Preventing Dehydration-Related Hospitalizations: A …hosppeds.aappublications.org/content/hosppeds/3/3/204.full.pdfeffective outpatient care.3 A study of all pediatric hospitalizations

RESEARCH ARTICLE

204 | VOLUME 3 • ISSUE 3 www.hospitalpediatrics.org

AUTHORSLeticia Shanley, MD, Vineeta Mittal, MD, andGlenn Flores, MD

Department of Pediatrics, University of Texas Southwestern, Dallas, Texas

KEY WORDSpediatric, ambulatory care, dehydration, gastro-enteritis, hospitalization, secondary prevention, hospitalized child

ABBREVIATIONSACSC: ambulatory-care–sensitive conditionIAP: inpatient attending physicianORS: oral rehydration solutionPCP: primary care provider

www.hospitalpediatrics.orgdoi:10.1542/hpeds.2012-0094

Address correspondence to Leticia Shanley, MD, Division of General Pediatrics Department of Pediatrics, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390. E-mail: [email protected]

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: Supported in part by a grant to GF by the Robert Wood Johnson Foundation Harold Amos Faculty Development Program.

abstract OBJECTIVE: The goal of this study was to identify the proportion of dehydration-related ambulatory care–sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability.

METHODS: A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care–sensitive conditions admitted to an urban hospital over 14 months.

RESULTS: Eighty-fi ve children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identifi ed inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identifi ed parents providing insuffi cient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P < .01). Parental dissatisfaction with their child’s PCP and a history of avoiding primary care due to costs or insurance problems were associated with signifi cantly higher odds of preventable hospitalization.

CONCLUSIONS: Up to 45% of dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insuffi cient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.

Preventing Dehydration-Related Hospitalizations: A Mixed-Methods Study of Parents, Inpatient Attendings, and Primary Care Physicians

Dehydration-related hospitalizations are common and costly, at 73 936 hospital discharges and $562 million in costs per year.1,2 Dehydration-related hospital-izations are classifi ed as preventable, and are considered an ambulatory care–sensitive condition (ACSC) because they potentially can be avoided with timely, effective outpatient care.3

A study of all pediatric hospitalizations due to ACSCs revealed that dehydration/gastroenteritis was the second most common ACSC, after asthma.4 Despite the conclusion that ACSC hospitalizations can be prevented with timely, effi cient outpatient care, the study identifi ed, according to specifi c diagnoses, substantial

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variability in the reasons hospitaliza-tions were preventable. For example, admissions for seizures and urinary tract infections were assessed as less avoidable than those due to asthma, dehydration, and skin conditions. In addition, medication-related reasons were the most common reason for preventable asthma hospitalizations, but were less important for several other ACSCs.5 Given this variability among ACSC diagnoses, the substan-tial proportion of ACSC admissions for dehydration, and the limited research on specifi cally how dehydration-related hospitalizations can be prevented, the goals of the current study were to identify: (1) the proportion of ACSC hospitalizations due to dehydration assessed as avoidable by the parents, primary care providers (PCPs), and inpatient physicians (IAPs) of hospi-talized children; (2) the reasons why these hospitalizations may have been preventable; and (3) the factors asso-ciated with preventability.

METHODSA detailed description of the study methods is available elsewhere.4 A summary of relevant methods and a description of analyses are presented in the following sections.

Defi nitions

Consistent with previous works,4,5 the term “preventable” is used to describe any hospital admission that was con-sidered to be preventable according to at least 1 of the sources interviewed (parents, PCPs, or IAPs).

Participants

Participants were included in the study by using the following criteria: (1) children (≤18 years old) with an ACSC primary diag-nosis of dehydration, vomiting, or diarrhea; and (2) admission to the inpatient service

during a 20-month period (May 1997–December 1998). Children were excluded from the study for the following reasons: (1) direct admission to the PICU; (2) the parents were unavailable for interview during the hospital stay, such as in cases under investigation for suspected neglect or abuse; and (3) hospitalization was for conditions in which the primary diagnosis listed was not dehydration, vomiting, or diarrhea. A daily review of the inpatient-service census was conducted to identify children admitted for dehydration, with cross-referencing and confi rmation through in -spection of medical records.

Data Collection and Questionnaire

Baseline sociodemographic data were abstracted from each child’s medi-cal record. The child’s age, admission diagnosis, name of the regular pedia-trician (if the child had one), name of the IAP, type of insurance, child’s race/ethnicity (as per the parent/legal guardian), educational attainment of the parent/legal guardian (referred to as the parent), and combined monthly family income were recorded.

The parent of each admitted child com-pleted a questionnaire, in English or Spanish, that was orally administered by a trained, bilingual Latina research assistant. For parents whose primary language was other than English or Spanish and who had limited English profi ciency, the research assistant ad ministered the questionnaire with the assistance of a medical inter-preter from the hospital’s interpreter services. A 4-month pilot study was conducted to refi ne the fi nal question-naire. Parents were also asked why their child was admitted and whether they believed anything could have prevented the hospital admission. If parents assessed the hospitalization as preventable, they were then asked to specify the reason(s). Parents who reported that the child had visited a

physician or the parents had spoken to a physician before the hospitalization were asked to assess their general satisfaction with the physician’s care. When the parents reported that their child had no regular health care pro-vider, they were asked where the child was taken for checkups, vaccinations, and acute care. All parents were asked to assess whether their child had easy access to health care, whether health care costs or problems with health insurance ever kept them from obtain-ing needed medical care, and whether they ever experienced diffi culties in obtaining medications for their child due to excessive costs or because the medications were not covered by their health insurance.

Attempts were made to conduct a brief in-person or telephone interview with the PCP (for children with a reg-ular physician) and IAP of each hos-pitalized child. Physicians were asked to assess if the child’s hospitaliza-tion was preventable and to provide detailed reasons for their assessment. When the physician could not ini-tially be contacted for an interview, a minimum of 10 subsequent efforts to conduct an interview were made over at least 1 month. When the PCP also was the IAP, an assessment of pre-ventability was recorded only for the PCP.

Two researchers independently coded how each source assessed the pre-ventability of a given hospitalization. All reasons for the physician assess-ment were then independently cat-egorized. The independent coding and categorizations of the 2 researchers were compared, and any disagreements were discussed and settled by con-sensus. There were no cases in which consensus could not be reached.





Analyses

Bivariate analyses were performed by using the χ2 test or Fisher’s exact test (for comparisons with low expected cell counts) for categorical variables, and Wilcoxon’s 2-sample test for con-tinuous variables; a 2-tailed P < .05 was considered statistically signifi -cant. Sociodemographic and health-services use characteristics and the preventability of hospitalizations of patients with dehydration, consistent with previous research,4 were com-pared with the characteristics and hospitalizations of 469 children admit-ted with other ACSCs at the same hospital during the same time inter-val; the goal was to examine whether characteristics of dehydration-related hospitalizations differ from those of other ACSC hospitalizations. “Don’t know” responses to the question regarding the preventability of a hos-pitalization were coded as missing. To assess interobserver agreement on the preventability of the dehydra-tion-related hospitalizations, κ coef-fi cients were calculated by using SAS software (SAS Institute, Inc, Cary, NC), and interpreted using the scale of Landis and Koch.6 Multivariable analyses were performed using step-wise logistic regression, with an initial α-to-enter of .15, and a fi nal P < .05. The dependent variable was the pre-ventability of the dehydration-related hospitalization (dichotomized as yes/no), according to at least 1 source. The independent variables chosen for analysis were those used in the previ-ous research on preventable pediatric hospitalizations.4 In cases in which an independent variable was defi ned in multiple ways, separate models were run for each defi nition. All variables found to be signifi cant in the step-wise regression were included in a

fi nal model that further adjusted for children’s insurance coverage, poverty status, and parental educational attain-ment. All statistical analyses were per formed using SAS version 8.2 software.7

Informed Consent and Institutional Review Board Approval

Written informed consent was ob tained from the parent of every participat-ing child. The Boston Medical Center institutional review board approved the study.

RESULTSDehydration was the second most fre-quent ACSC diagnosis, accounting for 15% of all hospitalizations. A total of 85 dehydration-related hospitalizations, from among 554 ACSC hospitaliza-tions, fulfi lled initial study enrollment criteria. No parents refused to partici-pate in the study. Children admitted for dehydration were signifi cantly younger than those admitted for other ACSCs, with a mean age of 1.6 versus 4.8 years (Table 1). The 2 groups did not signifi -cantly differ in health insurance cov-erage, with three-quarters of children insured by public coverage. More than 85% of children were either African American or Latino. No signifi cant intergroup differences existed in race/ethnicity, parental educational attain-ment, family income, the child having a regular pediatrician, or the parent contacting the PCP (by telephone or offi ce visit) before admission. In both groups, most children had a regular physician, and most parents reported being satisfi ed with their child’s care and having easy access to care. A minority reported ever having diffi -culty obtaining medical care for their child because of cost or insurance problems, or diffi culty obtaining a child’s medication.

Preventability of Dehydration-Related Hospitalizations

One-quarter of parents assessed their child’s dehydration-related hospital-ization as preventable, compared with 33% of PCPs and 19% of IAPs (Table 2). The proportion of hospitalizations ass es sed as preventable by parents or PCPs did not signifi cantly differ from the proportion assessed as preventable for other ACSCs. IAPs were signifi cantly less likely to assess dehydration-related hospitalizations as preventable, compared with other ACSCs, at 19% versus 34% (P < .01). The proportion of dehydration-related hospitalizations assessed as preventable varied depen-ding on the source, ranging from as low as 12% for agreement among all 3 sources (parents and the 2 physician groups) to as high as 45% for any of these 3 sources. Illustrative cases of agreement and disagreement are pro-vided in Fig 1.

Reasons for Preventability of Dehydration-Related Hospitalizations

Parent/Patient-Related

The most common reasons cited for preventability of dehydration-related hospitalizations differed according to the assessing source (Table 3). Nearly three-quarters (71%) of PCPs cited a parent/patient-related reason, a sig-nifi cantly greater proportion than the 28% of parents and 38% of IAPs cit-ing a parent/patient-related reason. In contrast, 57% of parents and 46% of IAPs reported a physician-related reason, compared with 23% of PCPs, although these differences were not statistically signifi cant.

Inadequate prevention (more fl uids at home), parents not adequately educat-ing themselves, and delay in or not bring-ing the child in for follow-up care were




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TABLE 1 Selected Features of Children Admitted for Dehydration, Compared With Children Admitted for Other ACSCs

Feature Dehydration (n = 85) Other ACSCs (n = 469) Pa

Mean age, y (range) 1.6 (0–18) 4.8 (0–18) <.001Health insurance coverage, % .86 None 17 16 Public 74 73 Private 9 11Race/ethnicity, % .64 African-American 57 63 Latino 29 23 White 9 10 Asian/Pacifi c islander 5 4Parent not a high school graduate, % 37 43 .33Median annual family income, $ 12 000 12 072 .27Child has regular physician, % 94 94 .88Parent contacted PCP (by telephone

or offi ce visit) before admission, %56 54 .70

Parent satisfi ed/very satisfi ed with regular physician’s care, %

9 89 .47

Child has easy access to medical care, % 87 90 .40Child not brought in for medical care

because of cost or insurance problems, %8 8 .94

Ever had diffi culty obtaining child’s medication, %

13 15 .60

a Wilcoxon 2-sample test used for continuous factors and χ2 test for categorical factors.

TABLE 2 Proportions of Dehydration-Related Hospitalizations Assessed as Preventable by Source

Source % of Hospitalizations Assessed as Preventable P

Dehydration (n = 85) Other ACSCs (n = 469)

Parentsa 25 24 .85

PCPsb 33 29 .54

IAPsc 19 34 .01Any of 3 sources 45 47 .76Any physician source 30 38 .12All 3 sources 12 13 .96

Data are given as %. a A total of 83 parents responded for children with dehydration; 427 parents responded for children with other ACSCs.b A total of 52 PCPs responded for children with dehydration; 326 PCPs responded for children with other ACSCs.c A total of 69 IAPs responded for children with dehydration; 450 IAPs responded for children with other ACSCs.

the most common parent-related fac-tors leading to preventable dehydration-related hospitalizations, as assessed by parents (Table 4). The 2 physician groups identified inadequate pre-vention and delay in or not seeking follow-up care as the most frequent parent-related factors, but did not iden-tify lack of parental self-education as a reason.

Some parent/patient-related reasons were identifi ed by only 1 source. For example, about one-third of parents cited failure to adequately educate themselves as a reason for avoid-able hospitalization (Table 4). PCPs uniquely identifi ed parents not going to the clinic before the hospitalization (25%), needing to call the PCP earlier (16%), and medication-related concerns

(8%) as reasons for avoidable hospi-talizations. IAPs uniquely reported a child lacking a PCP (20%) as a rea-son for a preventable hospitalization. There were no statistically signifi cant intergroup differences ac cording to assessing source for these reasons.

Physician-Related

Both physician groups were sig-nifi cantly more likely than parents to report that the admission was inap-propriate (Table 5). More than one-third of parents cited poor quality of care as a physician-related factor, compared with none for both physician groups. IAPs uniquely identifi ed that overly short observation times in the emergency department and the need for observation units as reasons for pre-ventable hospitalization. All 3 sources reported that inadequate education of the parent (by the physician) was a reason for preventable hospitalization. Other reasons identifi ed by parents were their child was discharged too early, or inadequate or no interven tion was administered during hospitalization.

Other Reasons

The remaining reasons occurred infre-quently and included no reason given, and “don’t know” responses from par-ents or physicians.

Multivariable Analyses

Two factors were signifi cantly asso-ciated with dehydration-related hos-pitalizations, as assessed by the IAP (Table 6). A history of the parents not bringing their child to the physician because of costs or insurance prob-lems was associated with 12 times the adjusted odds of a preventable hospi-talization, and parental dissatisfaction with their child’s medical care with 7 times the adjusted odds of a prevent-able hospitalization.





FIGURE 1 Illustrative cases of agreement (A–D) and disagreement (E–G) among parents, PCPs, and IAPs about the preventability of dehydration-related hospitalizations for children. ER, emergency room.

DISCUSSIONThe study fi ndings indicate that 12% to 45% of dehydration-related hospi-talizations are preventable, depending on the assessing source. These fi nd-ings, when extrapolated to national data, suggest that as many as 8000 to 33 000 fewer hospital discharges annually and $67 to $253 million sav-ings in hospital costs could result from prevention of these hospitalizations.2

The results underscore the variability in assessing “avoidability” of dehydration-related hospitalizations by providers. Similar variability in assessments by parents and providers of preventable hospitalizations for asthma, pneumonia, urinary tract infections, and other ACSCs has been shown.4 When dehydration-related hospitalizations are analyzed in administrative databases, caution should be exercised, as more than one-half (55%–88%) of these admissions may be unavoidable.

Inadequate Prevention and Parental Education

One-half of parents and one-third of physicians reported that inadequate prevention (eg, not providing enough fl uids at home) was the reason for pre-ventable hospitalizations. In addition, one-fourth to one-third of parents and physicians cited inadequate paren-tal education by physicians as a rea-son why these hospitalizations could have been prevented. Oral rehydration solution (ORS) has proven effi cacy and safety as a fi rst-line therapy for the management of mild to moderate pediatric dehydration.8,9 Nevertheless, ORS is underused: studies docu-ment <10% of patients hospitalized for dehydration received ORS before admission.10–12 High-quality ORS edu-cation interventions have been shown




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to reduce dehydration-related hospi-talizations by 40%.13 These interven-tions consist of educating parents on the signs and symptoms of dehydra-tion, ORS home treatment, and when the PCP should be contacted. Our study fi ndings suggest that physician education of parents that focuses on home ORS therapy and indications for outpatient visits may prove use-ful in preventing dehydration-related hospitalizations.

Primary Care Access and Utilization

Although 94% of patients in our study had a PCP, 17% of parents, 25% of PCPs, and 40% of IAPs cited a delay in getting care or not making follow-up visits as the reason why the hospital-ization was preventable. Not receiv-ing timely care, defi ned as a delay in initial care or subsequent follow-up, has been shown to lead to poor health-care outcomes and increased costs.14,15 Barriers to obtaining timely

care and follow-up, other than not having a PCP, should be identifi ed. In addition, our study found that par-ents who previously had not brought their child to the physician because of costs or insurance problems had 12 times the odds of a preventable dehydration-related hospitalization for their child. These fi ndings suggest that improvements in primary care access and utilization might help to prevent dehydration-related hospitalizations.

Early Management of Dehydration

Three-fourths of PCPs and two-thirds of the IAPs cited inappropriate admis-sions as physician-related reasons for preventable dehydration-related hospitalizations. Substantial vari-ability exists in the preadmission management and the disposition of children with dehydration, including rehydration trials, laboratory evalu-ations, and utilization of observation units.9,11,16–19 Previous studies suggest

that most chil dren with acute dehydra-tion are suboptimally managed before admission.19 With effective guideline implementation, admissions for dehy-dration-related gastroenteritis can be reduced by one-third.20 Studies have also shown that the vast majority of dehydration-related hospitalizations can be managed effi ciently in obser-vation units,21 allowing for shorter lengths of stay and decreased inpa-tient bed utilization.16–18 Thus, devel-opment and use of evidence-based preadmission management guide-lines that include objective criteria for admission, ORS administration, and use of observation units may help reduce inappropriate dehydration-related hospitalizations.

Quality of Care

More than one-third of parents reported that poor quality of care was the reason for preventable dehydration-related hos pitalizations, whereas physicians did not report poor quality of care as a reason. Studies have shown that large variations exist in the care of children with dehydration-related gastroente ritis in the outpatient, emergency depart-ment, and hospitalized settings.22–25 The lack of validated mea sures for health-care quality in children with dehydra-tion makes assessment of quality of care diffi cult. Quality do mains, how-ever, have been identifi ed, and effi cient and patient-centered care is an impor-tant component of high-quality care. Parental participation in care, and decision-making and family-friendly environments that attempt to normalize family functioning, can contribute to improved care delivery.26 In addition, the use of clinical practice guidelines in the outpatient setting for children with gastroenteritis has been shown to decrease duration of illness and

TABLE 3 Proportion of Sources Assessing Preventability of Dehydration-Related Hospitalizations by Specifi c Reason

Reason % Sources Assessing Preventable P

Parent (n = 21/83) PCP (n = 17/52) IAP (n = 13/69)

Parent/patient-related 28 71 38 <.01Physician-related 57 23 46 .06No reason/don’t know 10 0 16 .28Others 5 6 0 .69

TABLE 4 Proportion of Parent-Related Reasons for Preventability of Dehydration-Related Hospitalizations by Source

Reason % Reasons Considered Preventable by Sourcea P

Parent (n = 6) PCP (n = 12) IAP (n = 5)

Inadequate prevention (more fl uids at home)

50 33 40 .85

Delayed or did not bring child in for follow-up care

17 25 40 .65

Parents did not adequately educate themselves 34 0 0 .09

Parents should have gone to clinic fi rst 0 25 0 .38Needed to call earlier 0 16 0 .40Medication related 0 8 0 .64Parents need to fi nd PCP for childb 0 0 20 .20

a Column totals exceed 100% because each source could choose >1 reason. b A total of total of 5 children did not have a regular PCP.





marginally improve weight gain.25 Efforts to improve quality of care through parental participation and use of clini-cal guidelines, therefore, might prevent dehydration-related hospitalizations.

Parental and Patient Satisfaction

Children with parents who were dissat-isfi ed with their child’s regular physician had greater odds of a dehydration-related hospitalization. Studies have assessed parental preferences and satisfaction with PCP care27–29; how-ever, before this study, a relation-ship between parental dissatisfaction with the PCP and an increased risk of hospitalization had not been noted. Efforts to understand the specifi c rea-sons for parental dissatisfaction with their child’s PCP might prove use-ful in reducing dehydration-related hospitalizations.

Study Limitations

Certain study limitations should be noted. This study was conducted in a single urban academic center with a

predominantly African-American and Latino population, who were primarily publicly insured and from low-income families. The fi ndings, therefore, may not necessarily generalize to rural, sub-urban, or nonacademic hospitals. Sam-ple sizes were not suffi ciently large to perform multivariable analyses for subcategories of dehydration-related hospitalizations. In addition, the survey data are more than a decade old; how-ever, the survey remains unique in its direct assessment of physicians and parents of children with potentially avoidable hospitalizations, and there have been no signifi cant management changes that would make the results and conclusions invalid. Comparisons with national data are not possible because analogous national data on the actual avoidability of pediatric ACSC hospitalizations do not exist.

CONCLUSIONSUp to 45% of dehydration-related hospitalizations may be avoidable. Inadequate parental education by

physicians, inadequate home rehydra-tion, delays in getting care, not com-ing in for follow-up visits, inadequate access to care due to insurance or cost issues, inappropriate admissions, poor quality of care, and parental dis-satisfaction with their child’s PCP were the reasons that these hospital-izations might have been prevented. Outpatient educational interventions, improved access to care, and the implementation of and adherence to early dehydration management guide-lines might help reduce dehydration-related hospitalizations.

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TABLE 5 Proportion of Physician-Related Reasons for Preventability of Dehydration-Related Hospitalizations by Source

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DOI: 10.1542/hpeds.2012-00942013;3;204Hospital Pediatrics

Leticia Shanley, Vineeta Mittal and Glenn FloresParents, Inpatient Attendings, and Primary Care Physicians

Preventing Dehydration-Related Hospitalizations: A Mixed-Methods Study of

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DOI: 10.1542/hpeds.2012-00942013;3;204Hospital Pediatrics

Leticia Shanley, Vineeta Mittal and Glenn FloresParents, Inpatient Attendings, and Primary Care Physicians

Preventing Dehydration-Related Hospitalizations: A Mixed-Methods Study of

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Pediatrics. All rights reserved. Print ISSN: 2154-1663. Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 2012. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly


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Preventing Dehydration-Related Hospitalizations: A …hosppeds.aappublications.org/content/hosppeds/3/3/204.full.pdfeffective outpatient care.3 A study of all pediatric hospitalizations

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