<p><strong>BACKGROUND AND OBJECTIVES: </strong>Pediatric inpatients with communication impairment may experience inadequate pain and symptom management. Research regarding potential variation in care among patients with and without communication impairment is hampered because existing pediatric databases do not include information about patient communication ability per se, even though these data sets do contain information about diagnoses and medical interventions that are probably correlated with the probability of communication impairment. Our objective was to develop and evaluate a classification model to identify patients in a large administrative database likely to be communication impaired.</p>

<p><strong>METHODS: </strong>Our sample included 236 hospitalized patients aged ≥12 months whose ability to communicate about pain had been assessed. We randomly split this sample into development (n = 118) and validation (n = 118) sets. A priori, we developed a set of specific diagnoses, technology dependencies, procedures, and medications recorded in the Pediatric Health Information System likely to be strongly associated with communication impairment. We used logistic regression modeling to calculate the probability of communication impairment for each patient in the development set, assessed the model performance, and evaluated the performance of the 11-variable model in the validation set.</p>

<p><strong>RESULTS: </strong>In the validation sample, the classification model showed excellent classification accuracy (area under the receiver operating characteristic curve 0.92; sensitivity 82.6%; 95% confidence interval, 74%-100%; specificity 86.3%; 95% confidence interval, 80%-97%). For the complete sample, the predicted probability of communication impairment demonstrated excellent calibration with the observed communication impairment status.</p>

<p><strong>CONCLUSIONS: </strong>Hospitalized pediatric patients with communication impairment can be accurately identified in a large hospital administrative database.</p>

<p><strong>OBJECTIVES: </strong>Polypharmacy is common in hospitalized children in the United States and has been identified as a major risk factor for exposure to potential drug-drug interactions. Little is known about the characteristics and prevalence of exposure of pediatric patients to polypharmacy and potential drug-drug interactions in PICUs.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study using the Pediatric Health Information System database.</p>

<p><strong>SETTING: </strong>Forty-two freestanding children's hospitals throughout the United States.</p>

<p><strong>PATIENTS: </strong>A total of 54,549 patients less than 18 years old cared for in PICUs in 2011. Patients in neonatal ICUs were not included.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>PICU patients were on average exposed to 10 distinct drugs each hospital day and to 20 drugs cumulatively during their hospitalization. Seventy-five percent of patients were exposed to greater than or equal to one potential drug-drug interaction regardless of severity level, 6% to greater than or equal to one contraindicated potential drug-drug interaction, 69% to greater than or equal to one major potential drug-drug interaction, 57% to greater than or equal to one moderate potential drug-drug interaction, 19% to greater than or equal to one minor potential drug-drug interaction. Potential drug-drug interaction exposures were significantly associated with specific diagnoses (p &lt; 0.001), presence of complex chronic conditions (p &lt; 0.001), increasing number of total distinct drugs used (p &lt; 0.001), increasing length of stay in PICU (p &lt; 0.001), and white race (p &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>Many PICU patients are exposed to substantial polypharmacy and potential drug-drug interactions. Future research should identify the risk of adverse drug events following specific potential drug-drug interaction exposures, especially the risk of adverse drug events due to multiple potential drug-drug interaction exposures, and determine the probability and magnitude of the actual harm (if any) for each specific potential drug-drug interaction, especially for multiple potential drug-drug interaction exposures.</p>

<p><strong>OBJECTIVE: </strong>To examine whether hospital type (children's hospital or generalist hospital) and surgeon specialty are associated with variations in surgical outcomes for hospitalized adolescents and young adults with inflammatory bowel disease (IBD) requiring surgery.</p>

<p><strong>METHODS: </strong>The 2007-2009 Perspective Data Warehouse was used to identify a retrospective cohort study of all inpatients 16 to 25 years old who received surgery for IBD. Multivariate regression, clustered at the hospital level, examined the association of hospital type and surgical specialty with surgical complications and 30-day readmissions.</p>

<p><strong>RESULTS: </strong>Surgery was performed in 917 hospitalizations of 598 patients across 20 children's hospitals and 198 general hospitals by 566 general surgeons, 46 pediatric surgeons, and 305 colorectal surgeons. After adjustment, children's hospitals had higher predicted probabilities of surgical complication (predicted probability [PP]: 35% [95% confidence interval (CI): 28-42]) compared with general hospitals (PP: 26% [95% CI: 23-29]). Despite higher complications among children's hospitals, pediatric surgeons had lowest predicated probabilities of surgical complication or 30-day readmission (PP: 24% [95% CI: 10-39]) compared with general surgeons (PP: 39% [95% CI: 35-43]) and colorectal surgeons (PP: 35% [95% CI: 28-42]).</p>

<p><strong>CONCLUSIONS: </strong>Disparate outcomes for adolescents and young adults receiving care in children's versus generalist hospitals and from different types of surgeons reveal the need to better understand how practice setting and surgical specialty may modify outcomes for a population that traverses a variety of health care settings.</p>

<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>

<p><strong>OBJECTIVE: </strong>To assess the prevalence and patterns of exposure to drugs and therapeutic agents among hospitalized pediatric patients.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study.</p>

<p><strong>SETTING: </strong>A total of 411 general hospitals and 52 children's hospitals throughout the United States.</p>

<p><strong>PATIENTS: </strong>A total of 587 427 patients younger than 18 years, excluding healthy newborns, hospitalized in 2006, representing one-fifth of all pediatric admissions in the United States.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>Daily and cumulative exposure to drugs and therapeutic agents.</p>

<p><strong>RESULTS: </strong>The most common exposures varied by patient age and by hospital type, with acetaminophen, albuterol, various antibiotics, fentanyl, heparin, ibuprofen, morphine, ondansetron, propofol, and ranitidine being among the most prevalent exposures. A considerable fraction of patients were exposed to numerous medications: in children's hospitals, on the first day of hospitalization, patients younger than 1 year at the 90th percentile of daily exposure to distinct medications received 11 drugs, and patients 1 year or older received 13 drugs; in general hospitals, 8 and 12 drugs, respectively. By hospital day 7, in children's hospitals, patients younger than 1 year at the 90th percentile of cumulative exposure to distinct distinct medications had received 29 drugs, and patients 1 year or older had received 35; in general hospitals, 22 and 28 drugs, respectively. Patients with less common conditions were more likely to be exposed to more drugs (P = .001).</p>

<p><strong>CONCLUSION: </strong>A large fraction of hospitalized pediatric patients are exposed to substantial polypharmacy, especially patients with rare conditions.</p>

<p><strong>CONTEXT: </strong>Appropriate use of opioids is essential to manage moderate-to-severe pain in children safely and effectively, yet published guidance regarding opioid treatment for pediatric patients is limited, potentially resulting in excessive variation in opioid use in pediatric patients across hospitals in the U.S.</p>

<p><strong>OBJECTIVES: </strong>The aim was to evaluate hospital variation in opioid use in pediatric inpatients.</p>

<p><strong>METHODS: </strong>Using data from the Pediatric Health Information System and the Premier Perspective Database regarding all pediatric inpatients in 626 hospitals, we examined hospital variation in opioid use and the length of opioid use, adjusting for patient demographic and clinical characteristics and for hospital type (children's vs. general) and hospital patient volume, using multilevel generalized linear regression modeling.</p>

<p><strong>RESULTS: </strong>Overall, 41.2% of all pediatric hospitalizations were exposed to opioids. Among the exposed patients, the mean length of exposure was 4.6 days. Exposure proportion and exposure length varied substantially across hospitals, even after accounting for patient demographic and clinical characteristics, hospital type and hospital patient volume, especially among terminal hospitalizations. For patients discharged alive vs. died, the adjusted exposure percentage for each hospital ranged from 0.7% to 99.1% (interquartile range [IQR]: 35.3%-59.9%) vs. 0.1% to 100.0% (IQR: 29.2%-66.2%), respectively, and the adjusted exposure length ranged from 1.0 to 8.4 days (IQR: 2.2-2.7 days) vs. 0.9 to 35.2 days (IQR: 4.0-7.4 days).</p>

<p><strong>CONCLUSION: </strong>The substantial hospital-level variation in opioid use in pediatric inpatients suggests room for improvement in clinical practice.</p>

<p><strong>BACKGROUND: </strong>Better knowledge of patient and cancer treatment factors associated with nausea/vomiting (NV) in pediatric oncology patients could enhance prophylaxis. We aimed to describe such factors in children receiving treatment for acute myeloid leukemia (AML).</p>

<p><strong>METHODS: </strong>Retrospective longitudinal cohort study of 1,668 hospitalized children undergoing treatment for AML from the Pediatric Health Information System database (39 hospitals, 1999-2010). Antiemetic alteration, which included switch (a change in prescribed 5-HT₃ receptor antagonists) and rescue (receipt of an adjunct antiemetic), were first validated and then used as surrogates of problematic NV. Logistic and negative binomial regression modeling were used to test whether patient characteristics were associated with problematic NV.</p>

<p><strong>RESULTS: </strong>Increasing age is associated with greater odds of experiencing antiemetic switch and higher relative rate of antiemetic rescue. Within a treatment cycle, each consecutive inpatient chemotherapy day decreased the likelihood of requiring antiemetic alteration. Each consecutive inpatient-day post-chemotherapy was associated with decreased need for switch, but increased need for rescue. Subsequent cycles of AML therapy were associated with lower odds of antiemetic switch on both chemotherapy and non-chemotherapy days, a lower rate of antiemetic rescue on chemotherapy days, and an increased rate of rescue on non-chemotherapy days.</p>

<p><strong>CONCLUSION: </strong>In pediatric patients with AML, increasing age is strongly associated with greater antiemetic alteration. Antiemetic alteration occurs early in treatment overall, and early within each admission. While additional cycles of therapy are associated with less alteration overall, there is persistent rescue in the days after chemotherapy, suggesting additional etiologies of NV in pediatric cancer patients.</p>

<p><strong>BACKGROUND: </strong>Administrative data are increasingly used to evaluate clinical outcomes and quality of care in pediatric congenital heart surgery (CHS) programs. Several published analyses of large pediatric administrative data sets have relied on the All Patient Refined Diagnosis Related Groups (APR-DRG, version 24) diagnostic classification system. The accuracy of this classification system for patients undergoing CHS is unclear.</p>

<p><strong>METHODS: </strong>We performed a retrospective cohort study of all 14,098 patients 0 to 5 years of age undergoing any of six selected congenital heart operations, ranging in complexity from isolated closure of a ventricular septal defect to single-ventricle palliation, at 40 tertiary-care pediatric centers in the Pediatric Health Information Systems database between 2007 and 2010. Assigned APR-DRGs (cardiac versus noncardiac) were compared using χ2 or Fisher's exact tests between those patients admitted during the first day of life versus later and between those receiving extracorporeal membrane oxygenation support versus those not. Recursive partitioning was used to assess the greatest determinants of APR-DRG type in the model.</p>

<p><strong>RESULTS: </strong>Every patient admitted on day 1 of life was assigned to a noncardiac APR-DRG (p&lt;0.001 for each procedure). Similarly, use of extracorporeal membrane oxygenation was highly associated with misclassification of CHS patients into a noncardiac APR-DRG (p&lt;0.001 for each procedure). Cases misclassified into a noncardiac APR-DRG experienced a significantly increased mortality (p&lt;0.001).</p>

<p><strong>CONCLUSIONS: </strong>In classifying patients undergoing CHS, APR-DRG coding has systematic misclassifications, which may result in inaccurate reporting of CHS case volumes and mortality.</p>

<p><strong>OBJECTIVES: </strong>Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort using the Pediatric Health Information System database.</p>

<p><strong>SETTING: </strong>Forty freestanding children's hospitals throughout the United States.</p>

<p><strong>PATIENTS: </strong>Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011.</p>

<p><strong>INTERVENTION: </strong>A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database.</p>

<p><strong>MAIN RESULTS: </strong>Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure.</p>

<p><strong>CONCLUSIONS: </strong>Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.</p>

<p><strong>OBJECTIVES: </strong>Adolescents and young adults (A/YA) with sickle cell disease (SCD) are hospitalized in both children's and general hospitals. We determined the effect of hospital type and provider specialty on outcomes of hospitalized A/YA with SCD and acute chest syndrome (ACS).</p>

<p><strong>METHODS: </strong>This retrospective cohort study used the 2007-2009 Premier Database, a large multi-institutional database, to identify 1476 patients ages 16 to 25 years with 2299 admissions with SCD and ACS discharged from 256 US hospitals from 2007 to 2009. Multilevel logistic regression and zero-truncated negative binomial regression were performed after adjustment for patient demographic, clinical, and hospital characteristics to test the association of hospital type and provider specialty on death, endotracheal intubation, simple or exchange transfusion, length of stay (LOS), and 30-day readmission.</p>

<p><strong>RESULTS: </strong>Of all admissions, 14 died and 45% were intubated. General hospitals had 13 deaths and were associated with higher intubation rates (predicted probability [PP], 48% [95% confidence interval (CI), 43%-52%]) and longer LOS (predicted mean LOS, 7.6 days [95% CI, 7.2-7.9]) compared with children's hospitals (PP of intubation, 24% [95% CI, 5%-42%]; and predicted mean LOS, 6.8 days [95% CI, 5.6-5.8]). There was no difference by hospital type or provider specialty in PP of simple or exchange transfusion, or 30-day readmission.</p>

<p><strong>CONCLUSIONS: </strong>General hospitals carry higher intubation risks for A/YA with SCD and ACS compared with children's hospitals. We need to better understand the drivers of these differences, including the role of staff expertise, hospital volume, and quality of ongoing SCD care.</p>