Disparities in patterns of care and outcomes for ambulatory‐care sensitive conditions remain a persistent problem for children.19 Many studies have focused on disparities in hospitalization rates and length of stay (LOS) related to asthma, however, few studies have focused on community‐acquired pneumonia (CAP) despite the fact that pneumonia is the most common, preventable, and potentially serious infection in childhood.10 Providers, payers, and families have a common interest in minimizing hospital LOS for different reasons (eg, minimizing costs, lost wages, exposure to antibiotic‐resistant bacteria), however, this interest is balanced against the potentially greater risk of readmission and adverse outcomes if LOS is inappropriately short. To date, the relationship between insurance status and LOS for CAP remains unexplored.

As in other conditions, substantial variation exists with respect to patterns of care and outcomes for children hospitalized with CAP.11 For example, children hospitalized in rural settings have a shorter LOS for pneumonia than those hospitalized in large urban settings.12 Children from racial/ethnic minorities tend to have higher rates of CAP‐associated complications, including death.11 Decades of prior studies have documented that uninsured children are less likely than insured children to make preventive care visits and obtain prescription medications, but differences in LOS or hospitalization rates between insured and uninsured children with CAP have not been studied.6, 8, 13, 14 Though imperfect, insurance status is 1 proxy for healthcare access, and current healthcare reform efforts aim to improve healthcare access and decrease socioeconomic gradients in health by increasing the number of insured American children. Nonetheless, quantifying the relationship between insurance status on LOS for children hospitalized with CAP is a first step towards understanding the influence of ambulatory care access on hospitalization for ambulatory‐care sensitive conditions.

The purpose of this study was to investigate the influence of insurance status and type on LOS for children hospitalized with CAP. In addition, we sought to determine if there were consistent trends over time in the association between insurance status and type with LOS for children hospitalized with CAP.

METHODS

RESULTS

The more than 10.5 million children sampled (unweighted) in KID during these 4 time periods (1997, 2000, 2003, and 2006) are representative of the more than 28.9 million children hospitalized in the United States. In each of these sample years, there were approximately 150,000 children hospitalized with pneumonia across the United States (Table 1). Of those hospitalized, 23% to 28% had a concomitant diagnosis of asthma; 6% to 8% had a pneumonia‐associated complication; and mortality was <0.01% in each sample year for patients hospitalized with pneumonia. In all years, among those with racial/ethnic data, the sample population was predominantly white boys less than 6 years old. The greatest proportion of children were hospitalized in urban non‐teaching settings, and also those children living in the southern regions of the United States.

There was little variation in the insurance status of children hospitalized with CAP between 1997 and 2006. In each of the sampled years, at least 40% of sampled children were privately insured, at least 40% were publicly insured, and approximately 5% were uninsured (Table 1). In all years, there were significant racial/ethnic disparities in insurance coverage such that whites were 4 to 6 times more likely to have private insurance than blacks, however, the large amount of missing race/ethnicity data warrant caution in interpreting this finding (Table 2; also see Supporting Information Appendix B in the online version of this article). We also found that children less than 1 year old were the most likely to be publicly insured in all years (see Supporting Appendix C in the online version of this article). There were also regional differences related to insurance coverage such that a greater proportion of children hospitalized in facilities located in the southern part of the United States were publicly insured. Notably, there were no significant differences in CAP‐associated mortality or asthma related to insurance coverage (Table 2). In 2006, CAP‐associated complications occurred in 8.5% of children with private insurance, 6.5% of children with public insurance, and 7.7% of uninsured children; the relative distribution of complications by insurance type were similar in previous years of the KID survey.

After examining the general and demographic characteristics, we then examined mean LOS for all children with CAP in each sample year (Table 3). The mean LOS for children with CAP was 3.44 days in 1997, with marginal decreases in subsequent years to a mean LOS of 3.18 days in 2006. The distribution of LOS for children with CAP revealed that nearly 70% of children were hospitalized for fewer than 3 days, another 22% to 28% were hospitalized for less than 1 week, and only 3% were hospitalized for more than 1 week. This distribution did not change substantially between 1997 and 2006. Next, we compared mean LOS by insurance type and race/ethnicity in unadjusted analyses. In each sample year, publicly insured children hospitalized with CAP had significantly longer LOS than privately insured children (P < 0.001). Similarly, in all years excepting 1997, uninsured children hospitalized with CAP had significantly shorter LOS than privately insured children. There were also significant racial differences in LOS for children with CAP, such that black children had longer LOS than white children with CAP. However, the large amount of missing data for race/ethnicity limited the robustness of this finding, and subsequent sensitivity analyses demonstrated that there were no consistent racial/ethnic disparities in LOS (see Supporting Appendix B in the online version of this article). These sensitivity analyses for missing race data did not alter our primary finding of shorter LOS for uninsured versus publicly or privately insured children.

After controlling for child age, race/ethnicity, gender, hospital type, transfer status, and presence of asthma or pneumonia‐associated complications, our multivariable analyses examining the relationship between insurance coverage and hospital LOS yielded the following results (Table 4). First, publicly insured children had significantly longer hospital stays than privately insured children, and uninsured children had significantly shorter hospital stays than privately insured children in all years except 1997. Second, children admitted with CAP at urban teaching children's hospitals had significantly longer LOS than those admitted to urban non‐teaching hospitals, and, in 2003, children admitted with CAP to rural hospitals had significantly shorter LOS than those admitted to urban non‐teaching hospitals. Third, children older than 1 year consistently had shorter hospital stays than infants less than 1 year old. Finally, though concomitant diagnosis of asthma did not consistently influence LOS, children who developed any complications had significantly longer LOS than those who did not. The cumulative impact of seemingly small differences in LOS is great. For example, in 2006, our model suggests that, for every 1000 children hospitalized with CAP in a given year, after adjusting for differences in sex, age, race, hospital‐type, region, transfer status, and diagnosis of asthma or complications, publicly insured children spend 90 to 130 more days in the hospital than privately insured children, whereas uninsured children spend between 40 to 90 fewer days in the hospital than privately insured children.

DISCUSSION

In this nationally representative sample selected over the past 10 years, we found that publicly insured children hospitalized with CAP have significantly longer LOS than those who are privately insured, and that, since 2000, uninsured children hospitalized with CAP have significantly shorter LOS than those who are privately insured. Though these observed differences are small, they are consistent across all 4 sampled years and, because CAP is one of the most common pediatric inpatient diagnoses, the cumulative impact of the observed differences on hospital LOS is great. Insurance status is often considered a proxy for access to preventive and ambulatory healthcare services or socioeconomic status. However, the underlying mechanisms relating insurance status to healthcare access, utilization, and ultimately, health outcomes are highly complex and difficult to elucidate.17 The observed variation in this study raises questions about the potential influence of insurance status on hospital discharge practices. Additional research is necessary to understand whether there are differences in processes of care (eg, performance of blood cultures or chest radiographs), quality of care, or other outcomes, such as readmissions, related to CAP inpatient management for children with different insurance coverage.

Apart from differences in hospital discharge practices, another possible explanation for uninsured children with CAP having shorter LOS is that these children have less severe disease than privately insured. This may occur if uninsured children with CAP are evaluated in the emergency department rather than the office setting, because emergency department providers may be more likely to admit children with CAP who lack a consistent access to ambulatory primary care services. Countering this alternative, prior studies have shown that uninsured groups are more likely to have greater disease severity than privately insured groups at the time of hospital admission.18, 19 In this study, we attempted to identify children with greater severity of disease using ICD‐9 codes for CAP‐associated complications. Though this is a relatively crude method that might lead to an underestimate of the total number of children with complications, we found that there were no significant differences in the prevalence of CAP‐associated complications between uninsured and insured groups in all sampled years.

On the other hand, uninsured patients may be released earlier by providers in order to reduce the amount of uncompensated care provided, or possibly because parents may urge providers to discharge their children, given their inability to pay forthcoming hospital bills and/or avoid further lost wages due to work absence.20, 21 In California, Bindman et al. demonstrated that decreasing the frequency of Medicaid recertification, and consequently increasing the likelihood of continuous insurance coverage, was associated with a decreased risk of hospitalization for ambulatory‐care sensitive conditions.5

We also found that children admitted to urban teaching children's hospitals with CAP had significantly longer LOS than those admitted to urban non‐teaching hospitals, whereas children in rural hospitals had significantly shorter LOS than those in urban non‐teaching hospitals in 2003. These findings are consistent with prior data from 1996 to1998 demonstrating that children admitted to rural hospitals in New York and Pennsylvania had significantly shorter LOS than large urban hospitals for 19 medical and 9 surgical conditions, including pneumonia.12 These findings may reflect underlying differences in between rural and urban hospital transfer practices, whereby rural hospitals may be more likely than urban hospitals to transfer children with relatively more severe illness to urban referral centers and retain children with less severe illness, leading to shorter LOS.12 Though our empiric understanding of differences in LOS between teaching and non‐teaching hospitals is currently limited, clinical experience supports the notion that there may be decreases in efficiency that occur in teaching hospitals, and are a result of the supervision required for care provided by trainees. It is also possible that, despite our exclusion of comorbid conditions, some children with complex or chronic medical conditions were included in this study. These children are often cared for at teaching hospitals, regardless of the primary cause for admission, and are more likely to have public insurance than other children, thus confounding the relationship between hospital type, insurance type and status, and LOS for children with CAP. The limitations of this dataset preclude further examination of this issue.

There are some limitations to this study. First, the KID data are cross‐sectional and causal inferences are limited. However, our results demonstrating that uninsured children hospitalized with CAP had shorter LOS than privately insured children were quite consistent in each sample year, suggesting that our results are a true association. Additionally, insurance status in KID is typically collected at admission, however, it is not possible to determine whether specific changes to insurance status that occurred during the hospitalization were applied to the data. The impact of this limitation would depend on the type of insurance obtained by the patient. If uninsured patients obtained public insurance, our study would underestimate the increased LOS for publicly insured patients, compared with privately insured patients, but have no effect on the difference in LOS between uninsured and privately insured patients. In the unlikely event that uninsured patients obtained private insurance, then our study would underestimate the difference for uninsured patients, compared with privately insured patients, biasing our current study results towards the null. Second, a substantial proportion of sampled children had missing data for race/ethnicity. To assess the impact of the missing race/ethnicity data on our results, we conducted sensitivity analyses and found that, though difficult to make any definitive conclusions about the relationship between race/ethnicity and LOS for children with CAP, there were no changes to our primary findings regarding differences in LOS between children with different insurance status and type. Third, KID does not include data about other unmeasured confounders (eg, parent income, parent education, regular source of care) that might be related to LOS, as well as a broad spectrum of pediatric outcomes. Serious consideration of expanding KID to include these variables is warranted. Fourth, the other category of insurance is not uniformly coded across states in the KID database. While some states use this category to classify public insurance options other than Medicare and Medicaid, other states include private insurance options in this group. Thus, it is possible that some patients with public insurance are misclassified as having other insurance. We would expect such misclassification to bias our findings towards the null hypothesis. Finally, we focused on the relationship between child health insurance status and CAP, only 1 ambulatory care‐sensitive condition. Additional research examining the relationship between insurance type and other ambulatory care‐sensitive conditions is warranted.

In summary, we found that, after multivariable adjustment, uninsured children hospitalized with community‐acquired pneumonia had significantly shorter LOS than privately insured children, and publicly insured children had a significantly longer hospital stay than privately insured children in these 4 nationally representative samples from 1997 to 2006. Current federal and state efforts to increase enrollment of children into insurance programs are a first step in reducing healthcare disparities. However, insurance coverage alone does not guarantee access to healthcare, thus, these efforts in isolation will likely be insufficient to achieve optimal health for the children of our country. As healthcare reform legislation is implemented, these findings provide hospitals and policy makers additional impetus to develop ways to achieve the ideal length of stay for every child; this ideal state will be achieved when clinical status and course, rather than nonclinical factors such as insurance type or provider's unease with ambulatory follow‐up, determine the duration of hospitalization for every child.

Disparities in patterns of care and outcomes for ambulatory‐care sensitive conditions remain a persistent problem for children.19 Many studies have focused on disparities in hospitalization rates and length of stay (LOS) related to asthma, however, few studies have focused on community‐acquired pneumonia (CAP) despite the fact that pneumonia is the most common, preventable, and potentially serious infection in childhood.10 Providers, payers, and families have a common interest in minimizing hospital LOS for different reasons (eg, minimizing costs, lost wages, exposure to antibiotic‐resistant bacteria), however, this interest is balanced against the potentially greater risk of readmission and adverse outcomes if LOS is inappropriately short. To date, the relationship between insurance status and LOS for CAP remains unexplored.

As in other conditions, substantial variation exists with respect to patterns of care and outcomes for children hospitalized with CAP.11 For example, children hospitalized in rural settings have a shorter LOS for pneumonia than those hospitalized in large urban settings.12 Children from racial/ethnic minorities tend to have higher rates of CAP‐associated complications, including death.11 Decades of prior studies have documented that uninsured children are less likely than insured children to make preventive care visits and obtain prescription medications, but differences in LOS or hospitalization rates between insured and uninsured children with CAP have not been studied.6, 8, 13, 14 Though imperfect, insurance status is 1 proxy for healthcare access, and current healthcare reform efforts aim to improve healthcare access and decrease socioeconomic gradients in health by increasing the number of insured American children. Nonetheless, quantifying the relationship between insurance status on LOS for children hospitalized with CAP is a first step towards understanding the influence of ambulatory care access on hospitalization for ambulatory‐care sensitive conditions.

The purpose of this study was to investigate the influence of insurance status and type on LOS for children hospitalized with CAP. In addition, we sought to determine if there were consistent trends over time in the association between insurance status and type with LOS for children hospitalized with CAP.

METHODS

RESULTS

The more than 10.5 million children sampled (unweighted) in KID during these 4 time periods (1997, 2000, 2003, and 2006) are representative of the more than 28.9 million children hospitalized in the United States. In each of these sample years, there were approximately 150,000 children hospitalized with pneumonia across the United States (Table 1). Of those hospitalized, 23% to 28% had a concomitant diagnosis of asthma; 6% to 8% had a pneumonia‐associated complication; and mortality was <0.01% in each sample year for patients hospitalized with pneumonia. In all years, among those with racial/ethnic data, the sample population was predominantly white boys less than 6 years old. The greatest proportion of children were hospitalized in urban non‐teaching settings, and also those children living in the southern regions of the United States.

There was little variation in the insurance status of children hospitalized with CAP between 1997 and 2006. In each of the sampled years, at least 40% of sampled children were privately insured, at least 40% were publicly insured, and approximately 5% were uninsured (Table 1). In all years, there were significant racial/ethnic disparities in insurance coverage such that whites were 4 to 6 times more likely to have private insurance than blacks, however, the large amount of missing race/ethnicity data warrant caution in interpreting this finding (Table 2; also see Supporting Information Appendix B in the online version of this article). We also found that children less than 1 year old were the most likely to be publicly insured in all years (see Supporting Appendix C in the online version of this article). There were also regional differences related to insurance coverage such that a greater proportion of children hospitalized in facilities located in the southern part of the United States were publicly insured. Notably, there were no significant differences in CAP‐associated mortality or asthma related to insurance coverage (Table 2). In 2006, CAP‐associated complications occurred in 8.5% of children with private insurance, 6.5% of children with public insurance, and 7.7% of uninsured children; the relative distribution of complications by insurance type were similar in previous years of the KID survey.

After examining the general and demographic characteristics, we then examined mean LOS for all children with CAP in each sample year (Table 3). The mean LOS for children with CAP was 3.44 days in 1997, with marginal decreases in subsequent years to a mean LOS of 3.18 days in 2006. The distribution of LOS for children with CAP revealed that nearly 70% of children were hospitalized for fewer than 3 days, another 22% to 28% were hospitalized for less than 1 week, and only 3% were hospitalized for more than 1 week. This distribution did not change substantially between 1997 and 2006. Next, we compared mean LOS by insurance type and race/ethnicity in unadjusted analyses. In each sample year, publicly insured children hospitalized with CAP had significantly longer LOS than privately insured children (P < 0.001). Similarly, in all years excepting 1997, uninsured children hospitalized with CAP had significantly shorter LOS than privately insured children. There were also significant racial differences in LOS for children with CAP, such that black children had longer LOS than white children with CAP. However, the large amount of missing data for race/ethnicity limited the robustness of this finding, and subsequent sensitivity analyses demonstrated that there were no consistent racial/ethnic disparities in LOS (see Supporting Appendix B in the online version of this article). These sensitivity analyses for missing race data did not alter our primary finding of shorter LOS for uninsured versus publicly or privately insured children.

After controlling for child age, race/ethnicity, gender, hospital type, transfer status, and presence of asthma or pneumonia‐associated complications, our multivariable analyses examining the relationship between insurance coverage and hospital LOS yielded the following results (Table 4). First, publicly insured children had significantly longer hospital stays than privately insured children, and uninsured children had significantly shorter hospital stays than privately insured children in all years except 1997. Second, children admitted with CAP at urban teaching children's hospitals had significantly longer LOS than those admitted to urban non‐teaching hospitals, and, in 2003, children admitted with CAP to rural hospitals had significantly shorter LOS than those admitted to urban non‐teaching hospitals. Third, children older than 1 year consistently had shorter hospital stays than infants less than 1 year old. Finally, though concomitant diagnosis of asthma did not consistently influence LOS, children who developed any complications had significantly longer LOS than those who did not. The cumulative impact of seemingly small differences in LOS is great. For example, in 2006, our model suggests that, for every 1000 children hospitalized with CAP in a given year, after adjusting for differences in sex, age, race, hospital‐type, region, transfer status, and diagnosis of asthma or complications, publicly insured children spend 90 to 130 more days in the hospital than privately insured children, whereas uninsured children spend between 40 to 90 fewer days in the hospital than privately insured children.

DISCUSSION

In this nationally representative sample selected over the past 10 years, we found that publicly insured children hospitalized with CAP have significantly longer LOS than those who are privately insured, and that, since 2000, uninsured children hospitalized with CAP have significantly shorter LOS than those who are privately insured. Though these observed differences are small, they are consistent across all 4 sampled years and, because CAP is one of the most common pediatric inpatient diagnoses, the cumulative impact of the observed differences on hospital LOS is great. Insurance status is often considered a proxy for access to preventive and ambulatory healthcare services or socioeconomic status. However, the underlying mechanisms relating insurance status to healthcare access, utilization, and ultimately, health outcomes are highly complex and difficult to elucidate.17 The observed variation in this study raises questions about the potential influence of insurance status on hospital discharge practices. Additional research is necessary to understand whether there are differences in processes of care (eg, performance of blood cultures or chest radiographs), quality of care, or other outcomes, such as readmissions, related to CAP inpatient management for children with different insurance coverage.

Apart from differences in hospital discharge practices, another possible explanation for uninsured children with CAP having shorter LOS is that these children have less severe disease than privately insured. This may occur if uninsured children with CAP are evaluated in the emergency department rather than the office setting, because emergency department providers may be more likely to admit children with CAP who lack a consistent access to ambulatory primary care services. Countering this alternative, prior studies have shown that uninsured groups are more likely to have greater disease severity than privately insured groups at the time of hospital admission.18, 19 In this study, we attempted to identify children with greater severity of disease using ICD‐9 codes for CAP‐associated complications. Though this is a relatively crude method that might lead to an underestimate of the total number of children with complications, we found that there were no significant differences in the prevalence of CAP‐associated complications between uninsured and insured groups in all sampled years.

On the other hand, uninsured patients may be released earlier by providers in order to reduce the amount of uncompensated care provided, or possibly because parents may urge providers to discharge their children, given their inability to pay forthcoming hospital bills and/or avoid further lost wages due to work absence.20, 21 In California, Bindman et al. demonstrated that decreasing the frequency of Medicaid recertification, and consequently increasing the likelihood of continuous insurance coverage, was associated with a decreased risk of hospitalization for ambulatory‐care sensitive conditions.5

We also found that children admitted to urban teaching children's hospitals with CAP had significantly longer LOS than those admitted to urban non‐teaching hospitals, whereas children in rural hospitals had significantly shorter LOS than those in urban non‐teaching hospitals in 2003. These findings are consistent with prior data from 1996 to1998 demonstrating that children admitted to rural hospitals in New York and Pennsylvania had significantly shorter LOS than large urban hospitals for 19 medical and 9 surgical conditions, including pneumonia.12 These findings may reflect underlying differences in between rural and urban hospital transfer practices, whereby rural hospitals may be more likely than urban hospitals to transfer children with relatively more severe illness to urban referral centers and retain children with less severe illness, leading to shorter LOS.12 Though our empiric understanding of differences in LOS between teaching and non‐teaching hospitals is currently limited, clinical experience supports the notion that there may be decreases in efficiency that occur in teaching hospitals, and are a result of the supervision required for care provided by trainees. It is also possible that, despite our exclusion of comorbid conditions, some children with complex or chronic medical conditions were included in this study. These children are often cared for at teaching hospitals, regardless of the primary cause for admission, and are more likely to have public insurance than other children, thus confounding the relationship between hospital type, insurance type and status, and LOS for children with CAP. The limitations of this dataset preclude further examination of this issue.

There are some limitations to this study. First, the KID data are cross‐sectional and causal inferences are limited. However, our results demonstrating that uninsured children hospitalized with CAP had shorter LOS than privately insured children were quite consistent in each sample year, suggesting that our results are a true association. Additionally, insurance status in KID is typically collected at admission, however, it is not possible to determine whether specific changes to insurance status that occurred during the hospitalization were applied to the data. The impact of this limitation would depend on the type of insurance obtained by the patient. If uninsured patients obtained public insurance, our study would underestimate the increased LOS for publicly insured patients, compared with privately insured patients, but have no effect on the difference in LOS between uninsured and privately insured patients. In the unlikely event that uninsured patients obtained private insurance, then our study would underestimate the difference for uninsured patients, compared with privately insured patients, biasing our current study results towards the null. Second, a substantial proportion of sampled children had missing data for race/ethnicity. To assess the impact of the missing race/ethnicity data on our results, we conducted sensitivity analyses and found that, though difficult to make any definitive conclusions about the relationship between race/ethnicity and LOS for children with CAP, there were no changes to our primary findings regarding differences in LOS between children with different insurance status and type. Third, KID does not include data about other unmeasured confounders (eg, parent income, parent education, regular source of care) that might be related to LOS, as well as a broad spectrum of pediatric outcomes. Serious consideration of expanding KID to include these variables is warranted. Fourth, the other category of insurance is not uniformly coded across states in the KID database. While some states use this category to classify public insurance options other than Medicare and Medicaid, other states include private insurance options in this group. Thus, it is possible that some patients with public insurance are misclassified as having other insurance. We would expect such misclassification to bias our findings towards the null hypothesis. Finally, we focused on the relationship between child health insurance status and CAP, only 1 ambulatory care‐sensitive condition. Additional research examining the relationship between insurance type and other ambulatory care‐sensitive conditions is warranted.

In summary, we found that, after multivariable adjustment, uninsured children hospitalized with community‐acquired pneumonia had significantly shorter LOS than privately insured children, and publicly insured children had a significantly longer hospital stay than privately insured children in these 4 nationally representative samples from 1997 to 2006. Current federal and state efforts to increase enrollment of children into insurance programs are a first step in reducing healthcare disparities. However, insurance coverage alone does not guarantee access to healthcare, thus, these efforts in isolation will likely be insufficient to achieve optimal health for the children of our country. As healthcare reform legislation is implemented, these findings provide hospitals and policy makers additional impetus to develop ways to achieve the ideal length of stay for every child; this ideal state will be achieved when clinical status and course, rather than nonclinical factors such as insurance type or provider's unease with ambulatory follow‐up, determine the duration of hospitalization for every child.

Disparities in patterns of care and outcomes for ambulatory‐care sensitive conditions remain a persistent problem for children.19 Many studies have focused on disparities in hospitalization rates and length of stay (LOS) related to asthma, however, few studies have focused on community‐acquired pneumonia (CAP) despite the fact that pneumonia is the most common, preventable, and potentially serious infection in childhood.10 Providers, payers, and families have a common interest in minimizing hospital LOS for different reasons (eg, minimizing costs, lost wages, exposure to antibiotic‐resistant bacteria), however, this interest is balanced against the potentially greater risk of readmission and adverse outcomes if LOS is inappropriately short. To date, the relationship between insurance status and LOS for CAP remains unexplored.

As in other conditions, substantial variation exists with respect to patterns of care and outcomes for children hospitalized with CAP.11 For example, children hospitalized in rural settings have a shorter LOS for pneumonia than those hospitalized in large urban settings.12 Children from racial/ethnic minorities tend to have higher rates of CAP‐associated complications, including death.11 Decades of prior studies have documented that uninsured children are less likely than insured children to make preventive care visits and obtain prescription medications, but differences in LOS or hospitalization rates between insured and uninsured children with CAP have not been studied.6, 8, 13, 14 Though imperfect, insurance status is 1 proxy for healthcare access, and current healthcare reform efforts aim to improve healthcare access and decrease socioeconomic gradients in health by increasing the number of insured American children. Nonetheless, quantifying the relationship between insurance status on LOS for children hospitalized with CAP is a first step towards understanding the influence of ambulatory care access on hospitalization for ambulatory‐care sensitive conditions.

The purpose of this study was to investigate the influence of insurance status and type on LOS for children hospitalized with CAP. In addition, we sought to determine if there were consistent trends over time in the association between insurance status and type with LOS for children hospitalized with CAP.

METHODS

RESULTS

The more than 10.5 million children sampled (unweighted) in KID during these 4 time periods (1997, 2000, 2003, and 2006) are representative of the more than 28.9 million children hospitalized in the United States. In each of these sample years, there were approximately 150,000 children hospitalized with pneumonia across the United States (Table 1). Of those hospitalized, 23% to 28% had a concomitant diagnosis of asthma; 6% to 8% had a pneumonia‐associated complication; and mortality was <0.01% in each sample year for patients hospitalized with pneumonia. In all years, among those with racial/ethnic data, the sample population was predominantly white boys less than 6 years old. The greatest proportion of children were hospitalized in urban non‐teaching settings, and also those children living in the southern regions of the United States.

There was little variation in the insurance status of children hospitalized with CAP between 1997 and 2006. In each of the sampled years, at least 40% of sampled children were privately insured, at least 40% were publicly insured, and approximately 5% were uninsured (Table 1). In all years, there were significant racial/ethnic disparities in insurance coverage such that whites were 4 to 6 times more likely to have private insurance than blacks, however, the large amount of missing race/ethnicity data warrant caution in interpreting this finding (Table 2; also see Supporting Information Appendix B in the online version of this article). We also found that children less than 1 year old were the most likely to be publicly insured in all years (see Supporting Appendix C in the online version of this article). There were also regional differences related to insurance coverage such that a greater proportion of children hospitalized in facilities located in the southern part of the United States were publicly insured. Notably, there were no significant differences in CAP‐associated mortality or asthma related to insurance coverage (Table 2). In 2006, CAP‐associated complications occurred in 8.5% of children with private insurance, 6.5% of children with public insurance, and 7.7% of uninsured children; the relative distribution of complications by insurance type were similar in previous years of the KID survey.

After examining the general and demographic characteristics, we then examined mean LOS for all children with CAP in each sample year (Table 3). The mean LOS for children with CAP was 3.44 days in 1997, with marginal decreases in subsequent years to a mean LOS of 3.18 days in 2006. The distribution of LOS for children with CAP revealed that nearly 70% of children were hospitalized for fewer than 3 days, another 22% to 28% were hospitalized for less than 1 week, and only 3% were hospitalized for more than 1 week. This distribution did not change substantially between 1997 and 2006. Next, we compared mean LOS by insurance type and race/ethnicity in unadjusted analyses. In each sample year, publicly insured children hospitalized with CAP had significantly longer LOS than privately insured children (P < 0.001). Similarly, in all years excepting 1997, uninsured children hospitalized with CAP had significantly shorter LOS than privately insured children. There were also significant racial differences in LOS for children with CAP, such that black children had longer LOS than white children with CAP. However, the large amount of missing data for race/ethnicity limited the robustness of this finding, and subsequent sensitivity analyses demonstrated that there were no consistent racial/ethnic disparities in LOS (see Supporting Appendix B in the online version of this article). These sensitivity analyses for missing race data did not alter our primary finding of shorter LOS for uninsured versus publicly or privately insured children.

After controlling for child age, race/ethnicity, gender, hospital type, transfer status, and presence of asthma or pneumonia‐associated complications, our multivariable analyses examining the relationship between insurance coverage and hospital LOS yielded the following results (Table 4). First, publicly insured children had significantly longer hospital stays than privately insured children, and uninsured children had significantly shorter hospital stays than privately insured children in all years except 1997. Second, children admitted with CAP at urban teaching children's hospitals had significantly longer LOS than those admitted to urban non‐teaching hospitals, and, in 2003, children admitted with CAP to rural hospitals had significantly shorter LOS than those admitted to urban non‐teaching hospitals. Third, children older than 1 year consistently had shorter hospital stays than infants less than 1 year old. Finally, though concomitant diagnosis of asthma did not consistently influence LOS, children who developed any complications had significantly longer LOS than those who did not. The cumulative impact of seemingly small differences in LOS is great. For example, in 2006, our model suggests that, for every 1000 children hospitalized with CAP in a given year, after adjusting for differences in sex, age, race, hospital‐type, region, transfer status, and diagnosis of asthma or complications, publicly insured children spend 90 to 130 more days in the hospital than privately insured children, whereas uninsured children spend between 40 to 90 fewer days in the hospital than privately insured children.

DISCUSSION

In this nationally representative sample selected over the past 10 years, we found that publicly insured children hospitalized with CAP have significantly longer LOS than those who are privately insured, and that, since 2000, uninsured children hospitalized with CAP have significantly shorter LOS than those who are privately insured. Though these observed differences are small, they are consistent across all 4 sampled years and, because CAP is one of the most common pediatric inpatient diagnoses, the cumulative impact of the observed differences on hospital LOS is great. Insurance status is often considered a proxy for access to preventive and ambulatory healthcare services or socioeconomic status. However, the underlying mechanisms relating insurance status to healthcare access, utilization, and ultimately, health outcomes are highly complex and difficult to elucidate.17 The observed variation in this study raises questions about the potential influence of insurance status on hospital discharge practices. Additional research is necessary to understand whether there are differences in processes of care (eg, performance of blood cultures or chest radiographs), quality of care, or other outcomes, such as readmissions, related to CAP inpatient management for children with different insurance coverage.

Apart from differences in hospital discharge practices, another possible explanation for uninsured children with CAP having shorter LOS is that these children have less severe disease than privately insured. This may occur if uninsured children with CAP are evaluated in the emergency department rather than the office setting, because emergency department providers may be more likely to admit children with CAP who lack a consistent access to ambulatory primary care services. Countering this alternative, prior studies have shown that uninsured groups are more likely to have greater disease severity than privately insured groups at the time of hospital admission.18, 19 In this study, we attempted to identify children with greater severity of disease using ICD‐9 codes for CAP‐associated complications. Though this is a relatively crude method that might lead to an underestimate of the total number of children with complications, we found that there were no significant differences in the prevalence of CAP‐associated complications between uninsured and insured groups in all sampled years.

On the other hand, uninsured patients may be released earlier by providers in order to reduce the amount of uncompensated care provided, or possibly because parents may urge providers to discharge their children, given their inability to pay forthcoming hospital bills and/or avoid further lost wages due to work absence.20, 21 In California, Bindman et al. demonstrated that decreasing the frequency of Medicaid recertification, and consequently increasing the likelihood of continuous insurance coverage, was associated with a decreased risk of hospitalization for ambulatory‐care sensitive conditions.5

We also found that children admitted to urban teaching children's hospitals with CAP had significantly longer LOS than those admitted to urban non‐teaching hospitals, whereas children in rural hospitals had significantly shorter LOS than those in urban non‐teaching hospitals in 2003. These findings are consistent with prior data from 1996 to1998 demonstrating that children admitted to rural hospitals in New York and Pennsylvania had significantly shorter LOS than large urban hospitals for 19 medical and 9 surgical conditions, including pneumonia.12 These findings may reflect underlying differences in between rural and urban hospital transfer practices, whereby rural hospitals may be more likely than urban hospitals to transfer children with relatively more severe illness to urban referral centers and retain children with less severe illness, leading to shorter LOS.12 Though our empiric understanding of differences in LOS between teaching and non‐teaching hospitals is currently limited, clinical experience supports the notion that there may be decreases in efficiency that occur in teaching hospitals, and are a result of the supervision required for care provided by trainees. It is also possible that, despite our exclusion of comorbid conditions, some children with complex or chronic medical conditions were included in this study. These children are often cared for at teaching hospitals, regardless of the primary cause for admission, and are more likely to have public insurance than other children, thus confounding the relationship between hospital type, insurance type and status, and LOS for children with CAP. The limitations of this dataset preclude further examination of this issue.

There are some limitations to this study. First, the KID data are cross‐sectional and causal inferences are limited. However, our results demonstrating that uninsured children hospitalized with CAP had shorter LOS than privately insured children were quite consistent in each sample year, suggesting that our results are a true association. Additionally, insurance status in KID is typically collected at admission, however, it is not possible to determine whether specific changes to insurance status that occurred during the hospitalization were applied to the data. The impact of this limitation would depend on the type of insurance obtained by the patient. If uninsured patients obtained public insurance, our study would underestimate the increased LOS for publicly insured patients, compared with privately insured patients, but have no effect on the difference in LOS between uninsured and privately insured patients. In the unlikely event that uninsured patients obtained private insurance, then our study would underestimate the difference for uninsured patients, compared with privately insured patients, biasing our current study results towards the null. Second, a substantial proportion of sampled children had missing data for race/ethnicity. To assess the impact of the missing race/ethnicity data on our results, we conducted sensitivity analyses and found that, though difficult to make any definitive conclusions about the relationship between race/ethnicity and LOS for children with CAP, there were no changes to our primary findings regarding differences in LOS between children with different insurance status and type. Third, KID does not include data about other unmeasured confounders (eg, parent income, parent education, regular source of care) that might be related to LOS, as well as a broad spectrum of pediatric outcomes. Serious consideration of expanding KID to include these variables is warranted. Fourth, the other category of insurance is not uniformly coded across states in the KID database. While some states use this category to classify public insurance options other than Medicare and Medicaid, other states include private insurance options in this group. Thus, it is possible that some patients with public insurance are misclassified as having other insurance. We would expect such misclassification to bias our findings towards the null hypothesis. Finally, we focused on the relationship between child health insurance status and CAP, only 1 ambulatory care‐sensitive condition. Additional research examining the relationship between insurance type and other ambulatory care‐sensitive conditions is warranted.

In summary, we found that, after multivariable adjustment, uninsured children hospitalized with community‐acquired pneumonia had significantly shorter LOS than privately insured children, and publicly insured children had a significantly longer hospital stay than privately insured children in these 4 nationally representative samples from 1997 to 2006. Current federal and state efforts to increase enrollment of children into insurance programs are a first step in reducing healthcare disparities. However, insurance coverage alone does not guarantee access to healthcare, thus, these efforts in isolation will likely be insufficient to achieve optimal health for the children of our country. As healthcare reform legislation is implemented, these findings provide hospitals and policy makers additional impetus to develop ways to achieve the ideal length of stay for every child; this ideal state will be achieved when clinical status and course, rather than nonclinical factors such as insurance type or provider's unease with ambulatory follow‐up, determine the duration of hospitalization for every child.

There is increasing evidence that the transfer of medically complex patients across different settings can be associated with poor communication and patient dissatisfaction with the care received, potentially leading to negative clinical outcomes. While medical schools are beginning to introduce curricula on these transitions of care, few have been evaluated and subjected to peer review with the purpose of finding the most effective teaching and training methods.

Older adults and those with multiple chronic diseases frequently require medical care that spans multiple locations, and thus are most at risk for poor clinical outcomes during care transitions.1, 2 Medication errors and adverse drug reactions after hospital discharge are common.3, 4 Unsuccessful care transitions may also result in nonelective readmission after discharge, and there is evidence that readmissions may be a quality indicator for hospital care.57 Poor communication between patients and their healthcare providers is another element of poorly executed care transitions. Qualitative studies show that patients are frequently dissatisfied with the discharge process and are often unprepared to assume responsibility for their own care when they leave the hospital.8 Communication among providers can also be suboptimal. One meta‐analysis found that hospital physicians and primary care providers communicated infrequently and the availability of discharge summaries at the postdischarge visit was low, which may have affected the quality of care.9

Knowing that these gaps are common, there have been signs of increased emphasis on improving communication and working in teams as part of health professions training. The Institute of Medicine, in its 2003 report Health Professions Education: A Bridge to Quality,10 stressed education on management of chronic diseases, working in interdisciplinary teams, as well as a focus on quality improvement. In addition, the American Association of Medical Colleges (AAMC) encouraged training medical students on preparing safe discharge plans in its 2007 geriatrics competencies.11

Some medical schools have introduced care transitions curricula, though few have published data on their effectiveness. A search for teaching products using care transitions or transitional care on the online educational portals POGOe (Portal of Geriatric Online Education) and MedEdPortal yielded a total of 7 unique sets of teaching materials on care transitions for medical students.1218 However, a search on PubMed in July 2010 for peer‐reviewed articles on care transitions curricula developed for medical students which contained evaluation data only yielded 3 articles.1921 These 3 curricula, written by Bray‐Hall et al., Lai et al., and Ouchida et al., respectively, all trained third‐year medical students on diverse aspects of the discharge process using methods such as lectures, workshops, and patient visits, and showed favorable skill and knowledge outcomes.

Recognizing the importance of care transitions in medical education, a new curriculum addressing this topic was developed and introduced for fourth‐year medical students at the Emory University School of Medicine in 2009. The broad goal for this module was to develop a course concentrating on concrete skills that would train students to perform better care transitions while minimizing the time they had to spend away from a busy Internal Medicine sub‐internship. This curriculum used a mixed approach that included face‐to‐face teaching with faculty, online didactic instruction and interaction, and direct patient care. The course objectives were for students to develop a working fund of knowledge on care transitions, to learn to write a complete discharge summary, and to communicate the elements of a safe discharge plan. This article will describe the implementation of this curriculum and its evaluation.

METHODS

The Emory Care Transitions Curriculum started in August 2009 with fourth‐year medical students at the Emory University School of Medicine. This section will describe the details of the implementation of this curriculum, as well as the evaluation methodology and results.

Course Description

The course consisted of 3 components, each associated with specific student assignments: a slide presentation on care transitions with an associated case discussion, training on discharge summaries, and the execution of a postdischarge phone call. Figure 1 describes the course delivery schedule.

Figure 1

Slide Presentation and Case Discussion

This section started on day 2 of the clerkship, with a face‐to‐face lecture titled Transitions of Care: Why They Are Important, and How to Improve Them. It included the following components: definition of the different posthospital discharge options, explanation of the reasons for the complexity of care transitions in high‐risk patient populations, and an enumeration of methods to improve the safety of care transitions. Students also read a review article on the topic to further add to their fund of knowledge.23

The second part of the section involved discussion of a case posted on Blackboard (a discussion board) designed to highlight some of the challenges associated with care transitions. The case included 2 successive discharge summaries for an elderly patient with congestive heart failure: 1 for the initial exacerbation, and the other for a readmission. Using an online discussion board, students were asked to report the strong points and shortcomings of the patient's management, as well as those of the discharge summaries. Then the students were asked to post responses to at least 2 of their classmates' reports on the discussion board.

Training on Discharge Summaries

During the module, students received training on how to prepare a complete and informative discharge summary. This online training consisted of a lecture prepared by a faculty member (M.A.E.) and the use of a discharge summary template based on a guide prepared by the Boston Association of Academic Hospitalists (BAAHM), which is part of a toolkit available from the Society of Hospital Medicine.24 After reading the lecture, each student selected 1 of the patients they cared for during their rotation, and wrote a discharge summary. They posted it to a Blackboard discussion board, and were then asked to comment on one of their classmates' reports on the same forum. Faculty (M.A.E. and R.C.) also gave online feedback to each student about their discharge summary.

Postdischarge Phone Call

Students were also assigned to communicate with the patient for whom they prepared a discharge summary by performing a postdischarge phone call within a week of the patient's departure from the hospital. They reviewed a discharge checklist adapted from Ideal Discharge for an Elderly Patient: A Hospitalist Checklist, issued by the Society of Hospital Medicine.25 This document contains the necessary elements of a safe discharge plan, and used these points as the basis of the patient phone interview. The goal of the call and the use of the checklist was to reinforce the main elements of communication with patients that need to occur before they leave the hospital.

Students then used the checklist as the basis for a short (<400 words) report discussing the strong points and shortcomings of their patient's discharge, and posted it on a Blackboard discussion board. They were also asked to comment on at least one of their classmates' reports on the board. Faculty (M.A.E. and R.C.) also participated in the discussion board, commenting at least once on all students' reports.

RESULTS

The 121 students who took the module completed both the pre‐ and posttests. Table 1 details the mean pre‐ and posttest Likert scores for all confidence and attitude questions, as well as the changes in the 25‐point total confidence and attitude score from pre‐ to posttest. The change in confidence scores among survey participants was statistically significant (P < 0.001), while the change in attitude score was not (P = 0.07). Table 2 compares the percentage of correct answers before and after the course for individual knowledge questions, as well as for the entire knowledge quiz. Changes in total knowledge scores were statistically significant: the mean percentage of correct answers out of 10 questions was 68% on the pretest, and 82% on the posttest (P < 0.001).

Table 3 measures the changes in confidence, attitude, and knowledge scores by the period of the year in which students took the course. One‐way ANOVA tests for each of the 3 domains did not find statistically significant changes in confidence, attitude, or knowledge scores among the 3 trimesters in which we divided the module's calendar.

Table 4 shows satisfaction scores on the posttest. The overall Likert rating for the course was 3.9, with 97.5% of students rating it good or better. The highest‐rated individual component of the course by Likert score was the training on discharge summaries, with a rating of 4.1. The lowest‐rated by this parameter was the congestive heart failure case, with a rating of 3.6. The online discussion across all topics had the lowest percentage of students rating it good or above, at 83.5%.

As for student discharge summaries, 109 out of 121 (90.1%) met all the criteria in order to be deemed satisfactory; 109 out of 121 (90.1%) of postdischarge phone call reports met both required components. Both these results exceeded the goal of 80% set before the course started.

DISCUSSION

The Emory Care Transitions Curriculum for fourth‐year medical students started in the 20092010 academic year with the main goal of teaching students transferable skills that would ultimately lead to their participating in safer hospital discharges in their future practice as physicians. At the end of this course, students exhibited greater confidence in managing the discharge process, improved overall fund of knowledge relating to care transitions, and a demonstration of appropriate skills related to preparing discharge summaries and communicating with patients at discharge. This was all executed with a delivery method that students found engaging.

Analyzing the results, it is noteworthy that confidence improved, while attitudes did not. Even though confidence in performing a task does not necessarily reflect one's ability to perform it, our students' confidence scores may serve as a proxy for their ability to manage tasks related to the discharge process, like managing medications and preparing discharge summaries. Thus, while some studies suggest that self‐assessment among physicians may not always relate well to competence,26, 27 in our study, students did demonstrate skills in discharge summary preparation and in identifying the most relevant aspects of patient communication at hospital discharge. As for the absence of attitude change, this may have partly been a function of the fact that students in our group started with attitude scores that were already quite high, with a mean pretest attitude score of 20.7 out of 25.

Changes in student confidence, attitudes, and knowledge from pre‐ to posttest did not vary significantly across the academic year. Thus, one could interpret from our findings that more experienced students who took the module close to graduation benefited similarly from the course to those who completed it earlier, at least according to those rubrics. Another possible source of variation in student experience was the hospital in which students rotated: the demographics of GMH, with its large uninsured population; AVAMC, with more elderly patients; and EUH, with a more affluent profile, are certainly different. However, the number of students rotating at EUH and AVAMC were comparatively too small to attempt to draw any conclusions about how rotation site affected student experiences.

The use of a blended approach that integrated face‐to‐face didactics, patient care, and online learning offered some advantages. Curricular goals were achieved through a course that required only 2 hours of in‐person faculty time with students. This is significant, considering the time demands that academic medical faculty usually face. This approach also permitted students who were participating in a busy clinical rotation, and had limited opportunities to meet as a group, the ability to do coursework at their own pace. Another strength of the study is that all students who participated in the rotation were able to complete their surveys.

As for limitations, it is worth noting that in a course with a blended curriculum, the online discussion had the lowest percentage of students rating it good or better. Part of the perceived difficulty may have resulted from the fact that there are no other courses in the Emory medical curriculum that utilize discussion boards or distance learning methods as teaching tools. Despite this generation of students' technological savvy, this new mode of discussion may have proven difficult to pick up when they were in the midst of a busy clinical rotation. This serves as a reminder that while online curricula have proven successful in this and other settings, each element needs to be tailored to the audience. One other factor to be considered while interpreting this study's results is that this study utilized some survey instruments that have not been previously validated, even though they were developed in consultation with experts in the field of care transitions education.

We used a dichotomous, criteria‐based system to rate students' discharge summaries and reports of postdischarge phone calls. While this quantitative approach allowed us to more objectively define the quality of students' work, it did offer some disadvantages. First, even though we based the rating system for discharge summaries on a BAAHM template, it was not subjected to more extensive validation. Moreover, the quantitative approach diverted us from finding themes and other qualitative data from students' write‐ups, which could potentially have given us a fuller picture of their work.

This study contributes to the small, but growing, literature on care transitions education. The studies by Bray‐Hall et al., Lai et al., and Ouchida et al.,1921 used different methodologies, but all were directed at third‐year students using curricula with classroom and clinical learning, and showed favorable outcomes in knowledge and skills. The present study also showed positive results in students' knowledge and skills, but targeted it toward graduating medical students and included a focus on concrete skills, such as discharge summary preparation. It also utilized a nontraditional delivery approach which reached its objectives while also limiting the demands on faculty and students' face time during busy clinical rotations, which is especially important when considering that students were dispersed at multiple sites.

It is likely that medical schools will implement more care transitions curricula in coming years, as organizations like the AAMC11 and the Institute of Medicine10 increase the pressure to train future doctors to better address the needs of older and chronically ill patients, who require care from professionals of multiple disciplines, in disparate care settings. Moreover, the 2010 Patient Protection and Affordable Care Act28 contains provisions with financial incentives for hospitals to decrease readmissions. Once these become widely implemented, there will be a greater impetus to train medical practitioners to discharge patients more safely. When that occurs, medical schools will have additional compelling reasons to offer courses that teach students skills to execute better care transitions. The hoped‐for outcome of these curricula will ultimately be safer and more effective patient care.

There is increasing evidence that the transfer of medically complex patients across different settings can be associated with poor communication and patient dissatisfaction with the care received, potentially leading to negative clinical outcomes. While medical schools are beginning to introduce curricula on these transitions of care, few have been evaluated and subjected to peer review with the purpose of finding the most effective teaching and training methods.

Older adults and those with multiple chronic diseases frequently require medical care that spans multiple locations, and thus are most at risk for poor clinical outcomes during care transitions.1, 2 Medication errors and adverse drug reactions after hospital discharge are common.3, 4 Unsuccessful care transitions may also result in nonelective readmission after discharge, and there is evidence that readmissions may be a quality indicator for hospital care.57 Poor communication between patients and their healthcare providers is another element of poorly executed care transitions. Qualitative studies show that patients are frequently dissatisfied with the discharge process and are often unprepared to assume responsibility for their own care when they leave the hospital.8 Communication among providers can also be suboptimal. One meta‐analysis found that hospital physicians and primary care providers communicated infrequently and the availability of discharge summaries at the postdischarge visit was low, which may have affected the quality of care.9

Knowing that these gaps are common, there have been signs of increased emphasis on improving communication and working in teams as part of health professions training. The Institute of Medicine, in its 2003 report Health Professions Education: A Bridge to Quality,10 stressed education on management of chronic diseases, working in interdisciplinary teams, as well as a focus on quality improvement. In addition, the American Association of Medical Colleges (AAMC) encouraged training medical students on preparing safe discharge plans in its 2007 geriatrics competencies.11

Some medical schools have introduced care transitions curricula, though few have published data on their effectiveness. A search for teaching products using care transitions or transitional care on the online educational portals POGOe (Portal of Geriatric Online Education) and MedEdPortal yielded a total of 7 unique sets of teaching materials on care transitions for medical students.1218 However, a search on PubMed in July 2010 for peer‐reviewed articles on care transitions curricula developed for medical students which contained evaluation data only yielded 3 articles.1921 These 3 curricula, written by Bray‐Hall et al., Lai et al., and Ouchida et al., respectively, all trained third‐year medical students on diverse aspects of the discharge process using methods such as lectures, workshops, and patient visits, and showed favorable skill and knowledge outcomes.

Recognizing the importance of care transitions in medical education, a new curriculum addressing this topic was developed and introduced for fourth‐year medical students at the Emory University School of Medicine in 2009. The broad goal for this module was to develop a course concentrating on concrete skills that would train students to perform better care transitions while minimizing the time they had to spend away from a busy Internal Medicine sub‐internship. This curriculum used a mixed approach that included face‐to‐face teaching with faculty, online didactic instruction and interaction, and direct patient care. The course objectives were for students to develop a working fund of knowledge on care transitions, to learn to write a complete discharge summary, and to communicate the elements of a safe discharge plan. This article will describe the implementation of this curriculum and its evaluation.

METHODS

The Emory Care Transitions Curriculum started in August 2009 with fourth‐year medical students at the Emory University School of Medicine. This section will describe the details of the implementation of this curriculum, as well as the evaluation methodology and results.

Course Description

The course consisted of 3 components, each associated with specific student assignments: a slide presentation on care transitions with an associated case discussion, training on discharge summaries, and the execution of a postdischarge phone call. Figure 1 describes the course delivery schedule.

Figure 1

Slide Presentation and Case Discussion

This section started on day 2 of the clerkship, with a face‐to‐face lecture titled Transitions of Care: Why They Are Important, and How to Improve Them. It included the following components: definition of the different posthospital discharge options, explanation of the reasons for the complexity of care transitions in high‐risk patient populations, and an enumeration of methods to improve the safety of care transitions. Students also read a review article on the topic to further add to their fund of knowledge.23

The second part of the section involved discussion of a case posted on Blackboard (a discussion board) designed to highlight some of the challenges associated with care transitions. The case included 2 successive discharge summaries for an elderly patient with congestive heart failure: 1 for the initial exacerbation, and the other for a readmission. Using an online discussion board, students were asked to report the strong points and shortcomings of the patient's management, as well as those of the discharge summaries. Then the students were asked to post responses to at least 2 of their classmates' reports on the discussion board.

Training on Discharge Summaries

During the module, students received training on how to prepare a complete and informative discharge summary. This online training consisted of a lecture prepared by a faculty member (M.A.E.) and the use of a discharge summary template based on a guide prepared by the Boston Association of Academic Hospitalists (BAAHM), which is part of a toolkit available from the Society of Hospital Medicine.24 After reading the lecture, each student selected 1 of the patients they cared for during their rotation, and wrote a discharge summary. They posted it to a Blackboard discussion board, and were then asked to comment on one of their classmates' reports on the same forum. Faculty (M.A.E. and R.C.) also gave online feedback to each student about their discharge summary.

Postdischarge Phone Call

Students were also assigned to communicate with the patient for whom they prepared a discharge summary by performing a postdischarge phone call within a week of the patient's departure from the hospital. They reviewed a discharge checklist adapted from Ideal Discharge for an Elderly Patient: A Hospitalist Checklist, issued by the Society of Hospital Medicine.25 This document contains the necessary elements of a safe discharge plan, and used these points as the basis of the patient phone interview. The goal of the call and the use of the checklist was to reinforce the main elements of communication with patients that need to occur before they leave the hospital.

Students then used the checklist as the basis for a short (<400 words) report discussing the strong points and shortcomings of their patient's discharge, and posted it on a Blackboard discussion board. They were also asked to comment on at least one of their classmates' reports on the board. Faculty (M.A.E. and R.C.) also participated in the discussion board, commenting at least once on all students' reports.

RESULTS

The 121 students who took the module completed both the pre‐ and posttests. Table 1 details the mean pre‐ and posttest Likert scores for all confidence and attitude questions, as well as the changes in the 25‐point total confidence and attitude score from pre‐ to posttest. The change in confidence scores among survey participants was statistically significant (P < 0.001), while the change in attitude score was not (P = 0.07). Table 2 compares the percentage of correct answers before and after the course for individual knowledge questions, as well as for the entire knowledge quiz. Changes in total knowledge scores were statistically significant: the mean percentage of correct answers out of 10 questions was 68% on the pretest, and 82% on the posttest (P < 0.001).

Table 3 measures the changes in confidence, attitude, and knowledge scores by the period of the year in which students took the course. One‐way ANOVA tests for each of the 3 domains did not find statistically significant changes in confidence, attitude, or knowledge scores among the 3 trimesters in which we divided the module's calendar.

Table 4 shows satisfaction scores on the posttest. The overall Likert rating for the course was 3.9, with 97.5% of students rating it good or better. The highest‐rated individual component of the course by Likert score was the training on discharge summaries, with a rating of 4.1. The lowest‐rated by this parameter was the congestive heart failure case, with a rating of 3.6. The online discussion across all topics had the lowest percentage of students rating it good or above, at 83.5%.

As for student discharge summaries, 109 out of 121 (90.1%) met all the criteria in order to be deemed satisfactory; 109 out of 121 (90.1%) of postdischarge phone call reports met both required components. Both these results exceeded the goal of 80% set before the course started.

DISCUSSION

The Emory Care Transitions Curriculum for fourth‐year medical students started in the 20092010 academic year with the main goal of teaching students transferable skills that would ultimately lead to their participating in safer hospital discharges in their future practice as physicians. At the end of this course, students exhibited greater confidence in managing the discharge process, improved overall fund of knowledge relating to care transitions, and a demonstration of appropriate skills related to preparing discharge summaries and communicating with patients at discharge. This was all executed with a delivery method that students found engaging.

Analyzing the results, it is noteworthy that confidence improved, while attitudes did not. Even though confidence in performing a task does not necessarily reflect one's ability to perform it, our students' confidence scores may serve as a proxy for their ability to manage tasks related to the discharge process, like managing medications and preparing discharge summaries. Thus, while some studies suggest that self‐assessment among physicians may not always relate well to competence,26, 27 in our study, students did demonstrate skills in discharge summary preparation and in identifying the most relevant aspects of patient communication at hospital discharge. As for the absence of attitude change, this may have partly been a function of the fact that students in our group started with attitude scores that were already quite high, with a mean pretest attitude score of 20.7 out of 25.

Changes in student confidence, attitudes, and knowledge from pre‐ to posttest did not vary significantly across the academic year. Thus, one could interpret from our findings that more experienced students who took the module close to graduation benefited similarly from the course to those who completed it earlier, at least according to those rubrics. Another possible source of variation in student experience was the hospital in which students rotated: the demographics of GMH, with its large uninsured population; AVAMC, with more elderly patients; and EUH, with a more affluent profile, are certainly different. However, the number of students rotating at EUH and AVAMC were comparatively too small to attempt to draw any conclusions about how rotation site affected student experiences.

The use of a blended approach that integrated face‐to‐face didactics, patient care, and online learning offered some advantages. Curricular goals were achieved through a course that required only 2 hours of in‐person faculty time with students. This is significant, considering the time demands that academic medical faculty usually face. This approach also permitted students who were participating in a busy clinical rotation, and had limited opportunities to meet as a group, the ability to do coursework at their own pace. Another strength of the study is that all students who participated in the rotation were able to complete their surveys.

As for limitations, it is worth noting that in a course with a blended curriculum, the online discussion had the lowest percentage of students rating it good or better. Part of the perceived difficulty may have resulted from the fact that there are no other courses in the Emory medical curriculum that utilize discussion boards or distance learning methods as teaching tools. Despite this generation of students' technological savvy, this new mode of discussion may have proven difficult to pick up when they were in the midst of a busy clinical rotation. This serves as a reminder that while online curricula have proven successful in this and other settings, each element needs to be tailored to the audience. One other factor to be considered while interpreting this study's results is that this study utilized some survey instruments that have not been previously validated, even though they were developed in consultation with experts in the field of care transitions education.

We used a dichotomous, criteria‐based system to rate students' discharge summaries and reports of postdischarge phone calls. While this quantitative approach allowed us to more objectively define the quality of students' work, it did offer some disadvantages. First, even though we based the rating system for discharge summaries on a BAAHM template, it was not subjected to more extensive validation. Moreover, the quantitative approach diverted us from finding themes and other qualitative data from students' write‐ups, which could potentially have given us a fuller picture of their work.

This study contributes to the small, but growing, literature on care transitions education. The studies by Bray‐Hall et al., Lai et al., and Ouchida et al.,1921 used different methodologies, but all were directed at third‐year students using curricula with classroom and clinical learning, and showed favorable outcomes in knowledge and skills. The present study also showed positive results in students' knowledge and skills, but targeted it toward graduating medical students and included a focus on concrete skills, such as discharge summary preparation. It also utilized a nontraditional delivery approach which reached its objectives while also limiting the demands on faculty and students' face time during busy clinical rotations, which is especially important when considering that students were dispersed at multiple sites.

It is likely that medical schools will implement more care transitions curricula in coming years, as organizations like the AAMC11 and the Institute of Medicine10 increase the pressure to train future doctors to better address the needs of older and chronically ill patients, who require care from professionals of multiple disciplines, in disparate care settings. Moreover, the 2010 Patient Protection and Affordable Care Act28 contains provisions with financial incentives for hospitals to decrease readmissions. Once these become widely implemented, there will be a greater impetus to train medical practitioners to discharge patients more safely. When that occurs, medical schools will have additional compelling reasons to offer courses that teach students skills to execute better care transitions. The hoped‐for outcome of these curricula will ultimately be safer and more effective patient care.

There is increasing evidence that the transfer of medically complex patients across different settings can be associated with poor communication and patient dissatisfaction with the care received, potentially leading to negative clinical outcomes. While medical schools are beginning to introduce curricula on these transitions of care, few have been evaluated and subjected to peer review with the purpose of finding the most effective teaching and training methods.

Older adults and those with multiple chronic diseases frequently require medical care that spans multiple locations, and thus are most at risk for poor clinical outcomes during care transitions.1, 2 Medication errors and adverse drug reactions after hospital discharge are common.3, 4 Unsuccessful care transitions may also result in nonelective readmission after discharge, and there is evidence that readmissions may be a quality indicator for hospital care.57 Poor communication between patients and their healthcare providers is another element of poorly executed care transitions. Qualitative studies show that patients are frequently dissatisfied with the discharge process and are often unprepared to assume responsibility for their own care when they leave the hospital.8 Communication among providers can also be suboptimal. One meta‐analysis found that hospital physicians and primary care providers communicated infrequently and the availability of discharge summaries at the postdischarge visit was low, which may have affected the quality of care.9

Knowing that these gaps are common, there have been signs of increased emphasis on improving communication and working in teams as part of health professions training. The Institute of Medicine, in its 2003 report Health Professions Education: A Bridge to Quality,10 stressed education on management of chronic diseases, working in interdisciplinary teams, as well as a focus on quality improvement. In addition, the American Association of Medical Colleges (AAMC) encouraged training medical students on preparing safe discharge plans in its 2007 geriatrics competencies.11

Some medical schools have introduced care transitions curricula, though few have published data on their effectiveness. A search for teaching products using care transitions or transitional care on the online educational portals POGOe (Portal of Geriatric Online Education) and MedEdPortal yielded a total of 7 unique sets of teaching materials on care transitions for medical students.1218 However, a search on PubMed in July 2010 for peer‐reviewed articles on care transitions curricula developed for medical students which contained evaluation data only yielded 3 articles.1921 These 3 curricula, written by Bray‐Hall et al., Lai et al., and Ouchida et al., respectively, all trained third‐year medical students on diverse aspects of the discharge process using methods such as lectures, workshops, and patient visits, and showed favorable skill and knowledge outcomes.

Recognizing the importance of care transitions in medical education, a new curriculum addressing this topic was developed and introduced for fourth‐year medical students at the Emory University School of Medicine in 2009. The broad goal for this module was to develop a course concentrating on concrete skills that would train students to perform better care transitions while minimizing the time they had to spend away from a busy Internal Medicine sub‐internship. This curriculum used a mixed approach that included face‐to‐face teaching with faculty, online didactic instruction and interaction, and direct patient care. The course objectives were for students to develop a working fund of knowledge on care transitions, to learn to write a complete discharge summary, and to communicate the elements of a safe discharge plan. This article will describe the implementation of this curriculum and its evaluation.

METHODS

The Emory Care Transitions Curriculum started in August 2009 with fourth‐year medical students at the Emory University School of Medicine. This section will describe the details of the implementation of this curriculum, as well as the evaluation methodology and results.

Course Description

The course consisted of 3 components, each associated with specific student assignments: a slide presentation on care transitions with an associated case discussion, training on discharge summaries, and the execution of a postdischarge phone call. Figure 1 describes the course delivery schedule.

Figure 1

Slide Presentation and Case Discussion

This section started on day 2 of the clerkship, with a face‐to‐face lecture titled Transitions of Care: Why They Are Important, and How to Improve Them. It included the following components: definition of the different posthospital discharge options, explanation of the reasons for the complexity of care transitions in high‐risk patient populations, and an enumeration of methods to improve the safety of care transitions. Students also read a review article on the topic to further add to their fund of knowledge.23

The second part of the section involved discussion of a case posted on Blackboard (a discussion board) designed to highlight some of the challenges associated with care transitions. The case included 2 successive discharge summaries for an elderly patient with congestive heart failure: 1 for the initial exacerbation, and the other for a readmission. Using an online discussion board, students were asked to report the strong points and shortcomings of the patient's management, as well as those of the discharge summaries. Then the students were asked to post responses to at least 2 of their classmates' reports on the discussion board.

Training on Discharge Summaries

During the module, students received training on how to prepare a complete and informative discharge summary. This online training consisted of a lecture prepared by a faculty member (M.A.E.) and the use of a discharge summary template based on a guide prepared by the Boston Association of Academic Hospitalists (BAAHM), which is part of a toolkit available from the Society of Hospital Medicine.24 After reading the lecture, each student selected 1 of the patients they cared for during their rotation, and wrote a discharge summary. They posted it to a Blackboard discussion board, and were then asked to comment on one of their classmates' reports on the same forum. Faculty (M.A.E. and R.C.) also gave online feedback to each student about their discharge summary.

Postdischarge Phone Call

Students were also assigned to communicate with the patient for whom they prepared a discharge summary by performing a postdischarge phone call within a week of the patient's departure from the hospital. They reviewed a discharge checklist adapted from Ideal Discharge for an Elderly Patient: A Hospitalist Checklist, issued by the Society of Hospital Medicine.25 This document contains the necessary elements of a safe discharge plan, and used these points as the basis of the patient phone interview. The goal of the call and the use of the checklist was to reinforce the main elements of communication with patients that need to occur before they leave the hospital.

Students then used the checklist as the basis for a short (<400 words) report discussing the strong points and shortcomings of their patient's discharge, and posted it on a Blackboard discussion board. They were also asked to comment on at least one of their classmates' reports on the board. Faculty (M.A.E. and R.C.) also participated in the discussion board, commenting at least once on all students' reports.

RESULTS

The 121 students who took the module completed both the pre‐ and posttests. Table 1 details the mean pre‐ and posttest Likert scores for all confidence and attitude questions, as well as the changes in the 25‐point total confidence and attitude score from pre‐ to posttest. The change in confidence scores among survey participants was statistically significant (P < 0.001), while the change in attitude score was not (P = 0.07). Table 2 compares the percentage of correct answers before and after the course for individual knowledge questions, as well as for the entire knowledge quiz. Changes in total knowledge scores were statistically significant: the mean percentage of correct answers out of 10 questions was 68% on the pretest, and 82% on the posttest (P < 0.001).

Table 3 measures the changes in confidence, attitude, and knowledge scores by the period of the year in which students took the course. One‐way ANOVA tests for each of the 3 domains did not find statistically significant changes in confidence, attitude, or knowledge scores among the 3 trimesters in which we divided the module's calendar.

Table 4 shows satisfaction scores on the posttest. The overall Likert rating for the course was 3.9, with 97.5% of students rating it good or better. The highest‐rated individual component of the course by Likert score was the training on discharge summaries, with a rating of 4.1. The lowest‐rated by this parameter was the congestive heart failure case, with a rating of 3.6. The online discussion across all topics had the lowest percentage of students rating it good or above, at 83.5%.

As for student discharge summaries, 109 out of 121 (90.1%) met all the criteria in order to be deemed satisfactory; 109 out of 121 (90.1%) of postdischarge phone call reports met both required components. Both these results exceeded the goal of 80% set before the course started.

DISCUSSION

The Emory Care Transitions Curriculum for fourth‐year medical students started in the 20092010 academic year with the main goal of teaching students transferable skills that would ultimately lead to their participating in safer hospital discharges in their future practice as physicians. At the end of this course, students exhibited greater confidence in managing the discharge process, improved overall fund of knowledge relating to care transitions, and a demonstration of appropriate skills related to preparing discharge summaries and communicating with patients at discharge. This was all executed with a delivery method that students found engaging.

Analyzing the results, it is noteworthy that confidence improved, while attitudes did not. Even though confidence in performing a task does not necessarily reflect one's ability to perform it, our students' confidence scores may serve as a proxy for their ability to manage tasks related to the discharge process, like managing medications and preparing discharge summaries. Thus, while some studies suggest that self‐assessment among physicians may not always relate well to competence,26, 27 in our study, students did demonstrate skills in discharge summary preparation and in identifying the most relevant aspects of patient communication at hospital discharge. As for the absence of attitude change, this may have partly been a function of the fact that students in our group started with attitude scores that were already quite high, with a mean pretest attitude score of 20.7 out of 25.

Changes in student confidence, attitudes, and knowledge from pre‐ to posttest did not vary significantly across the academic year. Thus, one could interpret from our findings that more experienced students who took the module close to graduation benefited similarly from the course to those who completed it earlier, at least according to those rubrics. Another possible source of variation in student experience was the hospital in which students rotated: the demographics of GMH, with its large uninsured population; AVAMC, with more elderly patients; and EUH, with a more affluent profile, are certainly different. However, the number of students rotating at EUH and AVAMC were comparatively too small to attempt to draw any conclusions about how rotation site affected student experiences.

The use of a blended approach that integrated face‐to‐face didactics, patient care, and online learning offered some advantages. Curricular goals were achieved through a course that required only 2 hours of in‐person faculty time with students. This is significant, considering the time demands that academic medical faculty usually face. This approach also permitted students who were participating in a busy clinical rotation, and had limited opportunities to meet as a group, the ability to do coursework at their own pace. Another strength of the study is that all students who participated in the rotation were able to complete their surveys.

As for limitations, it is worth noting that in a course with a blended curriculum, the online discussion had the lowest percentage of students rating it good or better. Part of the perceived difficulty may have resulted from the fact that there are no other courses in the Emory medical curriculum that utilize discussion boards or distance learning methods as teaching tools. Despite this generation of students' technological savvy, this new mode of discussion may have proven difficult to pick up when they were in the midst of a busy clinical rotation. This serves as a reminder that while online curricula have proven successful in this and other settings, each element needs to be tailored to the audience. One other factor to be considered while interpreting this study's results is that this study utilized some survey instruments that have not been previously validated, even though they were developed in consultation with experts in the field of care transitions education.

We used a dichotomous, criteria‐based system to rate students' discharge summaries and reports of postdischarge phone calls. While this quantitative approach allowed us to more objectively define the quality of students' work, it did offer some disadvantages. First, even though we based the rating system for discharge summaries on a BAAHM template, it was not subjected to more extensive validation. Moreover, the quantitative approach diverted us from finding themes and other qualitative data from students' write‐ups, which could potentially have given us a fuller picture of their work.

This study contributes to the small, but growing, literature on care transitions education. The studies by Bray‐Hall et al., Lai et al., and Ouchida et al.,1921 used different methodologies, but all were directed at third‐year students using curricula with classroom and clinical learning, and showed favorable outcomes in knowledge and skills. The present study also showed positive results in students' knowledge and skills, but targeted it toward graduating medical students and included a focus on concrete skills, such as discharge summary preparation. It also utilized a nontraditional delivery approach which reached its objectives while also limiting the demands on faculty and students' face time during busy clinical rotations, which is especially important when considering that students were dispersed at multiple sites.

It is likely that medical schools will implement more care transitions curricula in coming years, as organizations like the AAMC11 and the Institute of Medicine10 increase the pressure to train future doctors to better address the needs of older and chronically ill patients, who require care from professionals of multiple disciplines, in disparate care settings. Moreover, the 2010 Patient Protection and Affordable Care Act28 contains provisions with financial incentives for hospitals to decrease readmissions. Once these become widely implemented, there will be a greater impetus to train medical practitioners to discharge patients more safely. When that occurs, medical schools will have additional compelling reasons to offer courses that teach students skills to execute better care transitions. The hoped‐for outcome of these curricula will ultimately be safer and more effective patient care.