selected. (Figure 1)
3
Relevant articled identified
from database N=83
Excluded articles which
were not relevant on basis
of title or abstract N=11
Articles assessed for
eligibility N=72
Excluded articles which
were not full-text N=21
Full-text articles assessed
for eligibility N=51
Excluded articles which
conducted outside the U.S.
N=11
Add articles related to
readmission rate N=7
Studies included in
literature review N=33
Figure 1. Process of identifying articles related to readmission and childhood asthma.
3.0
READMISSION RATE
According to statistics, the 30-day readmission rate for childhood asthma was reported to
go up from 2% to 11.3%. (21-23) The probability of readmission over time increased with each
subsequent admission and finally reached 30% over a 10-year study interval. (24) According to a
study conducted in New Jersey, the readmission of childhood asthma took place in almost 1/3 of
all hospital admissions from 1994 to 2000. (25)
In the 1950’s, some psychiatrists found that psychiatric patients were readmitted to
hospitals quite often. They began to realize that readmission rate could be an indicator to
4
differentiate the high-risk patients. (26, 27) Over the last few decades, chronic disease has become a
heavy burden for developed countries, as well as developing countries. Some researchers have
drawn their attention to the management of long-term care for patients with chronic disease.
Since the 1980’s, more and more clinicians have investigated the association between
readmission and quality of long-term care.
The understanding of readmission has developed more comprehensively over the same
period of time. In 1988, the Health Care Financing Administration encouraged peer review
organizations to investigate the relationship between inpatient quality and readmissions within
31 days of discharge. Holloway et al. published a research article the following year, illustrating
that the same-condition with risk-adjusted readmission could be a quality indicator for inpatient
care. (28) Benbassat et al. suggested that global readmission rate may not be a good quality
indicator because of its low specificity and low sensitivity, which was consistent with the study
result that Holloway did. (29) A more accurate readmission rate was needed, one that would be
condition-specific as well as carefully risk stratified. (30)
After the landmark report “To Err is Human: Building a Safer Health System” was
released by the Institute of Medicine, federal government and some non-government
organizations made significant investments in patient safety and quality improvement. The
Center for Medicare & Medicaid Services (CMS) mandated hospitals to report readmissions for
chronic heart failure, acute myocardial infarction, and pneumonia from June 2009. (31) The
United States government also initiated readmission reduction programs and gave financial
incentives to encourage hospitals to pay attention to this quality measure among the adult
population. (32)
When it comes to whether readmission rate of childhood asthma should be included in
the reduction program, there is still debate around the justification of readmission as a quality
measure for assessing hospital performance. Some researches indicated that not all readmissions
were avoidable and the median proportion of avoidable readmissions was 27.1%. (30, 33) Most
researchers believed that 3-month or 1-year readmission rates were associated with the quality of
care outside of hospitals. A study conducted by Kenyon et al. also put forward this concern. This
study illustrated that the 30-day readmission rate in most of children’s hospitals was less than 2%
and that it would reach to 10.9% at day 365. (21) This increasing trend indicated the difficulties in
5
long-term asthma control, although most hospitals performed adequately on reduction in 30-day
readmission rate.
Most studies assessed the quality of care at hospitals according to the 30-day readmission
rate. (34, 35) However, Joynt and Jha demonstrated that the 30-day readmission rate had limited
utilization in improving quality of care because readmissions were affected by hospitals’ patient
composition and the resources of the community in which it was located. (36) In addition, Dr.
Bardach and his colleagues found that condition-specific, risk-adjusted pediatric 30-day
readmission rate can hardly differentiate high-performance hospitals and low-performance
hospitals because of low patient volumes. (37) In order to get accurate assessment of healthcare
quality, some researchers suggested that the time window of readmission should be limited to a
shorter period of time, such as 3-day readmission or 7-day readmission. (36)
Although healthcare professionals would argue that it is not the right time to consider
readmission rate for childhood asthma as an indicator for reimbursement policy, its effectiveness
in assessing quality of care should be noted. Stephen Jencks, a former senior clinical adviser
once said that readmissions were not only due to mistakes made in the hospital, but also because
of inefficiency in transitions. (38) Kripalani and Moore et al. also illustrated the poor quality of
care on follow up due to the lack of communication between hospital based physicians and
outpatient doctors. (12, 15)The advice from these experts pointed out that the quality of
management for chronic disease could not be improved by simply providing financial incentives
to hospitals. In order to improve the quality of care, all healthcare professionals in the medical
delivery system should share accountability.
4.0
RISK FACTORS
Now that readmission rate is considered as an indicator assess the quality of healthcare
there is of great value to have a fully comprehension of risk factor for readmissions among
asthmatic patients. To elucidate the risk factors, the social ecological model will be used to
6
summarize all the predictors. Therefore, the risk factors will be illustrated at the individual,
interpersonal, community and institutional level.
4.1
INDIVIDUAL LEVEL
Children were at high risk of being admitted to all health care settings compared to
adults. (17) A cross sectional study indicated that adolescents and toddlers were less likely to
report using anti-inflammatory medication. (10) Another study indicated that there was a
significantly higher risk of subsequent hospitalization among patients between 3 to 5 years old.
(39)
Furthermore, adolescent children are characterized by a period of risk-taking behavior and are
less likely to comply with their treatment protocol. A study found that only 14% of children aged
13 to 14 years old used inhalers, and a significant number of these inhaler users smoked. (40)
In 1994, Mitchell et al. found the severity of asthma to be associated with increased risk
of readmission. (41) A study conducted by Minkovitz et al. also got a result consistent with
Mitchell et al., finding that children with severe asthma were more likely to be readmitted to
hospitals. In addition, this study also indicated that disease severity had a larger impact on
readmission rather than proper treatment or follow-up care. (42)
Racial disparities were found among asthma patients. Studies indicated that AfricanAmerican children with Medicaid or no insurance coverage were at higher risk of readmission.
(24, 43)
Consistent with this study, Beck et al. also found that African Americans were more likely
to be admitted compared to white children and were readmitted at a significantly shorter time. (44)
The reason behind racial disparity is complex and a lot of factors are intervolved with each other.
Socioeconomic disadvantage could not stand alone to predict high risk of readmission. Beck et
al. failed to find a significant association between socioeconomic determinants and readmission
difference, but indicated that 49% of racial disparities could be explained by socioeconomic
hardship variables. (44)
These studies may raise awareness with regards to children who live in economically
disadvantaged families. Some studies went a little further in exploring the reason behind this.
7
Yonas et al did a literature review on psychosocial stress and childhood asthma, finding that
psychological factors such as stress were significantly associated with poorer asthma control. (45)
Based on these study results, a way to explain why ethnicity and socioeconomic status are related
to readmission for asthma patients was discovered. Patients who live in economic disadvantaged
communities are more likely to experience violence and suffer from psychological stress, which
will result in improper management of asthma.
4.2
INTERPERSONAL LEVEL
Parents have the responsibility of caring for children with asthma. However, whether they
have the ability to properly take care of asthma patients remains unclear. A study conducted by
some researchers at Boston Children’s hospital investigated the relationship between parent’s
perception and children’s readmission. They found that parents’ pessimistic opinion toward their
child’s health at discharge was associated with readmission within 30 days. (22) Caregivers who
did not graduate high school proved to be associated with their child’s readmission. (46) Of note,
these studies demonstrated that caregivers who were unconfident with their ability and at low
level of education had less knowledge about asthma (10, 28) If caregivers cannot get in contact
with their child’s Primary Care Physician (PCP), their child is more likely to be readmitted to
hospitals. Another study proved this statement and found that patients with low access to medical
homes had significantly increased risk of readmission when compared to those with good access.
(47)
This result is consistent with the study at Boston Children’s hospital.
Parents with smoking habits will impose a negative impact on the management of
childhood asthma. A study found that there was a significant association between smoking and
readmission of asthma. (48) Exposure to parental smoking was found to be associated with asthma
exacerbation, which would result in readmissions. (49)
Family structure has gained attention as a critical determinant of child health. Nowadays,
there are more families in which both parents work. For parents with a child suffering from
asthma, they are faced with the challenge of balancing their time between work and taking care
8
of their child. A prospective study conducted at Cincinnati Children’s Hospital Medical Center
indicated that children with asthma spending nights away from home were the risk factors for
readmission. (50) This specific behavior may indicate many social problems such as family
structure, as well as psychological factors.
4.3
COMMUNITY LEVEL
Children exposed to nitrogen oxides or other pollutant chemicals had higher risk to
develop asthma. (51) Another study further explored the relationship between traffic-related air
pollution and readmission for asthma. It came out that the traffic-related air pollution was
significantly associated with readmission in white children. (52) The reason why they failed to
find the relationship among minorities was partly due to the unmatched covariates in smoke
exposure, psychological stress and other potential factors.
As aforementioned, asthmatic children raised in poor families were more likely to have
repeated readmission. A study found that children living in neighborhoods with a high proportion
of ethnic minority residents, high proportion of low income, as well as high proportion of
crowded housing conditions had the highest hospital readmission rates. (43)
4.4
INSTITUTIONAL LEVEL
Shorter hospitalization may represent incomplete treatment and premature discharge.
Patients may come back to hospitals after discharge because of improper treatment during initial
hospitalization. Researchers suspected that shorter length of stay was associated with
readmission. However, a longitudinal, retrospective cohort study indicated that shorter length of
stay was not significantly related to asthma readmission. (35) This study was limited by its
methodology of measuring readmission. Readmissions were identified when patients returned to
the same hospital. This study failed to capture the possible readmissions when patients went to
9
other healthcare facilities. Therefore, the relationship between shorter hospitalization for asthma
patients and readmission needs to be further studied.
Communication barriers between physicians and caregivers may result in improper
treatment. Gallagher et al. conducted a study to investigate the relationship between the language
barrier and readmission in the ED. They found out that children whose parents had a limited
understanding of English were more likely to be readmitted to the ED within 72 hours (OR=1.3,
CI=1.12-1.50). (53) With the Odd Ratio being only a little larger than 1, the extent to which the
language barrier contributed to readmission to the ED could not be confirmed. Furthermore, the
patients who were admitted to the ED were more likely to be readmitted than patients who were
scheduled for outpatient services. Therefore, the readmission rate may be the same no matter
whether the language barrier exists or not. The communication deficit between patients and
hospital-based doctors could result in unnecessary readmission, even though there is no language
barrier. Topal and his colleagues demonstrated that patients having taken a short-acting inhaled
beta-agonist within 6 hours before admission was an independent risk factor for 7-days
readmission among children. (54) If patients did not tell their doctors about their prior treatment, it
was likely that doctors might underestimate the severity of the asthma and prescribe improper
medicine. Furthermore, patients without prescription for high-dose inhaled steroids on release, as
well as the omission of physical examination were at high risk for being readmitted. (54)
Events that occur around the discharge period may contribute to preventable
readmissions. Forster et al. considered the assessment and communication of doctors and
patients around the time of discharge as aspects of the system requiring improvement. (13)
Because the condition of patients with chronic disease should be under surveillance even outside
of the hospital, communication between specialists and family physicians plays an important role
in ensuring patient safety. Walraven et al. conducted a study and found that patients having
hospital physician follow-up were significantly and independently less likely to die or get
urgently readmitted to the hospital in the first 30 days following discharge. (55) Topal also found
that lack of written guide plans were associated with patients readmission. (54) However, a
retrospective cohort study found an opposite result. This study found out that documenting PCP
follow-up plans was associated with higher 30-day readmission odds. (34) The explanation was
that physicians may be more likely to document PCP follow-up plans to patients with higher
10
possibility of readmission and that 30-day readmission may be a measure of access to care rather
than poor quality.
Because children over 6 years old spend most of their time at school, the regulation of
medication in schools, should be considered. A study showed that some public schools prohibit
students from carrying medication during classes. Yeatts et al. conducted a cross-sectional
survey in North Carolina in 1996, finding that 26% of inhaler users reported to not having
permission to carry their inhaler at school. (40)
5.0
CONCLUSION
Regarding to the justification of whether readmission rate can be considered as a quality
indicator, studies agreed upon the different utilization of readmission for various time frames.
Unlike other quality measures, readmission rate reflects not only the quality of care at hospital
but also the quality of care after discharge. 60-day or 1-year readmission rate are likely to reflect
the quality of care outside hospitals. Whereas, 30-day or even shorter time readmission rate is
related to the quality of care at hospitals. 30-day readmission rates are required to be publicly
reported to assess the quality of care at hospitals for chronic heart failure, acute myocardial
infarction, and pneumonia among adult patients. For childhood asthma, there is still debate
around the justification of 30-day readmission rate as an indicator of assessing quality of care at
hospitals. A more accurate time frame for readmission rate needs to be studied further.
As aforementioned, childhood asthma has become a heavy burden in the U.S. and China,
which is calling for strategies and interventions to deal with the problem. To be able to design
effective intervention programs on dealing with readmissions among patients with childhood
asthma, a fully comprehension is needed. However, the risk factors related to readmission among
children with asthma were complicated at an individual, interpersonal, community and
institutional level. In China, the increasing prevalence of childhood asthma has drawn the
attention of health care professionals. However, there is limited study to explore the reasons of
11
poor asthma management. Therefore, more studies should be involved to further explore the
deep reasons behind the intertwined risk factors.
Studies showed that the increasing readmission was associated with an uncoordinated
healthcare delivery system. The U.S. implemented related policies to create economic incentives
of encouraging more coordinated care, such as the bundled payment. (56) China emphasized the
role of family management for childhood asthma. The ideal situation would be to create a
multidisciplinary intervention that every healthcare organization could have shared
accountability, apart from patient’s self-management.
Table 1. Summary of recent studies
Reference
Study Design
Study population
Main Findings
Shaw MR et al.
Retrospective
cohort study
Pediatric patients
admitted from 2004 to
2008 in Washington
State
Children between 3 to 5 years old in
the asthma cohort demonstrated a
highest risk of subsequent
hospitalization (Hazard Ratio, 1.5;
95% CI, 1.23-1.83; P< .001)
Crosssectional
survey
School-based sample of
13 to 14 years old
students in CharlotteMecklenburg, North
Carolina public school
system
14% of students reported suing an
inhaler in the last 12 months. 26% of
inhaler users smoked, higher than
the smoking prevalence in the
sample population
Retrospective
cohort study
1034 individual children
aged 0-14 years
admitted for asthma
Previous admissions and severity
assessment were significantly related
to the increased risk of readmission.
(39)
Yeatts K et al.
(40)
Mitchell EA et
al. (41)
12
Table 1 Continued
Minkovitz CS
et al. (42)
Nested casecontrol study
119 patients aged 0 to 14 Children with multiple readmissions
years between 1993 to
were more likely to receive a
1995
pulmonary consultation during index
admission (23% multiple vs 4%
single, P=.001). The receipt of
asthmatic treatment was not found
difference between multiple
admission group and single
admission group.
Reference
Study Design
Study population
Main Findings
Liu SY et al.
Retrospective
cohort study
Children under 19 years
old at the time of index
asthma admission
between 2001 to 2005
Children insured by Medicaid at the
time of their index admission had
readmission rates than were 33%
higher than children who were
privately insured
Populationbased
prospective
cohort study
Enrolled 774 children,
aged 1 to 16 years
admitted for asthma.
African Americans were twice as
likely to be readmitted as whites
after adjustment for asthma severity
(Hazard Ratio, 1.98; 95% CI, 1.422.77). Socioeconomic status and
hardship explained 49% of the
difference.
Yonas MA et
al. (45)
Literature
Review
Literature Review
Psychological factors such as stress
were significantly associated with
poorer asthma control.
Berry JG et al.
(22)
Prospective
study
Patients from a freestanding children’s
hospital
Children had a lower readmission
rate (4.4 vs. 11.3%, P=0.004) and
lower adjusted readmission
likelihood (OR, 0.2) when their
parents strongly agreed with the
positive perception about their
children’s health from the index
admission.
Auger KA et
al. (46)
Prospective
cohort study
601 children aged 1 to
16 years old who had
been hospitalized for
asthma. Their caregivers
completed survey
Caregiver’s reported missing doses
was significantly associated with
readmission.
(43)
Beck AF et al.
(44)
13
Table 1 Continued
regarding to asthma
knowledge.
Auger KA et
al. (47)
Prospective
cohort study
601 children aged 1 to
Children with private insurance and
16 years hospitalized for good access had the lowest rates of
asthma.
readmission within a year compared
with other combinations of insurance
and access
Reference
Study Design
Study population
Main Findings
Howrylak JA et
al. (48)
Prospective
cohort study
774 children aged 1 to
16 years admitted for
asthma.
Detectable serum or salivary
cotinine was associated with
increased odds for readmission (OR,
2.35; 95% CI, 1.22-4.55).
Henderson AJ
Literature
review
Literature review
Exposure to parental smoking was
found to be associated with asthma
exacerbation.
Moncrief T et
al. (50)
Populationbase
prospective
cohort study
774 children aged 1 to
16 years old who
admitted for asthma
Spending nights away from home
was associated with readmission
(adjusted relative risk, 1.5; 95% CI,
1.2-6.4)
Patel MM et al.
Literature
review
Literature review
Children exposed to nitrogen oxides
or other pollutant chemicals had
higher risk to develop asthma
Newman NC et
al. (52)
Populationbase
prospective
cohort study
Children aged 1-16
years admitted for
asthma between 2010
and 2011
Higher TRAP exposure was
associated with higher readmission
rates (21% vs 16%, p=0.05). African
American children had a higher
readmission rate overall
Gallagher RA
et al. (53)
Retrospective
cohort study
Collected data from 2
administrative sources at
a pediatric, tertiary care
ED
Patients with limited English
proficiency were more likely to
return to the ED for admission (OR,
1.3; 95%CI, 1.12-1.50, P<.001)
Topal E et al.
Multicenter,
prospective
study
Patients between ages of Patients having taken a short-acting
6 months and 17 years inhaled beta2-agonist within 6 hours
who were admitted for
before admission was independently
(49)
(51)
(54)
14
Table 1 Continued
asthma attack at 3
teaching hospitals
associated with asthma relapse (OR,
2.43; 95% CI, 1.123-2.774; P=.01)
Not being given a written instruction
plan was associated with asthma
relapse (OR, 1.55; 95% CI, 1.0802.226; P=.02)
Van Walraven
C et al. (55)
Retrospective
cohort study
938,833 adults
discharged between
1995 to 2000
15
The adjusted risk of 30-day death or
non-elective readmission reduced to
7.3%, 7.0%, and 6.7% if patients had
1, 2, or 3 visits to hospital physician.
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