Publications by authors named "Matt Hall"

274 Publications

Trends in Adolescent Cannabis-Related Hospitalizations by State Legalization Laws, 2008-2019.

J Adolesc Health 2021 Sep 9. Epub 2021 Sep 9.

Department of Pediatrics, Mount Sinai Health System and Kravis Children's Hospital, New York, New York.

Purpose: Adolescent cannabis use is associated with adverse health outcomes. The impact of cannabis legalization on adolescent cannabis-related hospitalizations remains unknown. We sought to assess whether state cannabis legalization is associated with adolescent cannabis-related hospitalizations.

Methods: We conducted a retrospective cohort study of adolescent (11-17 years) hospitalizations at children's hospitals between January 1, 2008 and December 31, 2019 using the Inpatient Essentials database. We investigated differences in adolescent cannabis-related diagnosis during a hospitalization by state cannabis legalization status, including states with no legal use to medical cannabis laws (MCLs) and states with MCLs to nonmedical (>21 years old) cannabis laws (NMCLs).

Results: Of 1,898,432 adolescent hospitalizations in 18 states and Washington, DC, there were 37,562 (2%) hospitalizations with a cannabis-related diagnosis, with 8,457 (23%) in states with no legal use, 20,444 (54%) in MCL states, and 8,661 (23%) in NMCL states. There was an increase in adjusted odds of a cannabis-related hospitalization in MCL (odds ratio 1.05, 95% confidence interval 1.04-1.06) and NMCL states (odds ratio 1.03, 95% confidence interval 1.02-1.03) between 2008 and 2019. Characteristics associated with the greatest increase in adjusted odds of a cannabis-related hospitalization postpolicy change included adolescents without an underlying mental health or other substance use disorder in MCL and NMCL states (p < .001) and younger age in NMCL states (13 vs. 16 and 17 years old, p = .02 and p = .02).

Conclusions: Cannabis-related adolescent hospitalizations at children's hospitals are increasing, with a disproportionate increase postlegalization in states with NMCLs. Interventions are warranted to increase cannabis use identification and treatment among at-risk adolescents in the hospital-based setting.
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http://dx.doi.org/10.1016/j.jadohealth.2021.07.028DOI Listing
September 2021

Association of Race/Ethnicity and Social Determinants with Rehospitalization for Mental Health Conditions at Acute Care Children's Hospitals.

J Pediatr 2021 Aug 31. Epub 2021 Aug 31.

Monroe Carell Jr. Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

Objective: To evaluate associations of race/ethnicity and social determinants with 90-day rehospitalization for mental health conditions to acute care non-psychiatric children's hospitals.

Study Design: We conducted a retrospective cohort analysis of mental health hospitalizations for children aged 5 to 18 years from 2016-2018 at 32 freestanding U.S. children's hospitals using the Children's Hospital Association's Pediatric Health Information System (PHIS) database to assess the association of race/ethnicity and social determinants (insurance payer, neighborhood median household income, and rurality of patient home location) with 90-day rehospitalization. Risk factors for rehospitalization were modeled using mixed-effects multivariable logistic regression.

Results: Among 23,556 index hospitalizations, there were 1382 mental health rehospitalizations (5.9%) within 90 days. Non-Hispanic Black children were 26% more likely to be rehospitalized than non-Hispanic White children (adjusted odds ratio [aOR] 1.26, 95% CI 1.08-1.48). Those with government insurance were 18% more likely to be rehospitalized than those with private insurance (aOR 1.18, 95% CI 1.04-1.34). In contrast, those living in a suburban location were 22% less likely to be rehospitalized than those living in an urban location (suburban: aOR 0.78, 95% CI 0.63-0.97).

Conclusions: Non-Hispanic Black children and those with public insurance were at highest risk for 90-day rehospitalization, and risk was lower in those residing in suburban locations. Future work could focus on upstream interventions that will best attenuate social disparities to promote equity in pediatric mental healthcare.
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http://dx.doi.org/10.1016/j.jpeds.2021.08.078DOI Listing
August 2021

Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury.

Acad Emerg Med 2021 08;28(8):840-847

Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA.

Objective: Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury.

Methods: This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests.

Results: Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury.

Conclusions: Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.
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http://dx.doi.org/10.1111/acem.14318DOI Listing
August 2021

Pediatric palliative care parents' distress, financial difficulty, and child symptoms.

J Pain Symptom Manage 2021 Aug 20. Epub 2021 Aug 20.

Justin Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Context: Parents of patients with a serious illness experience psychological distress, which impacts parents' wellbeing and, potentially, their ability to care for their children. Parent psychological distress may be influenced by children's symptom burden and by families' financial difficulty.

Objectives: This study examined the associations among parent psychological distress, parent-reported patient symptoms, and financial difficulty, seeking to determine the relative association of financial difficulty and of patient symptoms to parent psychological distress.

Methods: Cross-sectional study of baseline data for 601 parents of 532 pediatric palliative care patients enrolled in a prospective cohort study conducted at seven US children's hospitals. Data included self-reported parent psychological distress and parent report of child's symptoms and family financial difficulty. We used ordinary least squares multiple regressions to examine the association between psychological distress and symptom score, between psychological distress and financial difficulty, and whether the degree of financial difficulty modified the relationship between psychological distress and symptom score.

Results: The majority of parents were moderately distressed (52%) or severely distressed (17%) and experienced some degree of financial difficulty (65%). While children's symptom scores and family financial difficulty together explained more of the variance in parental psychological distress than either variable alone, parental distress was associated more strongly, and to a larger degree, with financial difficulty than with symptom scores alone.

Conclusions: Parent psychological distress was associated with parent-reported patient symptoms and financial difficulty. Future work should examine these relationships longitudinally, and whether interventions to improve symptom management and ameliorate financial difficulties improve parental outcomes.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.08.004DOI Listing
August 2021

Variation in Diagnostic Testing and Empiric Acyclovir Use for HSV Infection in Febrile Infants.

Hosp Pediatr 2021 Sep 16;11(9):922-930. Epub 2021 Aug 16.

Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.

Background And Objectives: Clinicians evaluating for herpes simplex virus (HSV) in febrile infants must balance detection with overtesting, and there is no universally accepted approach to risk stratification. We aimed to describe variation in diagnostic evaluation and empirical acyclovir treatment of infants aged 0 to 60 days presenting with fever and determine the association between testing and length of stay (LOS).

Methods: In this retrospective 44-hospital observational study, we used the Pediatric Health Information System database to identify infants aged ≤60 days evaluated for fever in emergency departments from January 2016 through December 2017. We described hospital-level variation in laboratory testing, including HSV, imaging and other diagnostic evaluations, acyclovir use, and LOS. We assessed the relationship between HSV testing and LOS using generalized linear mixed effects models adjusted for age and illness severity.

Results: In 24 535 encounters for fever, the median HSV testing frequency across hospitals was 35.6% (interquartile range [IQR]: 28.5%-53.5%) for infants aged 0 to 21 days and 12% (IQR: 8.6%-15.7%) for infants aged 22 to 60 days. Among HSV-tested patients, median acyclovir use across hospitals was 79.2% (IQR: 68.1%-89.7%) for those aged 0 to 21 days and 63.6% (IQR: 44.1%-73%) for those aged 22 to 60 days. The prevalence of additional testing varied substantially by hospital and age group. Risk-adjusted LOS for HSV-tested infants was significantly longer than risk-adjusted LOS for those not tested (2.6 vs 1.9 days, < .001).

Conclusions: Substantial variation exists in diagnostic evaluation and acyclovir use, and infants who received HSV testing had a longer LOS than infants who did not. This variability supports the need for further studies to help clinicians better risk-stratify febrile infants and to guide HSV testing and treatment decisions.
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http://dx.doi.org/10.1542/hpeds.2020-003129DOI Listing
September 2021

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old.

Hosp Pediatr 2021 Sep 12;11(9):915-926. Epub 2021 Aug 12.

Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut.

Objectives: Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals.

Methods: We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions.

Results: We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 ( < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates ( = .70).

Conclusions: The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.
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http://dx.doi.org/10.1542/hpeds.2021-005936DOI Listing
September 2021

Comparative analysis of signal models for microscopic fractional anisotropy estimation using q-space trajectory encoding.

Neuroimage 2021 Nov 8;242:118445. Epub 2021 Aug 8.

UCL Great Ormond Street Institute of Child Health, University College London, London, UK.

Microscopic diffusion anisotropy imaging using diffusion-weighted MRI and multidimensional diffusion encoding is a promising method for quantifying clinically and scientifically relevant microstructural properties of neural tissue. Several methods for estimating microscopic fractional anisotropy (µFA), a normalized measure of microscopic diffusion anisotropy, have been introduced but the differences between the methods have received little attention thus far. In this study, the accuracy and precision of µFA estimation using q-space trajectory encoding and different signal models were assessed using imaging experiments and simulations. Three healthy volunteers and a microfibre phantom were imaged with five non-zero b-values and gradient waveforms encoding linear and spherical b-tensors. Since the ground-truth µFA was unknown in the imaging experiments, Monte Carlo random walk simulations were performed using axon-mimicking fibres for which the ground truth was known. Furthermore, parameter bias due to time-dependent diffusion was quantified by repeating the simulations with tuned waveforms, which have similar power spectra, and with triple diffusion encoding, which, unlike q-space trajectory encoding, is not based on the assumption of time-independent diffusion. The truncated cumulant expansion of the powder-averaged signal, gamma-distributed diffusivities assumption, and q-space trajectory imaging, a generalization of the truncated cumulant expansion to individual signals, were used to estimate µFA. The gamma-distributed diffusivities assumption consistently resulted in greater µFA values than the second order cumulant expansion, 0.1 greater when averaged over the whole brain. In the simulations, the generalized cumulant expansion provided the most accurate estimates. Importantly, although time-dependent diffusion caused significant overestimation of µFA using all the studied methods, the simulations suggest that the resulting bias in µFA is less than 0.1 in human white matter.
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http://dx.doi.org/10.1016/j.neuroimage.2021.118445DOI Listing
November 2021

Polysymptomatology in Pediatric Patients Receiving Palliative Care Based on Parent-Reported Data.

JAMA Netw Open 2021 Aug 2;4(8):e2119730. Epub 2021 Aug 2.

Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts.

Importance: Pediatric palliative care treats patients with a wide variety of advanced illness conditions, often with substantial levels of pain and other symptoms. Clinical and research advancements regarding symptom management for these patients are hampered by the scarcity of data on symptoms as well as an overreliance on clinician report.

Objective: To provide a detailed description of the symptoms among patients receiving pediatric palliative care based on parental report via a validated, structured symptom assessment measure.

Design, Setting, And Participants: Baseline data for this cross-sectional analysis were collected between April 10, 2017, and February 5, 2020, from pediatric palliative care programs in 7 children's hospitals located in Akron, Ohio; Boston, Massachusetts; Birmingham, Alabama; Houston, Texas; Minneapolis, Minnesota; Philadelphia, Pennsylvania; and Seattle, Washington. Data were collected in the hospital, outpatient, and home setting from patients 30 years of age or younger who were receiving pediatric palliative care at 1 of the study sites.

Exposures: Analyses were stratified by patients' demographic characteristics, including age, and by whether the patients had received a diagnosis of any of 10 non-mutually exclusive complex chronic condition categories.

Main Outcomes And Measures: Twenty symptoms measured via the modified Memorial Symptom Assessment Scale, which scores the frequency and severity of any symptom that is present and provides a total symptom score.

Results: Among the first 501 patients enrolled, the median age was 4.1 years (interquartile range, 0.8-12.9 years), 267 (53.3%) were male, and 356 (71.1%) were White. The most prevalent complex chronic conditions included gastrointestinal (357 [71.3%]), neurologic (289 [57.7%]), and cardiovascular (310 [61.9%]) conditions; 438 patients (87.4%) were technology dependent. Parents reported a mean (SD) of 6.7 (3.4) symptoms per patient and a median of 7 symptoms (interquartile range, 4-9 symptoms). A total of 367 patients (73.3%) had 5 or more symptoms. The 5 most prevalent symptoms were pain (319 [63.7%]; 95% CI, 59.4%-67.8%), lack of energy (295 [58.9%]; 95% CI, 54.5%-63.1%), irritability (280 [55.9%]; 95% CI, 51.5%-60.2%), drowsiness (247 [49.3%]; 95% CI, 44.9%-53.7%), and shortness of breath (232 [46.3%]; 95% CI, 41.9%-50.7%). Although older patients were reported by parents as having experienced more symptoms and having higher total symptom scores, variation across condition categories was relatively minor. Patients in the upper 10th percentile of total symptom scores had a median of 12.0 symptoms (interquartile range, 11-13).

Conclusions And Relevance: In this cross-sectional study, most children receiving palliative care were experiencing polysymptomatology. An important subgroup of patients frequently experienced numerous severe symptoms. Assessment and management of patients with polysymptomatology are critical aspects of pediatric palliative care.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.19730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343495PMC
August 2021

Clinically feasible diffusion MRI in muscle: Time dependence and initial findings in Duchenne muscular dystrophy.

Magn Reson Med 2021 Aug 2. Epub 2021 Aug 2.

Developmental Imaging and Biophysics, University College London, London, United Kingdom.

Purpose: To characterize the diffusion time-dependence in muscle in healthy adult volunteers, boys with Duchenne's muscular dystrophy (DMD), and age-matched controls in a clinically feasible acquisition time for pediatric applications.

Methods: Diffusion data were acquired using a pulsed gradient stimulated echo diffusion preparation at 5 different diffusion times (70, 130, 190, 250, and 330 ms), at 4 different b-values (0, 200, 400, 600, and 800 s/mm ) and 6 directions (orthogonal x, y, and z and diagonal xy, xz, and yz) and processed to obtain standard diffusion indices (mean diffusivity [MD] and fractional anisotropy [FA]) at each diffusion time.

Results: Time-dependent diffusion was seen in muscle in healthy adult volunteers, boys with DMD, and age-matched controls. Boys with DMD showed reduced MD and increased FA values in comparison to age matched controls across a range of diffusion times. A diffusion time of Δ = 190 ms had the largest effect size.

Conclusions: These results could be used to optimize diffusion imaging in this disease further and imply that these diffusion indices may become an important biomarker in monitoring progression in DMD in the future.
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http://dx.doi.org/10.1002/mrm.28945DOI Listing
August 2021

Trends and Variation in the Use of Observation Stays at Children's Hospitals.

J Hosp Med 2021 Jul 21. Epub 2021 Jul 21.

Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children.

Objective: The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals.

Design, Setting, And Participants: Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019).

Exposure, Main Outcomes, And Measures: Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models.

Results: The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals.

Conclusion: Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.
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http://dx.doi.org/10.12788/jhm.3622DOI Listing
July 2021

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

JAMA Netw Open 2021 Jul 1;4(7):e2117816. Epub 2021 Jul 1.

Department of Pediatrics, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Importance: 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.

Objectives: 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.

Design, Setting, And Participants: 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.

Main Outcomes And Measures: 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.

Results: 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).

Conclusions And Relevance: 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.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.17816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8314139PMC
July 2021

Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma.

J Pediatr 2021 Jul 17. Epub 2021 Jul 17.

Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.

Objectives: To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept.

Study Design: This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18 years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range = 0-100) when there was statistical evidence that the percentages were different.

Results: Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P = .46).

Conclusions: The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.
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http://dx.doi.org/10.1016/j.jpeds.2021.07.022DOI Listing
July 2021

Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma.

J Pediatr 2021 Jul 17. Epub 2021 Jul 17.

Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.

Objectives: To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept.

Study Design: This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18 years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range = 0-100) when there was statistical evidence that the percentages were different.

Results: Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P = .46).

Conclusions: The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.
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http://dx.doi.org/10.1016/j.jpeds.2021.07.022DOI Listing
July 2021

Prevalence, Risk Factors, and Outcomes of Influenza-Associated Neurologic Complications in Children.

J Pediatr 2021 Jul 1. Epub 2021 Jul 1.

Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

Objective: To determine the frequency of neurologic complications associated with influenza in hospitalized children.

Stud Design: We performed a cross-sectional study of children (2 months through 17 years of age) with influenza discharged from 49 children's hospitals in the Pediatric Health Information System during the influenza seasons of 2015-2020. Neurologic complications were defined as encephalopathy, encephalitis, aseptic meningitis, febrile seizure, nonfebrile seizure, brain abscess and bacterial meningitis, Reye syndrome, and cerebral infarction. We assessed length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, 30-day hospital readmissions, deaths, and hospital costs associated with these events. Patient-level risk factors associated with neurologic complications were identified using multivariable logistic regression.

Results: Of 29 676 children hospitalized with influenza, 2246 (7.6%) had a concurrent diagnosis of a neurologic complication; the most frequent were febrile seizures (5.0%), encephalopathy (1.7%), and nonfebrile seizures (1.2%). Hospital LOS, ICU admission, ICU LOS, deaths, and hospital costs were greater in children with neurologic complications compared with those without complications. Risk factors associated with neurologic complications included male sex (aOR 1.1, 95% CI 1.02-1.21), Asian race/ethnicity (aOR 1.7, 95% CI 1.4-2.1) (compared with non-Hispanic White), and the presence of a chronic neurologic condition (aOR 3.7, 95% CI 3.1-4.2).

Conclusions: Neurologic complications are common in children hospitalized with influenza, especially among those with chronic neurologic conditions, and are associated with worse outcomes compared with children without neurologic complications. These findings emphasize the strategic importance of influenza immunization and treatment, especially in high-risk populations.
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http://dx.doi.org/10.1016/j.jpeds.2021.06.075DOI Listing
July 2021

The Child Opportunity Index 2.0 and Hospitalizations for Ambulatory Care Sensitive Conditions.

Pediatrics 2021 Aug 2;148(2). Epub 2021 Jul 2.

Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio.

Background And Objectives: Hospitalizations for ambulatory care sensitive conditions (ACSCs) are thought to be avoidable with high-quality outpatient care. Morbidity related to ACSCs has been associated with socioeconomic contextual factors, which do not necessarily capture the complex pathways through which a child's environment impacts health outcomes. Our primary objective was to test the association between a multidimensional measure of neighborhood-level child opportunity and pediatric hospitalization rates for ACSCs across 2 metropolitan areas.

Methods: This was a retrospective population-based analysis of ACSC hospitalizations within the Kansas City and Cincinnati metropolitan areas from 2013 to 2018. Census tracts were included if located in a county where Children's Mercy Kansas City or Cincinnati Children's Hospital Medical Center had >80% market share of hospitalizations for children <18 years. Our predictor was child opportunity as defined by a composite index, the Child Opportunity Index 2.0. Our outcome was hospitalization rates for 8 ACSCs.

Results: We included 604 943 children within 628 census tracts. There were 26 977 total ACSC hospitalizations (46 hospitalizations per 1000 children; 95% confidence interval [CI]: 45.4-46.5). The hospitalization rate for all ACSCs revealed a stepwise reduction from 79.9 per 1000 children (95% CI: 78.1-81.7) in very low opportunity tracts to 31.2 per 1000 children (95% CI: 30.5-32.0) in very high opportunity tracts ( < .001). This trend was observed across cities and diagnoses.

Conclusions: Links between ACSC hospitalizations and child opportunity extend across metropolitan areas. Targeting interventions to lower-opportunity neighborhoods and enacting policies that equitably bolster opportunity may improve child health outcomes, reduce inequities, and decrease health care costs.
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http://dx.doi.org/10.1542/peds.2020-032755DOI Listing
August 2021

Intravenous Magnesium and Hospital Outcomes in Children Hospitalized With Asthma.

Hosp Pediatr 2021 Aug 1;11(8):785-793. Epub 2021 Jul 1.

Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Use of intravenous magnesium (IVMg) for childhood asthma exacerbations has increased significantly in the last decade. Emergency department administration of IVMg has been shown to reduce asthma hospitalization, yet most children receiving IVMg in the emergency department are subsequently hospitalized. Our objective with the study was to examine hospital outcomes of children given IVMg for asthma exacerbations.

Methods: We conducted a retrospective cohort study using data from the Pediatric Health Information System. We used propensity score matching to compare children who received IVMg on the first day of hospitalization with those who did not. Primary outcomes were initiation and duration of noninvasive positive pressure ventilation. Secondary outcomes included mechanical ventilation (MV) initiation, duration of MV, length of stay, and subsequent tertiary medication use. Primary analysis was restricted to children admitted to nonintensive care inpatient units.

Results: Overall, 91 309 hospitalizations met inclusion criteria. IVMg was administered in 25 882 (28.4%) children. After propensity score matching, IVMg was not significantly associated with lower initiation (adjusted odds ratio 0.88; 95% confidence interval [CI] 0.74-1.05) or shorter duration of noninvasive positive pressure ventilation (rate ratio 0.94; 95% CI 0.87-1.02). Similarly, no significant associations were seen for MV initiation, MV duration, or length of stay. IVMg was associated with lower subsequent tertiary medication use (adjusted odds ratio 0.66; 95% CI 0.60-0.72). However, the association was lost when ipratropium was removed from the tertiary medication definition.

Conclusions: IVMg administration was not significantly associated with improved hospital outcomes. Further study is needed to inform the optimal indications and timing of magnesium use during hospitalization.
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http://dx.doi.org/10.1542/hpeds.2020-004770DOI Listing
August 2021

Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events.

Hosp Pediatr 2021 Jun 28. Epub 2021 Jun 28.

Seattle Children's Hospital, Seattle, Washington.

Objectives: To evaluate (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE).

Methods: Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE.

Results: Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%).

Conclusions: The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.
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June 2021

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study.

Pediatrics 2021 Jul 24;148(1). Epub 2021 Jun 24.

Department of Pediatrics, State University of New York Downstate Health Sciences University and New York City Health and Hospitals/Kings County, Brooklyn, New York.

Background: The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes.

Methods: This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE.

Results: Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness ( < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%.

Conclusions: AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.
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http://dx.doi.org/10.1542/peds.2020-036095DOI Listing
July 2021

Evolving Cost-Quality Relationship in Pediatric Heart Surgery.

Ann Thorac Surg 2021 Jun 8. Epub 2021 Jun 8.

Department of Surgery, University of Florida, Gainesville, FL.

Background: For the >40,000 US children undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize healthcare value in this population.

Methods: Clinical information (Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010-2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, post-operative complications, length of stay (PLOS), and a composite.

Results: Overall 32 hospitals (n=45,315 patients) were included. Median adjusted cost/case varied across hospitals from $67,700 to $51,200 in the high vs. low cost tertile (ratio 1.32, 95% credible interval 1.29-1.35), and all quality metrics also varied across hospitals. Across cost tertiles there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk STAT 4-5 cases [adjusted median LOS 16.8 vs. 14.9 days in high vs. low cost tertile (ratio 1.13, 1.05-1.24)], and ICU PLOS.

Conclusions: Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to ICU PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.050DOI Listing
June 2021

ICD-10 Transition Influences Trends in Perforated Appendix Admission Rate.

J Surg Res 2021 10 30;266:345-351. Epub 2021 May 30.

Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois 60611. Electronic address:

Background: This study sought to evaluate the influence of International Classification of Diseases, Tenth Revision (ICD-10) transition on Perforated Appendix Admission Rate (PAAR), which is a commonly used indicator representing access to care developed by Agency for Healthcare Research and Quality (AHRQ).

Materials And Methods: In this interrupted time series study of Pediatric Health Information System database from 2013 to 2018, we employed three study phases (pre-implementation, washout, and initial implementation) to evaluate the influence of ICD-10 transition on trends in PAAR. ICD-10 diagnosis codes suggested by AHRQ's specifications were used to identify perforated and simple appendicitis, and PAAR was estimated accordingly. Generalized linear mixed models were used to examine the association of ICD-10 initial implementation and being documented as perforated appendicitis on encounter level.

Results: We identified a total of 94,810 encounters diagnosed with appendicitis, and almost all patients' characteristics were similar over the three study phases, except for PAAR. The pre-implementation PAAR in October 2013 was 33.1%, and the immediate influence of ICD-10 transition on PAAR was 3.2% (P = 0.002), with a 0.38% per quarter increase over time (P = 0.02). After adjusting for age, gender, race/ethnicity, payer, and year, the likelihood of being documented as having perforated appendicitis in 2016 was 1.5 times higher than the estimated likelihood before the implementation (adjusted Odds Ratio: 1.51; 95% Confidence Interval: 1.40-1.63; P < 0.001).

Conclusions: The 2015-2018 ICD-10 transition may be erroneously associated with an increasing trend of PAAR. Care should be taken when interpreting the metric during this period.
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http://dx.doi.org/10.1016/j.jss.2021.04.028DOI Listing
October 2021

Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions.

Pediatr Emerg Care 2021 Apr 20. Epub 2021 Apr 20.

From the Department of Surgery and Pediatrics, University of Vermont Medical Center and Children's Hospital, University of Vermont Larner College of Medicine, Burlington, VT Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI Division of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL Family Leader at Family Voices of Minnesota Children's Hospital Association, Lenexa, KS Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.

Objective: Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC.

Methods: A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit.

Results: Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]).

Conclusions: Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.
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http://dx.doi.org/10.1097/PEC.0000000000002437DOI Listing
April 2021

Impact of institutional routine surveillance endomyocardial biopsy frequency in the first year on rejection and graft survival in pediatric heart transplantation.

Pediatr Transplant 2021 Sep 18;25(6):e14035. Epub 2021 May 18.

Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA.

Background: Routine surveillance biopsy (RSB) is performed to detect asymptomatic acute rejection (AR) after heart transplantation (HT). Variation in pediatric RSB across institutions is high. We examined center-based variation in RSB and its relationship to graft loss, AR, coronary artery vasculopathy (CAV), and cost of care during the first year post-HT.

Methods: We linked the Pediatric Health Information System (PHIS) and Scientific Registry of Transplant Recipients (SRTR, 2002-2016), including all primary-HT aged 0-21 years. We characterized centers by RSB frequency (defined as median biopsies performed among recipients aged ≥12 months without rejection in the first year). We adjusted for potential confounders and center effects with mixed-effects regression analysis.

Results: We analyzed 2867 patients at 29 centers. After adjusting for patient and center differences, increasing RSB frequency was associated with diagnosed AR (OR 1.15 p = 0.004), a trend toward treated AR (OR 1.09 p = 0.083), and higher hospital-based cost (US$390 315 vs. $313 248, p < 0.001) but no difference in graft survival (HR 1.00, p = 0.970) or CAV (SHR 1.04, p = 0.757) over median follow-up 3.9 years. Center RSB-frequency threshold of ≥2/year was associated with increased unadjusted rates of treated AR, but no association was found at thresholds greater than this.

Conclusion: Center RSB frequency is positively associated with increased diagnosis of AR at 1 year post-HT. Graft survival and CAV appear similar at medium-term follow-up. We speculate that higher frequency RSB centers may have increased detection of clinically less important AR, though further study of the relationship between center RSB frequency and differences in treated AR is necessary.
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http://dx.doi.org/10.1111/petr.14035DOI Listing
September 2021

Waitlist and Post-Heart Transplant Outcomes for Children with Kawasaki Disease in the United States.

J Pediatr 2021 Aug 10;235:281-283.e4. Epub 2021 May 10.

Pediatric Cardiology, Monroe Carell Jr Children's Hospital, Nashville, TN.

We evaluated waitlist and post-heart transplant outcomes for children with Kawasaki disease and found that over 3 decades the number of patients requiring heart transplantation in the US is low. Also, patients with Kawasaki disease have similar waitlist and post-transplant outcomes compared with patients with dilated cardiomyopathy.
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http://dx.doi.org/10.1016/j.jpeds.2021.05.007DOI Listing
August 2021

Pediatric Firearm-Related Hospital Encounters During the SARS-CoV-2 Pandemic.

Pediatrics 2021 08 12;148(2). Epub 2021 May 12.

Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee.

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http://dx.doi.org/10.1542/peds.2021-050223DOI Listing
August 2021

Safety Events in Children's Hospitals During the COVID-19 Pandemic.

Hosp Pediatr 2021 06 6;11(6):e95-e100. Epub 2021 May 6.

Department of Pediatrics, Boston Children's Hospital and Harvard University, Boston, Massachusetts.

Background And Objectives: The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. Our objective was to compare pediatric hospitalization safety events during the pandemic versus previous years.

Methods: In this retrospective cohort study of hospitalizations in the Pediatric Health Information System, we compared Pediatric Quality Indicator (PDI) rates from March 15 to May 31, 2017-2019 (pre-COVID-19), with those from March 15 to May 31, 2020 (during COVID-19). Generalized linear mixed-effects models with adjustment for patient characteristics (eg, diagnosis, clinical severity) were used.

Results: There were 399 113 discharges pre-COVID-19 and 88 140 during COVID-19. Unadjusted PDI rates were higher during versus pre-COVID-19 for overall PDIs (6.39 vs 5.05; < .001). In adjusted analyses, odds of postoperative sepsis were higher during COVID-19 versus pre-COVID-19 (adjusted odds ratio 1.28 [95% confidence interval 1.04-1.56]). The remainder of the PDIs did not have increased adjusted odds during compared with pre-COVID-19.

Conclusions: Postoperative sepsis rates increased among children hospitalized during COVID-19. Efforts are needed to improve safety of postoperative care for hospitalized children.
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http://dx.doi.org/10.1542/hpeds.2020-004937DOI Listing
June 2021

Outcomes Associated With High- Versus Low-Frequency Laboratory Testing Among Hospitalized Children.

Hosp Pediatr 2021 Jun 5;11(6):563-570. Epub 2021 May 5.

Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee.

Background And Objectives: Previous pediatric studies have revealed substantial variation in laboratory testing for specific conditions, but clinical outcomes associated with high- versus low-frequency testing are unclear. We hypothesized that hospitals with high- versus low-testing frequency would have worse clinical outcomes.

Methods: We conducted a multicenter retrospective cohort study of patients 0 to 18 years old with low-acuity hospitalizations in the years 2018-2019 for 1 of 10 common All Patient Refined Diagnosis Related Groups. We identified hospitals with high-, moderate-, and low-frequency testing for 3 common groups of laboratory tests: complete blood cell count, basic chemistry studies, and inflammatory markers. Outcomes included length of stay, 7- and 30-day emergency department revisit and readmission rates, and hospital costs, comparing hospitals with high- versus low-frequency testing.

Results: We identified 132 391 study encounters across 44 hospitals. Laboratory testing frequency varied by hospital and condition. We identified hospitals with high- (13), moderate- (20), and low-frequency (11) laboratory testing. When we compared hospitals with high- versus low-frequency testing, there were no differences in adjusted hospital costs (rate ratio 0.89; 95% confidence interval 0.71-1.12), length of stay (rate ratio 0.98; 95% confidence interval 0.91-1.06), 7-day (odds ratio 0.99; 95% confidence interval 0.81-1.21) or 30-day (odds ratio 1.01; 95% confidence interval 0.82-1.25) emergency department revisit rates, or 7-day (odds ratio 0.84; 95% confidence interval 0.65-1.25) or 30-day (odds ratio 0.91; 95% confidence interval 0.76-1.09) readmission rates.

Conclusions: In a multicenter study of children hospitalized for common low-acuity conditions, laboratory testing frequency varied widely across hospitals, without substantial differences in outcomes. Our results suggest opportunities to reduce laboratory overuse across conditions and children's hospitals.
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http://dx.doi.org/10.1542/hpeds.2020-005561DOI Listing
June 2021

Trends in Length of Stay and Readmissions in Children's Hospitals.

Hosp Pediatr 2021 Jun 4;11(6):554-562. Epub 2021 May 4.

General Pediatrics, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background And Objectives: Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals.

Methods: Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix.

Results: Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased ( < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; < .001).

Conclusions: Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.
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http://dx.doi.org/10.1542/hpeds.2020-004044DOI Listing
June 2021

Reasons for Admissions to US Children's Hospitals During the COVID-19 Pandemic.

JAMA 2021 04;325(16):1676-1679

Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2021.4382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080216PMC
April 2021

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury.

J Pediatr 2021 Aug 22;235:178-183.e1. Epub 2021 Apr 22.

Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.

Objective: To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT).

Study Design: We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits.

Results: There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS.

Conclusions: Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
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August 2021
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