Abstract
Objective:
Healthcare utilization after bronchiolitis hospitalization is incompletely understood. We aimed to characterize readmissions and outpatient visits within one year after hospital discharge.
Patients and Methods:
Retrospective multicenter observational cohort study of children under 24-months old admitted with bronchiolitis between 1/1/2010 and 12/31/2019 to the Pediatric Health Information Systems (PHIS) database. A single-center nested subset using linked electronic health records allowed analysis of outpatient visits.
Results:
There were 308,306 admissions for bronchiolitis among 271,115 patients across 47 hospitals between 2010–2019. 6.0% (16,167/271,115) of patients were readmitted within 30 days after discharge, and 17.8% (48,332/271,115) of patients were readmitted within one year. 22.9% (16,919/74,001) of patients admitted to an intensive care unit and 26.8% (7,865/29,378) of patients undergoing mechanical ventilation were readmitted within one year. There were 1,438 patients with outpatient healthcare data available. There were a median (IQR) of 9 (6–13) outpatient visits per patient within one year after discharge. Outpatient healthcare use increased for 4 months following bronchiolitis hospitalization compared to previously reported age-matched controls. Higher income, white race, commercial insurance, complex chronic conditions, ICU admission, and mechanical ventilation were associated with higher outpatient utilization. Higher quartiles of outpatient use were associated with readmission for bronchiolitis and all-cause readmissions.
Conclusions:
Readmissions in the year after bronchiolitis hospitalization are common, and outpatient healthcare use is increased for 4 months following discharge. Prospective study is needed to track long-term outcomes of infants with bronchiolitis.
Keywords: Bronchiolitis, asthma, pediatrics, epidemiology
INTRODUCTION
Bronchiolitis is the most common cause of hospitalization for children under two years.1–7 While often perceived as benign; bronchiolitis is associated with lasting symptoms in a subset of children. Recurrent wheezing is common after hospitalization for bronchiolitis; as many as 40% of children have symptoms 36-months after discharge, and children admitted with bronchiolitis have high utilization of asthma controller medications for up to one year following hospitalization.8,9 More severe episodes of bronchiolitis are associated with a higher probability of subsequent asthma;10 infants admitted for bronchiolitis have an approximately 20% probability of subsequent admission for asthma or pneumonia.11
Despite the above associations, healthcare utilization following bronchiolitis hospitalization remains incompletely understood. Estimates of 30-day readmission rates range from 3.7%−6.4%, with younger age and lower socioeconomic status associated with readmission.12–14 A study of the National Health Services database in England estimated one-year readmissions as high as 37%, however this study was conducted over a single 12-month timespan.15 Additionally, to our knowledge, no study has analyzed outpatient healthcare utilization following bronchiolitis hospitalization. The AAP has highlighted long-term outcomes of bronchiolitis as a research need.1
The objective of the present study was to characterize one-year healthcare use among infants hospitalized with bronchiolitis. We sought to determine readmissions in a large multi-center children’s hospital database over a ten-year timespan. Additionally, we aimed to analyze outpatient healthcare utilization in a single-center nested subset analysis at a quaternary care children’s hospital and regional healthcare system.
METHODS
Patients:
This retrospective multicenter observational cohort study was approved by the local institutional review board. To determine a multicenter one-year readmission proportion among patients admitted with bronchiolitis, patients were included if they 1) had a first inpatient hospital admission with a diagnosis of bronchiolitis, 2) at an age of less than 24 months old, 3) between 1/1/2010 and 12/31/2019. To analyze outpatient healthcare utilization following bronchiolitis hospitalization, a nested single-center analysis was performed. The above cohort was filtered to include patients who additionally received ≥ 1 primary care visit within 0–12 months of hospitalization and ≥ 1 primary care visit ≥ 12 months after hospitalization within our healthcare system to eliminate loss to follow up. There were no exclusion criteria.
Data Source:
The cohort was identified by querying the Pediatric Health Information Systems (PHIS) database for inpatient encounters with International Classification of Diseases (ICD) diagnostic codes for bronchiolitis (ICD-9 466.1 or ICD-10 J21). PHIS is a quality-controlled administrative data warehouse of children’s hospitals maintained by the Children’s Hospital Association.16 Readmissions were identified by querying PHIS. Institutional records were linked to the PHIS encounters using a decryption key. Inpatient clinical variables were extracted from an enterprise data warehouse (EDW; Oracle, Austin, Texas) synchronized with the inpatient electronic health record (Cerner, North Kansas City, Missouri). Outpatient encounters for health system primary care clinics, specialty clinics, urgent care facilities, and emergency departments included data from the institution’s outpatient electronic health record (Epic, Verona, Wisconsin). Records were linked using the enterprise master patient index. Zip-code median income was extracted from PHIS and neighborhood area deprivation index (ADI) was extracted from the EDW. Outpatient encounters and readmissions were obtained for 1/1/2010 to 12/31/2020 and filtered to within one year of the index bronchiolitis hospitalization.
Statistical Analyses:
Vital signs, laboratory values, pharmacy prescriptions, and oxygen therapy underwent validation assessment prior to analysis. Demographics were described with summary statistics. For the multicenter cohort, mechanical ventilation was determined by ICD codes and includes both invasive and non-invasive ventilation. For the nested single-center cohort, mechanical ventilation was more precisely divided into invasive and non-invasive ventilation based on charting by respiratory therapists. Encounters were described using summary statistics. Monthly outpatient encounters following discharge were plotted. Patients were stratified according to level of respiratory support, and monthly healthcare utilization was compared using one-way Analysis of Variance (ANOVA) or Kruskal-Wallis rank-sum test. Because there was an increase in outpatient healthcare use during the first 4 months following bronchiolitis hospitalization compared to previously published population norms,17 patients were stratified into quartiles based on the number of outpatient healthcare visits in the first 4 months following discharge and compared using Kruskal-Wallis rank-sum test, chi-square test, or Fischer exact test. Readmission proportions were compared using chi-square or Fischer exact test. All statistical analyses were performed using RStudio (RStudio, Boston, MA) and R version 4.1.3 (R Foundation for Statistical Computing, Vienna, Austria).
Sensitivity Analysis:
To clarify whether outpatient healthcare utilization was related to bronchiolitis hospitalization or other underlying illness, we conducted a sensitivity analysis excluding patients with complex chronic conditions at the time of their index hospitalization.18
RESULTS
Demographics:
There were 308,306 admissions for bronchiolitis among 271,115 patients across 47 hospitals in PHIS between 2010–2019. Demographics are shown in Supplemental Table 1. Briefly, the median (IQR) age at admission was 5 (2–11) months. 18.5% (50,049/271,115) had a complex chronic condition. Specifically, 4.1% (11,200/271,115) were premature or had a neonatal condition and 3.3% (8,814/271,115) had a respiratory condition. 27.3% (74,001/271,115) were admitted to an ICU and 10.8% (29,378/271,115) received mechanical ventilation. Survival to discharge was 99.8% (270,611/271,115).
One-Year Readmissions:
17.8% (48,332/271,115) of patients were readmitted within one year after discharge a median (IQR) of 1 (1–2) times, for a total of 85,893 readmissions. The median (IQR) time to readmission was 1.9 (0.7–4.8) months. 6.0% (16,167/271,115) of patients were readmitted within 30 days after discharge. 9.9% (26,712/271,115) of patients were readmitted for bronchiolitis, with the remainder being readmitted for other diagnoses. The median (IQR) hospital-level 1-year readmission proportion was 18.3% (16.1% - 19.6%; Figure 1A). 26.9% (71,883/267,448) of patients received ICU care during their index bronchiolitis admission, and 10.6% (28,376/267,448) received mechanical ventilation. Severity of illness during the index hospitalization was correlated with readmission; the one-year readmission proportion was 22.9% (16,919/74,001) among patients admitted to the ICU and 26.8% (7,865/29,378) among patients undergoing mechanical ventilation, respectively (Figure 1B).
Figure 1: Readmissions Following Bronchiolitis Discharge.
Panel A shows the one-year readmission proportion after bronchiolitis hospitalization across the included 47 hospitals. The x-axis shows the hospitals (ranked by readmission proportion) and the y-axis shows the one-year readmission proportion. The black bars represent patients readmitted for bronchiolitis and the gray bars represent patients readmitted for other diagnoses. Panel B shows the cumulative readmission proportion over one-year following bronchiolitis hospitalization. The x-axis shows the months after discharge, and the y-axis shows the readmission proportion. The black line shows the overall readmission proportion. The dotted red line shows patients admitted to the general ward during their index admission. The dashed blue line shows patients admitted to the intensive care unit, and the dashed purple line shows patients who received mechanical ventilation.
Nested Single-Center Cohort Demographics:
There were 5,326 admissions for bronchiolitis among 4,791 patients at our center during the study period. Of those, 1,438/4,791 (30.0%) patients had primary care in our system and were included (Supplemental Figure 1). Demographics are listed in Supplemental Table 1. Briefly, the single-center cohort was younger (median [IQR] age 4 [1–9] versus 5 [2–11] months, p < 0.001) than the multi-center cohort. The single-center cohort also had a higher proportion of white patients (69.1% [993/1,438] versus 55.1% [149,378/271,115], p < 0.001), complex chronic conditions (20.7% [297/1,438] versus 18.5% [50,049/271,115], p = 0.033), and mechanical ventilation (15.4% [222/1,438] versus 10.8% [29,378/271,115], p < 0.001) than the multi-center cohort.
Outpatient Healthcare Use:
Outpatient healthcare use following hospitalization for bronchiolitis is shown in Figure 2. There were a median (IQR) of 9 (6–13) total outpatient physician or advanced practice provider visits per patient within 12 months after discharge. Utilization was higher across all visit types for the first 4 months after discharge compared to the remainder of the study period (Figure 2). Outpatient healthcare utilization was right tailed, with a small number of patients utilizing a large volume of outpatient care (Supplemental Figure 2). Severity of illness was correlated with increased outpatient healthcare utilization for approximately four months following hospital discharge (Figure 2). Patients in the highest quartile of healthcare utilization had more usage across all visit categories, but most markedly in sick visits to primary care offices and specialist visits (Table 1). The median (IQR) age at admission was 5 (2–10) months in patients in the lowest quartile and 5 (2–9) in patients in the highest quartile. Patients in the highest quartile were more often male, white, and from areas with higher household income and lower ADI (Table 1). They were more likely to have complex chronic conditions, a history of prematurity, and technology dependence (Table 1). There was no significant difference in presenting respiratory rate, heart rate, hemoglobin oxygen saturation, or laboratory values (e.g. pH, PCO2, electrolyte values, and inflammatory markers) at index admission between the quartiles of healthcare utilization (data not shown).
Figure 2: Healthcare Utilization Following Bronchiolitis Discharge.
Both panes show the number of visits per 1,000 patients on the y-axis against the month after discharge from a hospitalization for bronchiolitis on the x-axis. Each bar represents a one-month period. In the top pane, the shades of gray represent the visit types as per the scale on the right side of the graph. In the bottom pane, the bars are colored by the maximum level of respiratory support received during the index bronchiolitis hospitalization. The bar height represents the mean, and the error bars represent the standard error of the mean. Statistical significance according to one-way analysis of variance is shown in the stars underneath each month where: * represents p < 0.05 and ** represents p < 0.01.
Table 1.
Quartiles of Healthcare Utilization in the First 4 Months Following Hospitalization for Bronchiolitis.
| Total Outpatient Visits Within 4 Months | 4 (2, 6) | 2 (1, 2) | 3 (3, 3) | 5 (4, 5) | 8 (6, 10) | <0.001 |
| PCP: Routine Visits | 1 (1, 2) | 1 (0, 1) | 1 (1, 2) | 2 (1, 2) | 2 (1, 2) | <0.001 |
| PCP: Sick Visits | 1 (0, 3) | 0 (0, 1) | 1 (0, 2) | 2 (1, 3) | 4 (2, 5) | <0.001 |
| Specialist Visits | 0 (0, 1) | 0 (0, 0) | 0 (0, 0) | 0 (0, 1) | 2 (0, 4) | <0.001 |
| Urgent Care / ED Visits | 0 (0, 1) | 0 (0, 0) | 0 (0, 0) | 0 (0, 1) | 0 (0, 1) | <0.001 |
| Quartile Demographics | ||||||
| Age (Months) | 4 (1, 9) | 5 (2, 10) | 4 (1, 9) | 3 (1, 8) | 5 (2, 9) | <0.001 |
| Sex | <0.001 | |||||
| Female | 576 (40.1%) | 166 (46.1%) | 161 (44.7%) | 129 (35.8%) | 120 (33.5%) | |
| Male | 862 (59.9%) | 194 (53.9%) | 199 (55.3%) | 231 (64.2%) | 238 (66.5%) | |
| Race | <0.001 | |||||
| White | 993 (69.1%) | 194 (53.9%) | 250 (69.4%) | 272 (75.6%) | 277 (77.4%) | |
| Black | 357 (24.8%) | 142 (39.4%) | 86 (23.9%) | 68 (18.9%) | 61 (17.0%) | |
| Other | 88 (6.1%) | 24 (6.7%) | 24 (6.7%) | 20 (5.6%) | 20 (5.6%) | |
| 2010 Median Household Income | 35,727 (30,066, 42,614) | 32,652 (26,663, 39,431) | 36,038 (30,508, 43,390) | 36,074 (31,281, 42,614) | 36,074 (31,281, 43,713) | <0.001 |
| Area Deprivation Index | 70 (47, 88) | 77 (52, 94) | 72 (49, 89) | 69 (47, 86) | 64 (42, 85) | <0.001 |
| Insurance | <0.001 | |||||
| Commercial | 376 (26.1%) | 78 (21.7%) | 89 (24.7%) | 107 (29.7%) | 102 (28.5%) | |
| Government | 798 (55.5%) | 249 (69.2%) | 198 (55.0%) | 174 (48.3%) | 177 (49.4%) | |
| Other | 264 (18.4%) | 33 (9.2%) | 73 (20.3%) | 79 (21.9%) | 79 (22.1%) | |
| Any CCC | 297 (20.7%) | 45 (12.5%) | 53 (14.7%) | 70 (19.4%) | 129 (36.0%) | <0.001 |
| CCC: Cardiovascular | 63 (4.4%) | 9 (2.5%) | 9 (2.5%) | 17 (4.7%) | 28 (7.8%) | <0.001 |
| CCC: Premature/Neonatal | 63 (4.4%) | 8 (2.2%) | 7 (1.9%) | 20 (5.6%) | 28 (7.8%) | <0.001 |
| CCC: Respiratory | 83 (5.8%) | 12 (3.3%) | 7 (1.9%) | 17 (4.7%) | 47 (13.1%) | <0.001 |
| CCC: Technology Dependence | 81 (5.6%) | 6 (1.7%) | 14 (3.9%) | 22 (6.1%) | 39 (10.9%) | <0.001 |
| Index Admission Characteristics | ||||||
| ICU Admission | 400 (27.8%) | 87 (24.2%) | 97 (26.9%) | 95 (26.4%) | 121 (33.8%) | 0.030 |
| Highest Level of Respiratory Support | 0.002 | |||||
| Room Air | 330 (23.0%) | 97 (26.9%) | 87 (24.2%) | 80 (22.2%) | 66 (18.5%) | |
| Oxygen | 889 (61.9%) | 221 (61.4%) | 229 (63.8%) | 226 (62.8%) | 213 (59.7%) | |
| NIV | 100 (7.0%) | 23 (6.4%) | 23 (6.4%) | 23 (6.4%) | 31 (8.7%) | |
| IMV | 117 (8.1%) | 19 (5.3%) | 20 (5.6%) | 31 (8.6%) | 47 (13.2%) | |
| Received Albuterol | 765 (53.2%) | 211 (58.6%) | 181 (50.3%) | 173 (48.1%) | 200 (55.9%) | 0.020 |
| Received Steroids | 355 (24.7%) | 90 (25.0%) | 80 (22.2%) | 72 (20.0%) | 113 (31.6%) | 0.002 |
| Received Antibiotics | 640 (44.5%) | 175 (48.6%) | 145 (40.3%) | 156 (43.3%) | 164 (45.8%) | 0.14 |
| Readmissions | ||||||
| Ever Readmitted | 293 (20.4%) | 54 (15.0%) | 55 (15.3%) | 59 (16.4%) | 125 (34.9%) | <0.001 |
| Readmitted for Bronchiolitis* | 131 (9.1%) | 22 (6.1%) | 27 (7.5%) | 31 (8.6%) | 51 (14.2%) | <0.001 |
| Readmitted for Other Diagnoses* | 210 (14.6%) | 39 (10.8%) | 34 (9.4%) | 38 (10.6%) | 99 (27.7%) | <0.001 |
CCC: Complex Chronic Condition
IMV: Invasive Mechanical Ventilation
NIV: Non-Invasive Ventilation
PCP: Primary Care Physician
Note: patients with multiple readmissions could be admitted for bronchiolitis and for other diagnoses
Association Between Outpatient Healthcare Utilization and Readmission:
There were 567 readmissions within 1 year among 293/1,438 (20.4%) of patients in the single-center analysis. The readmission proportion in the single-center analysis was significantly higher than in the multi-center analysis (20.4% [293/1,438] versus 17.8% [48,332/271,115], p = 0.013). Higher quartiles of outpatient healthcare utilization within 4 months following bronchiolitis hospitalization were associated with all-cause readmissions, as well as bronchiolitis readmissions (Table 1).
Sensitivity Analyses:
The sensitivity analysis excluding patients with complex chronic conditions (CCCs) included 1,140/1,438 (79.3%) of the single-center cohort. Demographics are listed in Supplemental Table 2. Patients without CCCs had a lower one-year readmission proportion than either the multi-center analysis (14.8% [169/1,141] versus 17.8% [48,332/271,115], p = 0.008) or the single-center analysis (14.8% [169/1,141] versus 20.4% [293/1,438], p < 0.001). Patients without CCCs used fewer subspecialty visits after discharge, resulting in lower overall outpatient healthcare utilization (Supplemental Table 3). Similar to the single-center analysis, higher quartiles of outpatient healthcare utilization within 4 months following bronchiolitis hospitalization were associated with all-cause readmissions, as well as bronchiolitis readmissions (Supplemental Table 3).
DISCUSSION
This medical record and administrative database linkage study is the first to analyze both inpatient and outpatient healthcare utilization in the year following hospitalization for bronchiolitis. We report two major findings. First, readmissions are common in the first year after bronchiolitis, occurring in 17.8% of patients in this 47-hospital decade-long cohort. Second, outpatient healthcare use is increased for 4 months following bronchiolitis hospitalization in a large, integrated delivery and finance healthcare system in the United States.
Most prior studies have examined 30-day readmissions in patients with bronchiolitis.12–14 The 30-day readmission proportion of 6.0% in the present study is in agreement with previous work.12–14 However, the one-year readmission proportion of 17.8% suggests that previous studies likely do not capture the long-term outcomes of these infants. Indeed, readmission rates rose relatively sharply for approximately 4 months following hospitalization before reaching a constant level (Figure 1B). This is the same period during which we observed an increase in outpatient healthcare utilization in our single-center cohort (Figure 2). In both cases, the effect was most pronounced in more ill children; those requiring mechanical ventilation had higher outpatient healthcare use (Figure 2) and readmissions (Figure 1B).
During the first 4 months following hospitalization, patients with bronchiolitis utilized approximately 1.5 times as many outpatient visits as would be expected based on reports of primary care use among commercially-insured well children under two in the United States (Figure 2).17 Outpatient healthcare utilization was right-tailed, with a small number of patients incurring a large number of visits (Supplemental Figure 2), and frequent outpatient visits were associated with readmissions for bronchiolitis as well as all-cause readmissions (Table 1). Similar trends were seen in a sensitivity analysis excluding children with pre-existing complex chronic conditions (Supplemental Table 3), suggesting that there may be a sub-population of children who have prolonged vulnerability to subsequent respiratory infections after discharge. While prior studies have shown long-term differences in pulmonary function testing and more severe routine childhood illnesses in children with severe bronchiolitis,8,9,11,19,20 it remains unclear whether this association is casual or mirrors underlying genetic predisposition. Prospective study is needed to determine whether patients with severe bronchiolitis may benefit from early evaluation by a pulmonologist or intermittent corticosteroids during acute illnesses to reduce severity.21,22
The association between outpatient visits and hospital readmissions has important policy ramifications. The AAP has specific interest in predicting the course of patients with bronchiolitis1 and there is national interest in identifying “superusers” of healthcare as a method of cost-containment.23,24 A recent large randomized controlled trial highlighted that adult patients who demonstrate increased healthcare utilization for a period surrounding hospitalization commonly regress to a mean level of utilization.25 However, in our population, increased outpatient utilization was sustained for 4 months following discharge and associated with readmissions (Figure 2 and Table 1). This association is important, as previous studies have been unable to identify reliable predictors of readmission in bronchiolitis.12,13
In our study, patients in the highest quartile of healthcare utilization had generally more-severe illness (as assessed by higher rates of ICU admission and invasive mechanical ventilation). However, predicting “high-users” of healthcare at the time of index admission for bronchiolitis remains challenging. As shown in Table 1, only 30.3% (121/400) of patients admitted to an intensive care unit and 40.2% (47/117) of patients undergoing invasive mechanical ventilation for bronchiolitis were in the highest quartile of healthcare utilization after discharge. Thus, follow up programs for every intubated patient with bronchiolitis will likely be low yield. The harmonization of inpatient and outpatient medical records to predict long-term readmissions is an important goal of learning health systems.
Outpatient healthcare utilization is an amalgamation of disease severity, care-seeking thresholds, and barriers to care. We note concerning disparities in care locations between racial groups and socioeconomic strata. Patients with high healthcare utilization were more likely to be white, have commercial insurance, and live in more-affluent neighborhoods with lower area deprivation indices (ADI, Table 1). Race and ADI are both known to be associated with access to primary care.26,27 Because higher ADI is known to be associated with worse outcomes in other pediatric respiratory conditions,28,29 higher healthcare utilization among wealthier patients in the present study likely reflects ongoing disparities in pediatric care.
This study highlights the potential of harmonizing multiple health system data sources to understand patient trajectories. Many pediatric conditions such as bronchiolitis have very low inpatient mortality. As mortality continues to decline, there is increased interest in examining long-term outcomes. The interaction between patients and the healthcare system is complex, with patients often changing context. For example, a patient is seen in urgent care, admitted to the hospital, and then has a follow up appointment in a primary care office after discharge. Prominent inpatient databases often do not contain outcome data after discharge. We leveraged the readily available search tools of a quality-controlled national pediatric database16 to locate patients of interest and obtain demographic information, then used the institutional data warehouse to obtain detailed clinical information from an inpatient encounter, and a system-wide EDW to obtain information about follow up at dozens of different outpatient locations. Cross-platform linkages as demonstrated by our study offer the potential to understand disease arcs and complex long-term associations in exciting new ways. Mapping of multiple hospital systems to common data ontologies and standards such as the Observational Medical Outcomes Partnership (OMOP) and Fast Healthcare Interoperability Resources (FHIR) offers the promise of rapidly scaling such projects to analyze outcomes across multiple institutions.30,31
Our study has important limitations. First, patients may move out of the service area of PHIS hospitals during the follow up period, resulting in an underestimate of the one-year readmission proportion in the multi-center analysis. By contrast, patients in the single-center analysis could be filtered for ongoing primary care after 12 months, ensuring that they were not lost to follow up. However, this population represents patients who deliberately receive care within a quaternary children’s regional healthcare system, which may overestimate healthcare utilization relative to the population served by private practice clinics. Second, our definition of receiving healthcare within the system would exclude some patients with low healthcare utilization (less than 1 PCP visit per year). Given that approximately 5% of all children in the United States lack health insurance32 and likely consume very little healthcare, this may lead to a non-trivial overestimation of outpatient visits in the current study. Third, previously published outpatient visits were among commercially insured children,17 which made up only 26.1% of the single-center cohort in the present study. Because commercial insurance was associated with higher healthcare utilization than government insurance, the present study may underestimate the true increase in outpatient healthcare use after bronchiolitis hospitalization. Fourth, it remains unclear whether sociodemographic factors such as a race and neighborhood ADI truly influence biologic disease severity (for example, through airborne pollutant exposure), or reflect disparities in access to healthcare.
In conclusion, readmissions are common in the year following bronchiolitis hospitalization, and outpatient healthcare use is increased for approximately 4 months following discharge. Outpatient healthcare utilization is related to severity of illness during the index admission and associated with socioeconomic disparities. Prospective study is needed to track long-term outcomes of infants with bronchiolitis.
Supplementary Material
Supplemental Figure 2: Histogram of healthcare utilization within 12 months following hospitalization for bronchiolitis. Each panel represents a category of outpatient visit as shown in the label. The number of visits within 12 months is shown on the x-axis, and the number of patients are on the y-axis. Each bar represents one visit. To show trends clearly, the x-axis was limited at 15 visits within 12 months.
Supplemental Figure 1: Patient flow chart. Patient selection flow chart showing patient inclusion and exclusion based on primary care follow up.
Funding:
5T32HD040686-20 (JHP), 5K23NS104133 (AKA), K23DK116973 (DYF), 1K23HD099331-01A1 (CMH)
Footnotes
Disclosures: The authors have no conflicts of interest relevant to this article to disclose.
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Associated Data
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Supplementary Materials
Supplemental Figure 2: Histogram of healthcare utilization within 12 months following hospitalization for bronchiolitis. Each panel represents a category of outpatient visit as shown in the label. The number of visits within 12 months is shown on the x-axis, and the number of patients are on the y-axis. Each bar represents one visit. To show trends clearly, the x-axis was limited at 15 visits within 12 months.
Supplemental Figure 1: Patient flow chart. Patient selection flow chart showing patient inclusion and exclusion based on primary care follow up.