Gauging the impact of pediatric “frequent flyers”

Jay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative. This post is second of a three-part series.

Emerging evidence suggests that small groups of adult patients who are frequently readmitted to the hospital are responsible for a large proportion of health care costs. Is this also true in pediatrics? What impact do our young “frequent flyers” have on the inpatient health care system?

I’m fortunate to be part of a multi-state collaborative, supported by the Child Health Corporation of America, that is trying understand how to best deliver care to the neediest children. These patients have complex medical needs, who are fragile and predisposed to getting very, very sick. Often, they have multiple, chronic health conditions, neurodevelopmental/intellectual disabilities and impaired functional status, requiring feeding tubes, breathing tubes and other technology to maintain their health.

Many of them, like Jim, seem to be falling through the cracks. They’re using the health care system most often for health crises — enduring repeated hospitalizations — and less often for care that could prevent those crises from occurring.

We know that the majority of their health care expenditures occur when they are hospitalized. How much are frequent, possibly preventable readmissions to the hospital contributing to this cost?

In a study just published in JAMA (summarized here in a news release), we analyzed the records of more than 300,000 children admitted to one of 37 free-standing children’s hospitals across the country in 2003. We followed them through 2008, counting how many times they came back to the hospital. We established five categories, based on the number of readmissions each child experienced within 365 days of a previous discharge: none, one, two, three or four.

During the five-year follow-up period, a small group of patients (2.9 percent) were readmitted to the same hospital four or more times within a one-year period. These patients accounted for nearly 20 percent of all pediatric hospital admissions and one-quarter of inpatient expenditures, amounting to $3.4 billion. The median number of days between readmissions for our “frequent flyers” was 38 days.

The higher the readmission frequency, the more likely patients were to be 13 years and older, to have public insurance (like Medicaid), to be of non-Hispanic black ethnicity, to have neuromuscular diseases and other complex chronic health conditions, and to require technology assistance with feeding tubes and other medical devices.

Why were these patients coming back to the hospital repeatedly? Of those readmitted most frequently, 28.5 percent were readmitted for a problem within the same organ system – most commonly blood and immunologic problems, respiratory problems and nervous system problems. Moreover, 14 percent of admissions among patients readmitted the most frequently were for health conditions that are felt to be controllable with optimized outpatient/primary care – most commonly asthma, pneumonia and seizures.

These findings startled us. They were a wake-up call, urging us to take action and to ask more questions: How can we help these children and their families? How can we prevent those preventable readmissions? That’ll be the topic of my final post.