<p><strong>Importance: </strong>Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.</p>

<p><strong>Objectives: </strong>To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals.</p>

<p><strong>Design, Setting, and Participants: </strong>This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021.</p>

<p><strong>Main Outcomes and Measures: </strong>The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient.</p>

<p><strong>Results: </strong>There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18).</p>

<p><strong>Conclusions and Relevance: </strong>This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.</p>

<p><strong>OBJECTIVES: </strong>A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition.</p>

<p><strong>METHODS: </strong>We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome.</p>

<p><strong>RESULTS: </strong>Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators.</p>

<p><strong>CONCLUSIONS: </strong>Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.</p>

<p>Effective October 2015, all US health care institutions and practitioners transitioned to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding system, raising concerns about the validity of examining trends over time in clinical care, costs, and quality. For child mental health disorders, alignment with psychiatric diagnosis groups in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) is also required to consistently examine trends. This is because the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes differ for individual disorders, and child mental health disorders are reclassified under new psychiatric diagnosis groups. We thus developed the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS), which classifies child mental health disorders across coding systems and aligns with DSM-5 psychiatric diagnosis groups. To examine our system’s performance, we compared detection of these disorders in a Medicaid claims database against the Clinical Classification Software (CCS) groups and then examined identification of the disorders across ICD-9-CM and ICD-10-CM coding systems using a national pediatric hospitalization database.</p>

<p><strong>OBJECTIVE: </strong>To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups.</p>

<p><strong>METHODS: </strong>This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3-17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total healthcare spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group.</p>

<p><strong>RESULTS: </strong>Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year-olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (p&lt;0.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total healthcare spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group.</p>

<p><strong>CONCLUSIONS: </strong>Among children with MH conditions, mental and physical health comorbidities were common and spending for general healthcare outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical healthcare services and investigate whether current spending on MH services supports high-quality MH care.</p>

<p><strong>OBJECTIVE: </strong>To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU).</p>

<p><strong>STUDY DESIGN: </strong>Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital.</p>

<p><strong>RESULTS: </strong>From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH vs. non-MH diagnosis (50.7% vs. 12.7% cumulative increase, P&lt;.001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P&lt;.001). 44% of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs. 22.5%, P&lt;.001) and less transfers (9.3% vs. 16.2%, P&lt;.001).</p>

<p><strong>CONCLUSION: </strong>The increase in ED MH visits from 2012 to 2016 was four times greater than non-MH visits at US children's hospitals, and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN.</p>

<p><strong>METHODS: </strong>This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with ≥1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE.</p>

<p><strong>RESULTS: </strong>Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions (≥3 conditions: 49.1% vs 30.6%), and had more polypharmacy (≥5 other medication classes: 54.7% vs 31.2%), &lt; .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively.</p>

<p><strong>CONCLUSIONS: </strong>OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up.</p>

<p><strong>OBJECTIVE: </strong>To inform resource allocation toward a continuum of care for youth at risk of suicide, we examined unplanned 30-day readmissions after pediatric hospitalization for either suicide ideation (SI) or suicide attempt (SA).</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of a nationally representative sample of 133,516 hospitalizations for SI or SA among 6- to 17-year-olds to determine prevalence, risk factors, and characteristics of 30-day readmissions using the 2013 and 2014 Nationwide Readmissions Dataset (NRD). Risk factors for readmission were modeled using logistic regression.</p>

<p><strong>RESULTS: </strong>We identified 95,354 hospitalizations for SI and 38,162 hospitalizations for SA. Readmission rates within 30 days were 8.5% for SI and SA hospitalizations. Among 30-day readmissions, more than one-third (34.1%) occurred within 7 days. Among patients with any 30-day readmission, 11% had more than one readmission within 30 days. The strongest risk factors for readmission were SI or SA hospitalization in the 30 days preceding the index SI/SA hospitalization (adjusted odds ratio [AOR]: 3.14, 95% CI: 2.73-3.61) and hospitalization for other indications in the previous 30 days (AOR: 3.18, 95% CI: 2.67-3.78). Among readmissions, 94.5% were for a psychiatric condition and 63.4% had a diagnosis of SI or SA.</p>

<p><strong>CONCLUSIONS: </strong>Quality improvement interventions to reduce unplanned 30-day readmissions among children hospitalized for SI or SA should focus on children with a recent prior hospitalization and should be targeted to the first week following hospital discharge.</p>

<p><strong>FUNDING: </strong>Dr. Zima received funding from the Behavioral Health Centers of Excellence for California (SB852).</p>

<p><strong>OBJECTIVES: </strong>To determine the proportion of US children hospitalized for a primary mental health condition who are discharged to postacute care (PAC); whether PAC discharge is associated with demographic, clinical, and hospital characteristics; and whether PAC use varies by state.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study of a nationally representative sample of US acute care hospitalizations for children ages 2-20 years with a primary mental health diagnosis, using the 2009 and 2012 Kids' Inpatient Databases. Discharge to PAC was used as a proxy for transfer to an inpatient mental health facility. We derived adjusted logistic regression models to assess the association of patient and hospital characteristics with discharge to PAC.</p>

<p><strong>RESULTS: </strong>In 2012, 14.7% of hospitalized children (n = 248 359) had a primary mental health diagnosis. Among these, 72% (n = 178 214) had bipolar disorder, depression, or psychosis, of whom 4.9% (n = 8696) were discharged to PAC. The strongest predictors of PAC discharge were homicidal ideation (aOR, 24.9; 96% CI, 4.1-150.4), suicide and self-injury (aOR, 15.1; 95% CI, 11.7-19.4), and substance abuse-related medical illness (aOR, 5.0; 95% CI, 4.5-5.6). PAC use varied widely by state, ranging from 2.2% to 36.3%.</p>

<p><strong>CONCLUSIONS: </strong>The majority of children hospitalized primarily for a mood disorder or psychosis were not discharged to PAC, and safety-related conditions were the primary drivers of the relatively few PAC discharges. There was substantial state-to-state variation. Target areas for quality improvement include improving access to PAC for children hospitalized for mood disorders or psychosis and equitable allocation of appropriate PAC resources across states.</p>