title: Variation in risk-adjusted hospital readmission after treatment of appendicitis at 38 children's hospitals: an opportunity for collaborative quality improvement.
abstract: OBJECTIVE
  To identify risk factors associated with readmission for children treated with appendicitis, and to characterize variation in risk-adjusted readmission rates between children's hospitals.
  
  
  BACKGROUND
  Hospital readmission has been increasingly targeted as a marker for quality of care, yet little is known regarding risk factors associated with readmission or the degree of performance variation that exists between hospitals for this cohort of patients.
  
  
  METHODS
  Retrospective cohort study of 47,866 patients treated at 38 children's hospitals (2006-2010). Multivariate regression was used to examine and adjust for the influence of risk factors on 30-day readmission rates. Hospitals were considered performance outliers if their readmission rate and 95% confidence interval (CI) did not include the overall rate.
  
  
  RESULTS
  Factors associated with readmission included disease severity [high vs. low: odds ratio (OR) 4.57, 95% CI: 3.72-5.60; moderate vs. low: OR 2.29, 95% CI: 2.00-2.61] and insurance status (public vs. private: OR 1.14, 95% CI: 1.0-1.29). After adjustment for these factors, the relative decile-based performance rankings changed for 17 (45%) of the 38 hospitals and six (16%) hospitals changed the outlier status based on their standardized readmission rates. A 3.8-fold variation in standardized readmission rates was found across the 38 hospitals after adjustment (overall rate: 8.9%, range: 4.1%-15.4%, P < 0.0001), and 24 (63%) hospitals were identified as outliers (12 low performers and 12 high performers).
  
  
  CONCLUSIONS
  Significant variation in risk-adjusted readmission rates exists among children's hospitals after treatment of appendicitis, and outliers can be identified at both ends of the performance spectrum. These findings may have important implications for the identification and dissemination of "best practices" from exemplar hospitals.
authors.affiliation: Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Rice-Townsend
authors.forename: Matthew
authors.initials: M
authors.lastname: Hall
authors.forename: Jeff N
authors.initials: JN
authors.lastname: Barnes
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.forename: Shawn J
authors.initials: SJ
authors.lastname: Rangel
mesh_terms: D000293:Adolescent; D001064:Appendicitis / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010359:Patient Readmission; D058996:Quality Improvement / Q000458:organization & administration; D011787:Quality of Health Care; D012307:Risk Factors