Jessica L Bettenhausen1, Clemens Noelke2, Robert W Ressler2, Matthew Hall3, Mitch Harris4, Alon Peltz5, Katherine A Auger6, Ronald J Teufel7, Jeffrey E Lutmer8, Molly K Krager9, Harold K Simon10, Mark I Neuman11, Padmaja Pavuluri12, Rustin B Morse13, Pirooz Eghtesady14, Michelle L Macy15, Samir S Shah6, David C Synhorst9, James C Gay16. 1. Department of Pediatrics, Children's Mercy Kansas City and the University of Missouri, Kansas City (JL Bettenhausen, MK Krager, and DC Synhorst), Kansas City, Mo. Electronic address: jlbettenhausen@cmh.edu. 2. Heller School for Social Policy and Management, Brandeis University (C Noelke and RW Ressler), Waltham, Mass. 3. Children's Hospital Association (M Hall), Lenexa, Kans. 4. Children's Hospital Association (M Harris), Washington, DC. 5. Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute (A Peltz), Boston, Mass. 6. Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center (KA Auger and SS Shah), Cincinnati, Ohio. 7. Department of Pediatrics, Medical University of South Carolina (RJ Teufel II), Charleston, SC. 8. Division of Critical Care Medicine, Nationwide Children's Hospital (JE Lutmer), Columbus, Ohio. 9. Department of Pediatrics, Children's Mercy Kansas City and the University of Missouri, Kansas City (JL Bettenhausen, MK Krager, and DC Synhorst), Kansas City, Mo. 10. Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta (HK Simon), Atlanta, Ga. 11. Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School (MI Neuman), Boston, Mass. 12. Division of Hospital Medicine, Children's National Hospital (P Pavuluri), Washington, DC. 13. Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine (RB Morse), Columbus, Ohio. 14. Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St Louis and St Louis Children's Hospital (P Eghtesady), St Louis, Mo. 15. Ann & Robert H. Lurie Children's Hospital of Chicago and the Feinberg School of Medicine, Northwestern University (ML Macy), Chicago, Ill. 16. Department of Pediatrics, Vanderbilt University Medical Center (JC Gay), Nashville, Tenn.
Abstract
OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.
OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.
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