TOPLINE:

Families of children with complex chronic diseases reported challenges related to the child’s return to baseline health post-hospitalization, with only 12% of caregivers reporting this concern at discharge. Despite a positive transition experience from hospital to home, many parents reported that the child’s and family’s routines had not returned to baseline even 30 days after discharge.

METHODOLOGY:

• Researchers conducted a prospective cohort study at an urban, academic hospital for children to assess posthospitalization outcomes in children with complex chronic diseases recruited from July 2020 to October 2021.
• They initially recruited caregivers of children receiving primary care at an outpatient complex care center with at least one hospitalization of the child in the past year; 10 family members of such children participated in design sessions to evaluate and develop patient- and family-reported outcomes of transition effectiveness.
• Participants evaluated existing transition effectiveness measures, including the Pediatric Transition Experience Measure, Transition Quality Measure, and Global Family Quality of Life Scale, and reviewed a return-to-baseline measure that assessed progress toward prehospital baseline statuses of health, routines, and family functioning.
• Families completed the transition measure assessments at 7 and 30 days after discharge; correlations between the measures at 7 days after discharge and unplanned readmission at 30 days were assessed.
• A total of 124 families agreed to take part in the prospective study, and 102 of them (82%) provided some postdischarge information (median age of patients, 12.6 years).

TAKEAWAY:

• Families of children with complex chronic diseases rated transition measures highly, though only 26% of parents rated transitions as perfect on the Pediatric Transition Experience Measure. The proportion of parents who rated transitions as perfect varied with different measures.
• Only 12% of caregivers felt their child returned to baseline health status by discharge. At 7 days post-discharge, 35.4% rated their child as “back to baseline” (P < .001), and at 30 days the rate was 37.6%.
• More than 50% of parents reported that their child’s routine, family baseline, and sleep had not returned to normal at 7 days after hospitalization. Among the family routines assessed, return-to-baseline rates were the highest for work schedules, reaching 51.0% at 7 days and 58.8% at 30 days post-discharge.
• Overall, 4.9% of children had an unplanned readmission within 7 days and 12.8% within 30 days. The study found a weak or moderate correlation between transition measures and 30-day unplanned readmission. Return to baseline at 7 days for child health and routine, work schedule, and sleep was also moderately correlated with unplanned 30-day readmission.

IN PRACTICE:

“Collectively, these findings identify needed areas for intervention development and provide evidence of the utility of complementary PRO [patient- and family-reported outcome] measures in evaluating the effectiveness of transition interventions,” the authors of the study wrote.

SOURCE:

This study was led by Patrick W. Brady, MD, MSc, of the Division of Hospital Medicine at the Cincinnati Children’s Hospital Medical Center in Cincinnati. It was published online on December 4, 2025, in Pediatrics.

LIMITATIONS:

The participants were recruited from a single academic health system. Non-English-speaking families were excluded from the second phase of the study. The lack of a systematic review may have resulted in overlooking some relevant assessment tools.

DISCLOSURES:

This research received support from the Place Outcomes Research Award from Cincinnati Children’s Hospital Research Foundation. The authors reported having no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.