Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals.

2016

104-10

2016 Apr

1097-6833

OBJECTIVES: To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals.

STUDY DESIGN: Multicenter retrospective cohort analysis of 12 449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals.

RESULTS: In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively.

CONCLUSIONS: Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

10.1016/j.jpeds.2015.12.015

J. Pediatr.

26787380

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

2021

e2117816

2021 Jul 01

2574-3805

<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>

10.1001/jamanetworkopen.2021.17816

JAMA Netw Open

34309667

Trends in Use of Postdischarge Intravenous Antibiotic Therapy for Children.

2020

2020 Sep 23

1553-5606

<p>Children with complicated appendicitis, osteomyelitis, and complicated pneumonia have historically been treated with postdischarge intravenous antibiotics (PD-IV) using peripherally inserted central catheters (PICCs). Recent studies have shown no advantage and increased complications of PD-IV, compared with oral therapy, and the extent to which use of PD-IV has since changed for these conditions is not known. We used a national children's hospital database to evaluate trends in PD-IV during 2000-2018 for each of these three conditions. PD-IV decreased from 13% to 2% (risk ratio [RR], 0.15; 95% CI, 0.14-0.16) for complicated appendicitis, 61% to 22% (RR, 0.41; 95% CI, 0.39-0.43) for osteomyelitis, and 29% to 19% (RR, 0.63; 95% CI, 0.58-0.69) for complicated pneumonia. Despite these overall reductions, substantial variation in PD-IV use by hospital remains in 2018.</p>

10.12788/jhm.3422

J Hosp Med

32966197

Variation in tonsillectomy cost and revisit rates: analysis of administrative and billing data from US children's hospitals.

2020

2020 Jun 30

2044-5423

<p><strong>BACKGROUND: </strong>Tonsillectomy is one of the most common and cumulatively expensive surgical procedures in children. We determined if substantial variation in resource use, as measured by standardised costs, exists across hospitals for performing tonsillectomy and if higher resource use is associated with better quality of care, as measured by revisits to hospital.</p>

<p><strong>METHODS: </strong>We conducted a retrospective analysis of children undergoing routine outpatient tonsillectomy between 2011 to 2017 across US children's hospitals using an administrative and billing data source. The primary outcome measures were the hospital tonsillectomy standardised cost and the 30-day revisit rate to hospital. We analysed the interhospital variation in standardised cost by determining the number of outlier hospitals in standardised cost and the intraclass correlation coefficient.</p>

<p><strong>RESULTS: </strong>131 814 children (median age 6 years, IQR: 4,9; female sex 52.5%) underwent tonsillectomy for airway obstruction (62.9%) and infection (23.9%) across 28 hospitals. The median adjusted hospital standardised cost for tonsillectomy was $2392 (IQR: $1827, $2793; range: $1166 to $4222). There was substantial interhospital variation in costs as 11 (40%) hospitals were cost outliers, and the intraclass correlation coefficient was 0.62, suggesting that 62% of the variation in cost was attributable to variation between hospitals. The median hospital revisit rate was 9.5% (IQR: 7.8, 12.1) and higher hospital costs did not correlate with lower revisit rates ( =0.03, 95% CI -0.36 to 0.41; p=0.87).</p>

<p><strong>CONCLUSIONS: </strong>There is substantial variation in hospital resource use and standardised costs for routine outpatient tonsillectomy across US children's hospitals. Higher resource use is not associated with lower revisit rates. Further study is needed to understand the practices of lower resource use hospitals who deliver high quality of care.</p>

10.1136/bmjqs-2019-010730

BMJ Qual Saf

32606211

Effectiveness of Fundoplication or Gastrojejunal Feeding in Children With Neurologic Impairment.

2017

2017 Feb 03

2154-1663

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Gastroesophageal reflux (GER), aspiration, and secondary complications lead to morbidity and mortality in children with neurologic impairment (NI), dysphagia, and gastrostomy feeding. Fundoplication and gastrojejunal (GJ) feeding can reduce risk. We compared GJ to fundoplication using first-year postprocedure reflux-related hospitalization (RRH) rates.</p>

<p><strong>METHODS: </strong>We identified children with NI, dysphagia requiring gastrostomy tube feeding and GER undergoing initial GJ placement or fundoplication from January 1, 2007 to December 31, 2012. Data came from the Pediatric Health Information Systems augmented by laboratory, microbiology, and radiology results. GJ placement was ascertained using radiology results and fundoplication by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Subjects were matched within hospital using propensity scores. The primary outcome was first-year postprocedure RRH rate (hospitalization for GER disease, other esophagitis, aspiration pneumonia, other pneumonia, asthma, or mechanical ventilation). Secondary outcomes included failure to thrive, death, repeated initial intervention, crossover intervention, and procedural complications.</p>

<p><strong>RESULTS: </strong>We identified 1178 children with fundoplication and 163 with GJ placement, matching 114 per group. Matched sample RRH incident rate per child-year (95% confidence interval) for GJ was 2.07 (1.62-2.64) and for fundoplication 1.67 (1.28-2.18), P = .19. Odds of death were similar between groups. Failure to thrive, repeat of initial intervention, and crossover intervention were more common in the GJ group.</p>

<p><strong>CONCLUSIONS: </strong>In children with NI, GER, and dysphagia: fundoplication and GJ feeding have similar RRH outcomes. Either intervention can reduce future aspiration risk; the choice can reflect non-RRH-related complication risks, caregiver preference, and clinician recommendation.</p>

10.1542/hpeds.2016-0126

Hosp Pediatr

28159744

Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia.

2016

2016 Dec

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes.</p>

<p><strong>METHODS: </strong>This multicenter retrospective cohort study included children ≥2 months and &lt;18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed "all related revisits."</p>

<p><strong>RESULTS: </strong>Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46).</p>

<p><strong>CONCLUSIONS: </strong>Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.</p>

10.1542/peds.2016-1692

Pediatrics

27940695

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

2017

361-8

2017 Aug

1528-1140

<p><strong>OBJECTIVE: </strong>To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge.</p>

<p><strong>BACKGROUND: </strong>Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited.</p>

<p><strong>METHODS: </strong>We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting.</p>

<p><strong>RESULTS: </strong>In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%).</p>

<p><strong>CONCLUSIONS: </strong>Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.</p>

10.1097/SLA.0000000000001923

Ann. Surg.

27429024

Prioritization of comparative effectiveness research topics in hospital pediatrics.

2012

1155-64

2012 Dec

1538-3628

<p><strong>OBJECTIVE: </strong>To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics.</p>

<p><strong>DESIGN: </strong>Retrospective analysis of administrative and billing data for hospital encounters.</p>

<p><strong>SETTING: </strong>Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009.</p>

<p><strong>PARTICIPANTS: </strong>Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters.</p>

<p><strong>RESULTS: </strong>Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter.</p>

<p><strong>CONCLUSIONS: </strong>Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research--those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.</p>

10.1001/archpediatrics.2012.1266

Arch Pediatr Adolesc Med

23027409

Methodological quality of national guidelines for pediatric inpatient conditions.

2014

384-90

2014 Jun

1553-5606

<p><strong>BACKGROUND: </strong>Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown.</p>

<p><strong>OBJECTIVE: </strong>To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions.</p>

<p><strong>DESIGN: </strong>We searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient.</p>

<p><strong>RESULTS: </strong>Seventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78-0.87).</p>

<p><strong>CONCLUSIONS: </strong>We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives.</p>

10.1002/jhm.2187

J Hosp Med

24677729

Dexamethasone and risk of bleeding in children undergoing tonsillectomy.

2014

872-9

2014 May

1097-6817

<p><strong>OBJECTIVE: </strong>To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using a multihospital administrative database.</p>

<p><strong>SETTING: </strong>Thirty-six US children's hospitals.</p>

<p><strong>SUBJECTS: </strong>Children undergoing same-day tonsillectomy between the years 2004 and 2010.</p>

<p><strong>METHODS: </strong>We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7.</p>

<p><strong>CONCLUSIONS: </strong>In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.</p>

10.1177/0194599814521555

Otolaryngol Head Neck Surg

24493786