Healthcare team communication training in the United States: A scoping review.

The purpose of this literature review was to identify interventions designed to improve healthcare team communication in the United States. We conducted a review of peer-reviewed, English-language articles describing interventions aimed at improving healthcare team communication. We analyzed articles that met pre-specified inclusion and exclusion criteria and characterized who is testing communication interventions, the rationale for testing, and ways of measuring effectiveness. We descriptively categorized the strength and types of study findings. Thirty articles were retained in our analysis. Most assessments were conducted by academic medical centers, the Veterans Health Administration, and teaching hospitals. Interventions sought to improve teamwork, patient safety, clinical outcomes, costs of care, and enhance provider job satisfaction and well-being. Intervention strategies included didactic lectures, simulation, Crew Resource Management, quality improvement, or a combination of these approaches. The vast majority employed a pre-post survey design and measured outcomes using participant feedback. Many assessments failed to utilize a social science theory or communication-specific measures. Interventions with the best training content were conducted at academic medical centers, used a pre-post design, and utilized statistical analysis to analyze results. While interventions for improving healthcare team communication are diverse and have uneven effectiveness, early markers of success merit continued development and assessment.

A mixed-methods program evaluation of the Alda Healthcare Experience- a program to improve healthcare team communication.

BACKGROUND: Communication among interprofessional healthcare worker teams is critical to ensure a thriving and resilient workforce. We will evaluate the implementation and effectiveness of the Alda Healthcare Experience (AHE), a novel medical improvisation (improv) workshop designed to improve interprofessional communication skills among healthcare professionals. The AHE workshop includes a two-hour experiential training workshop led by an improv specialist and a clinical co-facilitator. In July 2022 we began implementing the AHE workshop by training 18 clinical co-facilitators who will co-facilitate the workshops for 550 healthcare workers from five hospital departments at Stony Brook University Hospital over the course of a year and a half. Using mixed-methods, we will conduct an Effectiveness-Implementation Hybrid Design project that includes an outcome evaluation (effectiveness) and a process evaluation (implementation). METHODS: Our outcome evaluation will assess the impact of the AHE workshop on short- and long-term improvement in interprofessional communication, stress, and professional fulfillment. The process evaluation component will examine programmatic, organizational, and individual facilitators or barriers to effective implementation of the AHE workshop. Qualitative methods will include dimensional analysis employing individual interviews of 20-40 AHE Project Participants, 5-10 Selected Informants, and all the clinical co-facilitators. Quantitative methods will use a quasi-experimental longitudinal design with an intervention group and surveillance of a control group (wait-list) and repeated assessments using validated instruments measuring communications skills, professional fulfillment, stress, burnout, uncertainty tolerance, and teamwork. DISCUSSION: Effective and efficient communication within healthcare teams is fundamental to building team cohesion that, in turn, supports individual resilience and builds positive organizational culture. The AHE program is an innovative approach to improve interprofessional healthcare communication and reduce healthcare worker burnout. In addition to institutional buy-in, rigorous evaluations of medical improv programs are necessary as a critical step in making such programs scalable. TRIAL REGISTRATION: N/A.

Adverse Perinatal Outcomes Predicted by Prenatal Maternal Stress Among U.S. Women at the COVID-19 Pandemic Onset.

BACKGROUND: High stress prenatally contributes to poor maternal and infant well-being. The coronavirus disease 2019 (COVID-19) pandemic has created substantial stress for pregnant women. PURPOSE: To understand whether stress experienced by women pregnant at the beginning of the pandemic was associated with a greater prevalence of adverse perinatal outcomes. METHODS: Pregnant women across the USA aged ≥18 years old enrolled in a prospective cohort study during the pandemic onset (T1) in April-May 2020. This report focuses on the 1,367 participants who gave birth prior to July-August 2020 (T2). Hierarchical logistic regression models predicted preterm birth, small for gestational age infants, and unplanned operative delivery from T1 stress, sociodemographic, and medical factors. RESULTS: After controlling for sociodemographic and medical factors, preterm birth was predicted by high prenatal maternal stress, delivering an infant small for gestational age was predicted by interpersonal violence and by stress related to being unprepared for birth due to the pandemic, and unplanned cesarean or operative vaginal delivery was predicted by prenatal appointment alterations, experiencing a major stressful life event, and by stress related to being unprepared for birth due to the pandemic. Independent of these associations, African American women were more likely than other groups to deliver preterm. CONCLUSION: Pregnant women who are experiencing high stress during the COVID-19 pandemic are at risk of poorer perinatal outcomes. A longitudinal investigation is critical to determine whether prenatal maternal stress and resulting outcomes have longer-term consequences for the health and well-being of children born in the midst of the current pandemic.

Healthcare workforce transformation: implementing patient-centered medical home standards in an academic medical center.

BACKGROUND: Large scale implementation of new strategies and healthcare delivery standards in academic medical centers (AMCs) requires training of healthcare workforce at different stages of their medical career. The patient-centered medical home (PCMH) model for healthcare delivery involves adoption by all members of the healthcare workforce, including seasoned professionals and trainees. Though widely known, the PCMH model has been implemented sporadically at large AMCs and methods to implement the model across healthcare workforce have not been well-documented. METHODS: To meet all PCMH standards and achieve sustainable level 3 recognition, the authors implemented in 2014-2015 a multi-pronged approach that capitalized on existing educational infrastructure among faculty, residents, and medical students. Within 18 months, the authors applied new interdisciplinary practices and policies, redesigned residency training in continuity practices and extensively modified medical school curricula. RESULTS: These innovative transformational education efforts addressed the six PCMH standards for faculty, residents, and undergraduate medical students. Faculty played a major role as system change agents and facilitators of learning. Residents learned to better understand patients' cultural needs, identify 'at-risk' patients, ensure continuity of care, and assess and improve quality of care. Medical students were exposed to PCMH core standards throughout their training via simulations, training in the community and with patients, and evaluation tasks. By implementing these changes across the healthcare workforce, the AMC achieved PCMH status in a short time, changed practice culture and improved care for patients and the community. Since then, the AMC has been able to maintain PCMH recognition annually with minimal effort. CONCLUSIONS: Successful strategies that capitalize on existing strengths in infrastructure complemented by innovative educational offerings and inter-professional partnerships can be adapted by other organizations pursuing similar transformation efforts. This widespread transformation across the healthcare workforce facilitate a deep-rooted change that enabled our academic medical center to sustain PCMH recognition.

Maternal and child patterns of Medicaid retention: a prospective cohort study.

BACKGROUND: We sought to determine whether maternal Medicaid retention influences child Medicaid retention because caregivers play a critical role in assuring children's health access. METHODS: We conducted a longitudinal prospective cohort study of a convenience sample of 604 Medicaid-eligible mother-child dyads followed from the infant's birth through 24 months of age with parent surveys. Individual enrollment status was abstracted from administrative Medicaid eligibility files. Generalized estimating equations quantified the effect of maternal Medicaid enrollment status on child Medicaid retention, adjusting for relevant covariates. Because varying lengths of gaps may have different effects on child health outcomes, Medicaid enrollment status was further categorized by length of gap: any gap, > 14-days, and > 60-days. RESULTS: This cohort consists primarily of African-American (94%), unmarried mothers (88%), with a mean age of 23.2 years. In multivariable analysis, children whose mothers experienced any gaps in coverage had 12.6 times greater odds of experiencing gaps when compared to children whose mothers were continuously enrolled. Use of varying thresholds to define coverage gaps resulted in similar odds ratios (> 14-day gap = 11.8, > 60-day gap = 16.8). Cash assistance receipt and maternal knowledge of differences between Temporary Assistance to Needy Families and Medicaid eligibility criteria demonstrated strong protective effects against child Medicaid disenrollment. CONCLUSIONS: Medicaid disenrollment remains a significant policy problem and maternal Medicaid retention patterns show strong effects on child Medicaid retention. Policymakers need to invest in effective outreach strategies, including family-friendly application processes, to reduce enrollment barriers so that all eligible families can take advantage of these coverage opportunities.

Improving Adherence to Care Recommendations Using a Community Health Worker (CHW) Intervention with the Pediatric Medical Home.

While CHW interventions improve health outcomes, evidence identifying specific domains of CHW-delivered support resulting in positive outcomes is limited. Our goals were to identify domains of CHW-delivered support that assist families with adhering to recommended pediatric care; and, to identify predictors of successful completion of an enriched medical home intervention (EMHI) using trained CHWs making home visits to provide health education and support positive health behaviors. We performed a prospective descriptive study of 88 families participating in a protocol-based EMHI. Completers (N = 46) finished the program with mutual agreement that the family can independently adhere to recommended clinical care. Non-completers (N = 42) were lost to follow-up or dropped out of the program before reaching this milestone. Using Grounded Theory, two trained coders evaluated CHW tasks recorded in an electronic database and classified these tasks across 17 domains. We assessed predictors of EMHI completion using logistic regression. The 88 EMHI participants were primarily <24 months of age (80 %), Hispanic (56 %), and Medicaid enrollees (67 %). Hispanic families (OR = 2.76, p = 0.04) and those with self-reported program goals to 'facilitate family's creation of a system to keep track of child's medical information' (OR = 3.11, p = 0.02) or a 'newborn-specific goal' (OR = 3.21, p = 0.04), such as feeding and safety tips, were more likely to complete the EMHI compared to their counterparts. The most consistent CHW tasks were supporting medical appointments, medication maintenance, and providing health education. CHW interventions designed to improve health behavior outcomes of 'at-risk' families, including Medicaid enrollees, may benefit from support in goal-setting and strategies to systematically manage their child's medical care.

Healthcare utilization by obese and overweight children.

OBJECTIVE: To examine the relationship between childhood obesity and health care use in a large, nationally representative group of children with measured anthropometrics. STUDY DESIGN: Analysis of 5 combined National Health and Nutrition Survey datasets from 2001 to 2010. Unadjusted and adjusted logistic regression models assessed the relationship between health care use variables and weight status (overweight: body mass index 85th to <95th percentile for age and sex; obese: body mass index ≥95th percentile for age and sex) for children 2-18 years of age. RESULTS: Overweight and obese children are more likely to receive their routine medical care in an emergency department than a primary care setting (overweight OR 1.95; 95% CI 1.22-3.14 and obese OR 1.88; 95% CI 1.24-2.86) than their normal-weight peers. After we adjusted for relevant covariates, this finding persisted among overweight, but not obese, children. Other health care use variables were not significantly associated with weight status. CONCLUSION: Overweight children may be more likely to use the emergency department than primary care settings for routine medical care. Interventions to establish primary care medical homes for overweight children merit consideration.

Challenges to implementation of developmental screening in urban primary care: a mixed methods study.

BACKGROUND: Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting. METHODS: Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion. RESULTS: Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child's strengths and limitations (88%). CONCLUSIONS: Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.

The influence of maternal health literacy and child's age on participation in social welfare programs.

The objective of this study is to determine the influence of maternal health literacy and child's age on participation in social welfare programs benefiting children. In a longitudinal prospective cohort study of 560 Medicaid-eligible mother-infant dyads recruited in Philadelphia, maternal health literacy was assessed using the test of functional health literacy in adults (short version). Participation in social welfare programs [Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), child care subsidy, and public housing] was self-reported at child's birth, and at the 6, 12, 18, 24 month follow-up interviews. Generalized estimating equations quantified the strength of maternal health literacy as an estimator of program participation. The mothers were primarily African-Americans (83%), single (87%), with multiple children (62%). Nearly 24% of the mothers had inadequate or marginal health literacy. Children whose mothers had inadequate health literacy were less likely to receive child care subsidy (adjusted OR = 0.54, 95% CI 0.34-0.85) than children whose mothers had adequate health literacy. Health literacy was not a significant predictor for TANF, SNAP, WIC or housing assistance. The predicted probability for participation in all programs decreased from birth to 24 months. Most notably, predicted WIC participation declined rapidly after age one. During the first 24 months, mothers with inadequate health literacy could benefit from simplified or facilitated child care subsidy application processes. Targeted outreach and enrollment efforts conducted by social welfare programs need to take into account the changing needs of families as children age.

Measurement of maternal instrumental support: findings from three population-based cohort studies.

To advance the conceptualization and measurement of mother-reported instrumental support, the degree to which an individual receives assistance in the completion of daily life tasks. The psychometric properties of a 9-item instrumental support scale were evaluated using classical (descriptive statistics, factor analyses, evaluation of construct validity) and modern (Rasch modeling, differential item functioning) methods. Differences in perceived instrumental support were evaluated as a function of mothers' socio-demographic characteristics. Factor analytic and differential item functioning analyses provided support for two components of instrumental support, household and childcare assistance. Instrumental support is distinct from structural support and the quality of mothers' social relationships. Socio-demographic characteristics (e.g., marital status, education level, income) are associated with access to instrumental support. Differentiating appropriately between support subtypes may reveal important differences in mother's qualitative instrumental support experiences and facilitate effective targeting of social support interventions.

Parental depressive symptoms and children's school attendance and emergency department use: a nationally representative study.

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997-2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7-2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4-3.0) and ADHD (3.8 %, 95 % CI 3.2-4.4) than among other children (1.6 %, 95 % CI 1.5-1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06-1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14-1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.

A family psychosocial risk questionnaire for use in pediatric practice.

The objective of this study is to develop new methods to better identify psychosocial risk such that children with the greatest risk of poor future outcomes receive more intensive preventive health services. Based on structured literature review and secondary data analysis, a 52-item psychosocial risk questionnaire was administered to 2,083 families of children (<36 months). To quantify the questionnaire's construct validity, developmental concern was assessed with the Ages and Stages Questionnaire version II (ASQ) [n = 1,163]. An iterative model selection process was used to produce the most parsimonious predictive model. Model fit was examined using c-statistics, the Hosmer-Lemeshow test, and a heuristic measure of model overfit based on the fitted log-likelihood values and associated number of degrees of freedom. We found 13 items easily obtained from parental report produced a regression model with a c-statistic of 0.70. Using an integer scoring system derived from the regression model, we calculated stratum specific likelihood ratios to revise a given prior probability of ASQ failure. The posterior probability of ASQ failure was 44.9 % for a child in the highest risk group (score >25) on the questionnaire, more than double our observed average failure rate of 19.5 %, while it was less than 7 % for a child with the lowest possible score on the questionnaire. Thirteen parent-reported items can be compiled into a summary psychosocial risk questionnaire that predicts failure on developmental screening among preschool children. With further validation, this questionnaire could conceivably be used by clinicians to tailor pediatric preventive care to children at varying levels of risk.

Program, cultural and neighbourhood factors related to attrition from a community-based enriched medical home program in the United States.

Attrition from clinical interventions targeting underserved populations is a substantive challenge to achieving optimal health outcomes. Our nationally recognised enriched medical home intervention (EMHI) utilised community health worker home visitation to improve health outcomes of children by engaging the entire family and removing barriers to care-seeking. Families were enrolled into the program between 2013 and 2016, and, as part of the evaluation of the program's success, we identified predictors of program completion by conducting a secondary analysis of 304 families participating in the EMHI evaluation research. Program completers finished participation in the EMHI with mutual agreement that the family can independently follow recommended care. Program non-completers were either lost to follow-up or dropped out before reaching this milestone. Data were collected using electronic medical records and validated self-report surveys to assess constructs such as social support, mental health difficulties and neighbourhood characteristics. The EMHI participants were primarily families with infants <24 months old, Medicaid-insured and Latino. In the multivariable logistic regression model, EMHI program factors as well as community factors independently predicted program continuation and retention. Specifically, families learning about newborn care or with preferred spoken language Spanish were more likely to complete the program. Participants reporting neighbourhood distrust had a greater likelihood of non-completion than others. Results underscore the importance of cultural competency and community involvement in program design and dissemination. Our findings are applicable to other home-based interventions with the goal of supporting underserved families in following recommended clinical care.

Process evaluation of a medical improvisation program for healthcare communication training.

BACKGROUND: Medical improvisation is an innovative approach to train healthcare professionals in effective communication. The success of this type of training depends on the active engagement of participants. METHOD: A total of 136 interprofessional healthcare workers completed surveys before and after a two-hour medical improvisation communication training session in October 2020. We investigated individual- and program-level contributors to participation outputs (e.g. engagement and experience). RESULTS: 97% of healthcare professionals in the participating department took part in the training. 82% described the training in positive terms or as a learning experience. Younger participants, medical doctors, and those who had difficulty tolerating uncertainty were less excited than others about training. Their engagement was associated with their excitement and group size. Uncertainty tolerance predicted engagement via a full mediation of excitement. CONCLUSIONS: Building excitement, reducing uncertainty about training, and capping group size are likely to improve participant's engagement and experience and will inform dissemination and implementation efforts.

Unmet Medical Needs and Food Insecurity in Children with Neurodevelopmental Disorders: Findings from the 2019 National Health Interview Survey (NHIS).

In the United States, 17% of children ages 3−17 have a developmental disorder. The complexity of care for such children require families to provide a significant amount of health care at home, representing a substantial economic cost. Our study identifies sociodemographic characteristics of children with neurodevelopmental disorders (NDD) that are predictive of unmet medical needs and food insecurity. We modeled the outcomes using a multivariable generalized linear model and a robust Cox proportional hazard model. Among children with NDD, 7.4% reported a delay in obtaining care, 3.6% avoided getting care and 17.3% live in a household that experienced food insecurity. Lack of health insurance and lack of usual source of care increased the risk for cost-related delay in medical care and cost-related avoidance of medical care. Children with NDD whose parents have less than a college degree and those from households with income <$75,000 had increased risk for food insecurity in the past 30 days. Our results underscore the need to implement additional screening to identify children with NDD who are at greater risk for unmet medical and social needs by health care providers and care coordination organizations.

Predictors of well child care adherence over time in a cohort of urban Medicaid-eligible infants.

BACKGROUND: Changes in well child care (WCC) adherence over time have not previously been examined. Our objective is to describe adherence rates to WCC over time in a low-income urban population of infants 0-24 months of age, and to identify predictors of WCC adherence in this population. METHODS: This is a secondary analysis of a cohort of Medicaid-eligible children followed from birth to 2 years between 2005 and 2008 with structured telephone surveys to assess maternal well-being, social support, and household and demographic information. For the 260 children attending 4 urban pediatric practices, WCC adherence was assessed based on visit data abstracted from electronic medical records. A random-intercept mixed effects logit model clustered on subject was used. RESULTS: 92% of the mothers were African-American, 27% had not finished high school, 87% were single, and 43% earned<$500/month; mean age was 23. WCC adherence decreased from 88% at 6 months to 47% (12 mo), 44% (18 mo), and 67% (24 mo). The difference across time periods was statistically significant (p<0.001). Married (OR 1.71, p=0.02) and primiparous (OR 1.89, p<0.001) mothers had significantly greater odds of adherence, along with women who reported having been adherent to prenatal care visits (OR 1.49, p=0.03) and those with the lowest household income (OR 1.40, p=0.03). CONCLUSIONS: Maternal education efforts should emphasize the importance of establishing WCC, especially for mothers of more than one child. Further studies using larger, more broadly defined populations are needed to confirm our findings that efforts to increase WCC adherence should be intensified after 6 months of age, particularly for children at higher risk.

Early identification of young children at risk for poor academic achievement: preliminary development of a parent-report prediction tool.

BACKGROUND: Early school success is clearly related to later health. A prediction index that uses parent report to assess children's risk for poor academic achievement could potentially direct targeted service delivery to improve child outcomes. METHODS: We obtained risk factors through literature review and used the National Longitudinal Survey of Youth 1979 Child Files to examine the predictive associations of these factors with academic achievement scores. RESULTS: Twenty predictors were identified including four strong predictors (maternal education, child gender, family income, and low birth weight). Significantly, 12 predictors explained 17-24% of score variance. CONCLUSIONS: Parent-reported factors provide predictive accuracy for academic achievement.

Maternal health literacy and late initiation of immunizations among an inner-city birth cohort.

To determine if maternal health literacy influences early infant immunization status. Longitudinal prospective cohort study of 506 Medicaid-eligible mother-infant dyads. Immunization status at age 3 and 7 months was assessed in relation to maternal health literacy measured at birth using the Test of Functional Health Literacy in Adults (short version). Multivariable logistic regression quantified the effect of maternal health literacy on immunization status adjusting for the relevant covariates. The cohort consists of primarily African-American (87%), single (87%) mothers (mean age 23.4 years). Health literacy was inadequate or marginal among 24% of mothers. Immunizations were up-to-date among 73% of infants at age 3 months and 43% at 7 months. Maternal health literacy was not significantly associated with immunization status at either 3 or 7 months. In multivariable analysis, compared to infants who had delayed immunizations at 3 months, infants with up-to-date immunizations at 3 months were 11.3 times (95%CI 6.0-21.3) more likely to be up-to-date at 7 months. The only strong predictors of up-to-date immunization status at 3 months were maternal education (high school graduate or beyond) and attending a hospital-affiliated clinic. Though maternal health literacy is not associated with immunization status in this cohort, later immunization status is most strongly predicted by immunization status at 3 months. These results further support the importance of intervening from an early age to ensure that infants are fully protected against vaccine preventable diseases.

Caregivers' perceptions of the relationship among weight, health status, and asthma in their children.

Asthma and obesity are the two most common childhood illnesses and are physiologically interrelated. Few studies have assessed parental perceptions and beliefs about this relationship to better target education and therapy. This study aimed to determine caregiver beliefs and perceptions regarding weight, health status, and asthma diagnoses. Data from a survey of caregivers to children aged 4-11 years are merged with corresponding anthropometric and medical data from the electronic medical record. Caregivers of children with asthma completed a supplemental questionnaire. Univariable and multivariable logistic regressions were used to evaluate associations between perception of health problem, asthma, and weight status. Increased weight status was ≥ 85th body mass index percentile per Centers for Disease Control classifications. Compared to caregivers of healthy children and those of children with healthy weight and asthma, caregivers of dual diagnosis children were more likely to identify weight as a health problem (OR = 3.89, 95% confidence interval [1.48, 10.21]). Nevertheless, only 31% of caregivers of children with dual diagnosis believed weight contributed to the severity of their child's asthma. Less than one third of caregivers of dual diagnosis children believed that these diagnoses are interrelated. Addressing this gap in understanding is a critical next step to developing family-centered interventions.

State-level child health system performance and the likelihood of readmission to children's hospitals.

OBJECTIVES: To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located. STUDY DESIGN: We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund. RESULTS: A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge. CONCLUSIONS: Hospital readmission rates are significantly related to the performance of the surrounding health care system.