<p><strong>OBJECTIVE: </strong>(1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation.</p>

<p><strong>DESIGN/SETTING: </strong>Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children</p>

<p><strong>MEASUREMENTS:</strong> Variation in trimmed standardized costs were assessed within and across regions. Linear mixed effects models were adjusted for patient- and encounter-level variables to assess drivers of variation.</p>

<p><strong>RESULTS:</strong> After adjusting for patient-level factors, variation remained. Using census division clusters, mean trimmed and adjusted total standardized costs were 120% higher for asthma ($1920 vs $4227), 46% higher for DKA ($7429 vs $10,881), and 150% higher for AGE ($3316 vs $8292) in the highest-cost compared with the lowest-cost region. Comparing hospitals in the same region, standardized costs were significantly different (P &lt; 0.001) for each condition in each region. Drivers of variation were encounter-level variables including length of stay and intensive care unit utilization. For this cohort, annual savings from reducing variation would equal $69.1 million at the interregional level and $25.2 million at the intraregional level.</p>

<p><strong>CONCLUSIONS:</strong> Pediatric hospital costs vary between and within regions. Future studies should examine how much of this variation is avoidable. To the extent that less spending does not compromise outcomes, care models may be adjusted to eliminate unwarranted variation and reduce costs.</p>

<p><strong>OBJECTIVES: </strong>To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models.</p>

<p><strong>STUDY DESIGN: </strong>We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy.</p>

<p><strong>RESULTS: </strong>For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age &lt;1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals.</p>

<p><strong>CONCLUSIONS: </strong>We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.</p>

<p><strong>IMPORTANCE: </strong>Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood.</p>

<p><strong>OBJECTIVE: </strong>To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015.</p>

<p><strong>EXPOSURES: </strong>Two risk-adjustment models: a baseline model adjusted for severity of illness and an SDH-enhanced model that adjusted for severity of illness and the following 4 SDH variables: race, ethnicity, payer, and median household income for the patient's home zip code.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>Change in a hospital's potentially preventable readmissions penalty status (ie, change in whether a hospital exceeded the penalty threshold) using an observed-to-expected potentially preventable readmissions ratio of 1.0 as a penalty threshold.</p>

<p><strong>RESULTS: </strong>For the 179 400 hospital discharges from the 43 hospitals meeting inclusion criteria, median (interquartile range [IQR]) hospital-level percentages for the SDH variables were 39.2% nonwhite (n = 71 300; IQR, 28.6%-54.6%), 17.9% Hispanic (n = 32 060; IQR, 6.7%-37.0%), and 58.7% publicly insured (n = 106 116; IQR, 50.4%-67.8%). The hospital median household income for the patient's home zip code was $40 674 (IQR, $35 912-$46 190). When compared with the baseline model, adjustment for SDH resulted in a change in penalty status for 3 hospitals within the 15-day window (2 were no longer above the penalty threshold and 1 was newly penalized) and 5 hospitals within the 30-day window (3 were no longer above the penalty threshold and 2 were newly penalized).</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>Risk adjustment for SDH changed hospitals' penalty status on a readmissions-based P4P measure. Without adjusting P4P measures for SDH, hospitals may receive penalties partially related to patient SDH factors beyond the quality of hospital care.</p>

<p><strong>OBJECTIVE: </strong>To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI).</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients &lt;19&nbsp;years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income.</p>

<p><strong>RESULTS: </strong>There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs.</p>

<p><strong>CONCLUSIONS: </strong>Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.</p>

<p><strong>OBJECTIVES: </strong>To describe readmissions among children hospitalized with H1N1 (influenza subtype, hemagglutinin1, neuraminidase 1) pandemic influenza and secondarily to determine the association of oseltamivir during index hospitalization with readmission.</p>

<p><strong>METHODS: </strong>We reviewed data from 42 freestanding children's hospitals contributing to the Pediatric Health Information System from May through December 2009 when H1N1 was the predominant influenza strain. Children were divided into 2 groups by whether they experienced complications of influenza during index hospitalization. Primary outcome was readmission at 3, 7, and 30 days among both patient groups. Secondary outcome was the association of oseltamivir treatment with readmission.</p>

<p><strong>RESULTS: </strong>The study included 8899 children; 6162 patients had uncomplicated index hospitalization, of whom 3808 (61.8%) received oseltamivir during hospitalization, and 2737 children had complicated influenza, of whom 1055 (38.5%) received oseltamivir. Median 3-, 7-, and 30-day readmission rates were 1.6%, 2.5%, and 4.7% for patients with uncomplicated index hospitalizations and 4.3%, 5.8%, and 10.3% among patients with complicated influenza. The 30-day readmission rates did not differ by treatment group among patients with uncomplicated influenza; however, patients with complicated index hospitalizations who received oseltamivir had lower all-cause 30-day readmissions than untreated patients. The most common causes of readmission were pneumonia and asthma exacerbations.</p>

<p><strong>CONCLUSIONS: </strong>Oseltamivir use for hospitalized children did not decrease 30-day readmission rates in children after uncomplicated index hospitalization but was associated with a lower 30-day readmission rate among children with complicated infections during the 2009 H1N1 pandemic. Readmission rates for children who had complicated influenza infection during index hospitalizations are high.</p>

<p><strong>OBJECTIVE: </strong>To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates.</p>

<p><strong>STUDY DESIGN: </strong>Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression.</p>

<p><strong>RESULTS: </strong>Mean LOS was &lt;3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all &lt;5%. Condition-specific readmission rates for complex patients ranged from &lt;1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10).</p>

<p><strong>CONCLUSION: </strong>In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.</p>