Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years.

2016

233-40

2016 Apr

2044-5423

BACKGROUND: Despite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.

METHODS: We used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004-2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.

RESULTS: Among 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.

CONCLUSIONS: Implementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.

10.1136/bmjqs-2015-004562

BMJ Qual Saf

26534995

Incidence of Life-Threatening Events in Children with Wolff-Parkinson-White Syndrome: Analysis of a Large Claims Database.

2021

2021 Dec 10

1556-3871

<p><strong>BACKGROUND: </strong>Previous estimates of life-threatening event (LTE) risk in Wolff-Parkinson-White (WPW) are limited by selection bias inherent to tertiary referral-based cohorts.</p>

<p><strong>OBJECTIVE: </strong>This analysis sought to measure LTE incidence in children with WPW in a large contemporary representative population.</p>

<p><strong>METHODS: </strong>A retrospective cohort study was conducted using claims data from the IBM MarketScan® Research Databases, evaluating WPW patients (age 1-18 years) from any encounter between 1/1/2013 and 12/31/2018. Subjects with congenital heart disease (CHD) and cardiomyopathy (CM) were excluded. The primary outcome was diagnosis of ventricular fibrillation (VF); a composite outcome, LTE, was defined as occurrence of VF and/or cardiac arrest. VF and LTE rates were compared to matched representative non-WPW controls (3:1 ratio).</p>

<p><strong>RESULTS: </strong>Prevalence of WPW was 0.03% (8,733/26,684,581) over median follow-up of 1.6 years (IQR 0.7-2.9). Excluding CHD/CM, 6,946 subjects were analyzed. LTE occurred in 49 subjects, including VF in 20. Incidence of VF was 0.8 events per 1000 person-years, and incidence of LTE was 1.9 events per 1000 person-years. There were no occurrences of VF in controls; rate of LTE was 70 times greater in WPW (0.7%, 95% CI: 0.5-0.9%) than in controls (0.01%, 95% CI: 0-0.02%).</p>

<p><strong>CONCLUSION: </strong>Use of a large claims dataset allowed for evaluation of VF and LTE risk in an unselected pediatric WPW population. The observed range of 0.8-1.9 events per 1000 person-years is consistent with prior reports from selected populations. Comparison of event rates to matched controls confirms and quantifies the significant elevation in VF and LTE risk in pediatric WPW.</p>

10.1016/j.hrthm.2021.12.009

Heart Rhythm

34902591

Resource utilization in children with paracorporeal continuous-flow ventricular assist devices.

2021

2021 Feb 22

1557-3117

<p><strong>BACKGROUND: </strong>Paracorporeal continuous-flow ventricular assist devices (PCF VAD) are increasingly used in pediatrics, yet PCF VAD resource utilization has not been reported to date.</p>

<p><strong>METHODS: </strong>Pediatric Interagency Registry for Mechanically Assisted Circulatory Support (PediMACS), a national registry of VADs in children, and Pediatric Health Information System (PHIS), an administrative database of children's hospitals, were merged to assess VAD implants from 19 centers between 2012 and 2016. Resource utilization, including hospital and intensive care unit length of stay (LOS), and costs are analyzed for PCF VAD, durable VAD (DVAD), and combined PCF-DVAD support.</p>

<p><strong>RESULTS: </strong>Of 177 children (20% PCF VAD, 14% PCF-DVAD, 66% DVAD), those with PCF VAD or PCF-DVAD are younger (median age 4 [IQR 0-10] years and 3 [IQR 0-9] years, respectively) and more often have congenital heart disease (44%; 28%, respectively) compared to DVAD (11 [IQR 3-17] years; 14% CHD); p &lt; 0.01 for both. Median post-VAD LOS is prolonged ranging from 43 (IQR 15-82) days in PCF VAD to 72 (IQR 55-107) days in PCF-DVAD, with significant hospitalization costs (PCF VAD $450,000 [IQR $210,000-$780,000]; PCF-DVAD $770,000 [IQR $510,000-$1,000,000]). After adjusting for patient-level factors, greater post-VAD hospital costs are associated with LOS, ECMO pre-VAD, greater chronic complex conditions, and major adverse events (p &lt; 0.05 for all). VAD strategy and underlying cardiac disease are not associated with LOS or overall costs, although PCF VAD is associated with higher daily-level costs driven by increased pharmacy, laboratory, imaging, and clinical services costs.</p>

<p><strong>CONCLUSION: </strong>Pediatric PCF VAD resource utilization is staggeringly high with costs primarily driven by pre-implantation patient illness, hospital LOS, and clinical care costs.</p>

10.1016/j.healun.2021.02.011

J Heart Lung Transplant

33744087

Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow.

2019

e007232

2019 Apr

1941-7632

<p><strong>BACKGROUND: </strong>In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown.</p>

<p><strong>METHODS AND RESULTS: </strong>Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all).</p>

<p><strong>CONCLUSIONS: </strong>In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.</p>

10.1161/CIRCINTERVENTIONS.118.007232

Circ Cardiovasc Interv

30998390

Significant mortality, morbidity and resource utilization associated with advanced heart failure in congenital heart disease in children and young adults.

2018

9-19

2018 Dec 05

1097-6744

<p><strong>BACKGROUND: </strong>Children with congenital heart disease (CHD) are at risk for advanced heart failure (AHF). We sought to define the mortality and resource utilization in CHD-related AHF in children and young adults.</p>

<p><strong>METHODS: </strong>All hospitalizations in the Pediatric Health Information System database involving patients ≤21 years old with a CHD diagnosis and heart failure requiring at least 7 days of continuous inotropic support between 2004 and 2015 were included. Hospitalizations including CHD surgery were excluded.</p>

<p><strong>RESULTS: </strong>Of 465,482 CHD hospitalizations, AHF was present in 2,712 (0.6%) [58% infant, 55% male, 30% single ventricle]. AHF therapies frequently used included extracorporeal membrane oxygenation (ECMO) (15%) and cardiac transplant (16%). Ventricular assist device (VAD) support was rare (3%), although VAD use significantly increased from 2004 to 2015 (P &lt; .0010). Hospital mortality in CHD with AHF was 26%, with higher mortality associated with single ventricle heart disease (OR 1.64, 95% CI 1.23-2.19; P = .0009), infancy (OR 1.71, 95% CI 1.17-2.5; P = .0057), non-white race (OR 1.28, 95% CI 1.04-1.59; p=0.0234), and chronic complex comorbidities (OR 1.76, 95% CI 1.34-2.30; P &lt; .0001). Over the 11-year study period, despite the significant increase in CHD-related AHF hospitalizations (P &lt; .0001), hospital mortality improved (P = .0011). Median hospital costs were $252,000, a 6-fold increase above those without AHF, and was primarily driven by hospital length of stay (P &lt; .0001).</p>

<p><strong>CONCLUSION: </strong>AHF in children with CHD in uncommon but increasing and is associated with significant morbidity, mortality and resource utilization. Approximately 1 in 5 children do not survive to hospital discharge. Many risk factors for mortality may not be modifiable, and further study is needed to identify modifiable risk factors and improve care for this complex population.</p>

10.1016/j.ahj.2018.11.010

Am. Heart J.

30639612

Emergency Department Visits by Children With Congenital Heart Disease.

2018

1817-1825

2018 Oct 09

1558-3597

<p><strong>BACKGROUND: </strong>Data related to the epidemiology and resource utilization of congenital heart disease (CHD)-related emergency department (ED) visits in the pediatric population is limited.</p>

<p><strong>OBJECTIVES: </strong>The purpose of this analysis was to describe national estimates of pediatric CHD-related ED visits and evaluate medical complexity, admissions, resource utilization, and mortality.</p>

<p><strong>METHODS: </strong>This was an epidemiological analysis of ED visit-level data from the 2006 to 2014 Nationwide Emergency Department Sample. Patients age&nbsp;&lt;18 years with CHD were identified using International Classification of Diseases-9th Revision-Clinical Modification codes. We evaluated time trends using weighted regression and tested the hypothesis that medical complexity, resource utilization, and mortality are higher in CHD patients.</p>

<p><strong>RESULTS: </strong>A total of 420,452 CHD-related ED visits (95% confidence interval [CI]: 416,897 to 422,443 visits) were identified, accounting for 0.17% of all pediatric ED visits. Those with CHD were more likely to be&nbsp;&lt;1 year of age (43% vs. 13%), and to have&nbsp;≥1 complex chronic condition (35% vs. 2%). CHD-related ED visits had higher rates of inpatient admission (46% vs. 4%; adjusted odds ratio: 1.89; 95% CI: 1.85 to 1.93), higher median ED charges ($1,266 [interquartile range (IQR): $701 to $2,093] vs. $741 [IQR: $401 to $1,332]), and a higher mortality rate (1% vs. 0.04%; adjusted odds ratio: 1.25; 95% CI: 1.07 to 1.45). Adjusted median charges for CHD-related ED visits increased from $1,219 (IQR: $673 to $2,138) to $1,630 (IQR: $901 to $2,799), while the mortality rate decreased from 1.13% (95% CI: 0.71% to 1.52%) to 0.75% (95% CI: 0.41% to 1.09%) over the 9 years studied.</p>

<p><strong>CONCLUSIONS: </strong>Children with CHD presenting to the ED represent a medically complex population at increased risk for morbidity, mortality, and resource utilization compared with those without CHD. Over 9 years, charges increased, but the mortality rate improved.</p>

10.1016/j.jacc.2018.07.055

J. Am. Coll. Cardiol.

30286926

Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the PHIS

2018

2018 Jun 01

2047-9980

<p><strong>BACKGROUND: </strong>Few data exist on resource utilization with pediatric ventricular assist devices (VADs). We tested the hypothesis that device type and adverse events are associated with increased resource utilization in pediatric patients supported with VADs.</p>

<p><strong>METHODS AND RESULTS: </strong>The Pediatric Interagency Registry for Mechanically Assisted Circulatory Support, a national registry of VADs in patients &lt;19&nbsp;years old, and the Pediatric Health Information System, an administrative database, were merged. Univariate analysis was performed assessing the association of all factors with the total cost and length of stay first. Significant variables (&lt;0.05) were subjected to multivariable analysis. The study included 142 patients from 19 centers with VAD implants from October 2012 to June 2016. The median age was 9&nbsp;years (interquartile range [IQR] 2-15), 84 (59%) supported with a continuous-flow VAD. Overall median hospital costs were $750&nbsp;000 (IQR $539&nbsp;000 to $1&nbsp;100&nbsp;000) with a median hospital length of stay of 81&nbsp;days (IQR 54-128). On multivariable analysis, device type and postoperative complications were not associated with resource utilization. Factors associated with increased costs included patient age, lower-volume VAD center, being intubated, being on extracorporeal membrane oxygenation, number of complex chronic medical conditions, and length of stay. Among continuous-flow VAD patients, discharge to home before transplant versus remaining hospitalized was associated with lower hospital costs (median $600&nbsp;000 [IQR $400&nbsp;000 to $820&nbsp;000] versus median $680&nbsp;000 [IQR $500&nbsp;000 to $970&nbsp;000], =0.03).</p>

<p><strong>CONCLUSION: </strong>VADs in pediatric patients are associated with high resource utilization. Increased resource utilization was associated with lower-volume VAD centers, disease severity at VAD implantation, and the presence of complex chronic medical conditions. Further study is needed to develop cost-effective strategies in this complex population.</p>

10.1161/JAHA.117.008380

J Am Heart Assoc

29858364

R Package for Pediatric Complex Chronic Condition Classification.

2018

596-8

2018 Jun 1

2168-6211

<p>Identification of children with complex chronic conditions (CCCs) is necessary to improve health care delivery and perform clinical research, because this patient population uses significant inpatient and outpatient medical resources. The original CCC classification was published in 2000. A second version was published in 2014 to reflect additions to the International Classification of Diseases system and the US adoption of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The CCC classification is widely used in research (currently cited in more than 100 peer-reviewed journal publications). However, the current approach to assigning the CCC categories in health care–related data sets is limited by proprietary software and computational inefficiency. SAS and Stata software to assign CCC categories were published as appendices to the 2014 update, but not all investigators have access to these statistical packages. In addition, increasingly large data sets are available to investigators. Although the data processing capability of individual computers continues to improve, the SAS and Stata software can take significant time to run on data sets with millions of observations. The objective of this project was to develop computationally efficient software to generate the CCC categories using R, a free, open-source statistical environment. We then compared the SAS, Stata, and R software with respect to accuracy and speed of classification on a typical desktop system.</p>

10.1001/jamapediatrics.2018.0256

JAMA Pediatr

29710063

Comparative effectiveness of senna to prevent problematic constipation in pediatric oncology patients receiving opioids: a multicenter study of clinically detailed administrative data.

2014

272-80

2014 Aug

1873-6513

<p><strong>CONTEXT: </strong>Pediatric oncology patients often receive prolonged courses of opioids, which can result in constipation.</p>

<p><strong>OBJECTIVES: </strong>Comparing patients who received senna matched with similar patients who received other oral bowel medications, determine the subsequent risk of "problematic constipation," assessed as the occurrence of the surrogate markers of receiving an enema, escalation of oral bowel medications, and abdominal radiographic imaging.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of hospitalized pediatric oncology patients less than 21&nbsp;years of age in 78 children's and adult hospitals between 2006 and 2011 who were started on seven consecutive days or more of opioid therapy and were started on an oral bowel medication within the first two days of opioid therapy. Clinically detailed administrative data were used from the Pediatric Health Information System and the Premier Perspective Database. After performing propensity score matching of similar patients who started senna and who started a different oral bowel medication, Cox regression modeling was used to compare the subsequent hazard of the surrogate markers.</p>

<p><strong>RESULTS: </strong>The final matched sample of 586 patients averaged 11.5&nbsp;years of age (range 0-20&nbsp;years); 41.8% (n&nbsp;=&nbsp;245) had blood cancer, 50.3% (n&nbsp;=&nbsp;295) had solid tumor cancer, and 7.9% (n&nbsp;=&nbsp;46) had brain cancer. Initiating senna therapy within two days of starting the prolonged opioid course, compared with initiating another oral bowel medication, was significantly associated with a lower hazard during the ensuing five days for receipt of an enema (hazard ratio [HR], 0.31; 95% CI, 0.11-0.91) or undergoing abdominal radiographic imaging (HR, 0.74; 95% CI, 0.55-0.98), was marginally associated with a lower hazard of oral bowel medicine escalation (HR, 0.78; 95% CI, 0.59-1.03), and overall was significantly associated with a lower hazard of the composite end point of problematic constipation (HR, 0.70; 95% CI, 0.56-0.88).</p>

<p><strong>CONCLUSION: </strong>Initiating senna therapy, compared with other oral bowel medications, diminishes the subsequent risk of surrogate markers of problematic constipation in this population.</p>

10.1016/j.jpainsymman.2013.09.009

J Pain Symptom Manage

24321507

Comparative Safety of Morphine Delivered via Intravenous Route versus Patient-Controlled Analgesia Device for Pediatric Inpatients.

2017

2017 Jan 03

1873-6513

<p><strong>BACKGROUND: </strong>Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database.</p>

<p><strong>METHODS: </strong>We assembled a retrospective cohort of pediatric inpatients between 5 and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and non-surgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to 2 days after drug administration.</p>

<p><strong>RESULTS: </strong>Surgical and non-surgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to 2 days after PCA exposure, though these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20-44% lower odds of same day CPR in both surgical and non-surgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients.</p>

<p><strong>CONCLUSION: </strong>In this large pediatric inpatient population, morphine administered via PCA device for surgical and non-surgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.</p>

10.1016/j.jpainsymman.2016.12.328

J Pain Symptom Manage

28062336