Search

Aim: To describe the hospital costs, hospital types and differences across states and territories for children with medical complexity cared for in Australian public hospitals.Methods: Retrospective national administrative database study of 212 Australian public hospitals from six states (excluding Queensland) and two territories that submitted cost data to the National Hospital Costing Data Collection for 2010-2011. Participants included all hospitalised patients with comparisons between adults and children (17 years of age and younger), and adults with chronic diseases and children with medical complexity. Total hospital costs were the main outcome measure.Results: The National Hospital Costing Data Collection contained data from 212 public hospitals; total admissions (adults and children) were 3 519 140 at a total hospital cost of $16 187 400 000. Children accounted for 350 499 (9.9%) of the admissions at a total hospital cost of $1 931 585 123 (11.9%). Of all children, those with medical complexity accounted for 48 758 (13.9%), and their total hospital costs were $620 948 769 (32.1%). Six children's hospitals had 145 213 (41%) of the total children admissions at a total hospital cost of $936 041 843 (48%). Across the states and territories, the number of childhood admissions ranged from 9164 to 146 618 with 4.7-14.8% for children with medical complexity. Total hospital costs ranged from $44 to $592 million with 15.4-39.4% for children with medical complexity.Conclusions: The national burden of hospitalised children is substantial. Children with medical complexity only account for a small percentage of hospitalisations but almost one third of total hospital costs for children, with children's hospitals bearing the major costs. [ABSTRACT FROM AUTHOR]

OBJECTIVE. Aspiration pneumonia is the most common cause of death in children with neurologic impairment who have gastroesophageal reflux disease. Fundoplications and gastrojejunal feeding tubes are frequently employed to prevent aspiration pneumonia in this population. Which of these approaches is more effective in preventing aspiration pneumonia and/or improving survival is unknown. The objective of this study was to compare outcomes for children with neurologic impairment and gastroesophageal reflux disease after either a first fundoplication or a first gastrojejunal feeding tube. PATIENTS AND METHODS. This was a retrospective, observational cohort study of children with neurologic impairment who had either a fundoplication or gastrojejunal feeding tube between January 1997 and December 2005 at a tertiary care children's hospital. Main outcome measures were postprocedure aspiration pneumonia-free survival and mortality. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances. RESULTS. Of the 366 children with neurologic impairment and gastroesophageal reflux disease, 43 had a first gastrojejunal feeding tube and 323 underwent a first fundoplication. Median length of follow-up was 3.4 years. Children who received a first fundoplication had similar rates of aspiration pneumonia and mortality after the procedure compared with those who had a first gastrojejunal feeding tube, when adjusting for the treatment assignment using propensity scores. CONCLUSIONS. Aspiration pneumonia and mortality are not uncommon events after either a first fundoplication or a first gastrojejunal feeding tube for the management of gastroesophageal reflux disease in children with neurologic impairment. Neither treatment option is clearly superior in preventing the subsequent aspiration pneumonia or improving overall survival for these children. This complex clinical scenario needs to be studied in a prospective, multicenter, randomized control trial to evaluate definitively whether 1 of these 2 management options is more beneficial. [ABSTRACT FROM AUTHOR]

OBJECTIVE. This study examined mechanisms of efficiency in a managed care hospitalist system on length of stay and total costs for common pediatric conditions. PATIENTS AND METHODS. We conducted a retrospective cohort study (October 1993 to July 1998) of patients in a not-for-profit staff model (HMO 1) and a non-staffmodel (HMO 2) managed care organization at a freestanding children's hospital. HMO 1 introduced a hospitalist system for patients in October 1996. Patients were included if they had 1 of 3 common diagnoses: asthma, dehydration, or viral illness. Linear regression models examining length-of-stay-specific costs for pre-hospitalist and posthospitalist systems were built. Distribution of length of stay for each diagnosis before and after the system change in both study groups was calculated. Interrupted time series analysis tested whether changes in the trends of length of stay and total costs occurred after implementation of the hospitalist system by HMO1 (HMO 2 as comparison group) for all 3 diagnoses combined. RESULTS. A total of 1970 patients with 1 of the 3 study conditions were cared for in HMO 1, and 1001 in HMO 2. After the hospitalist system was introduced in HMO 1, length of stay was reduced by 0.23 days (13%) for asthma and 0.19 days (11%) for dehydration; there was no difference for patients with viral illness. The largest relative reduction in length of stay occurred in patients with a shorter length of stay whose hospitalizations were reduced from 2 days to 1 day. This shift resulted in an average cost-per-case reduction of $105.51 (9.3%) for patients with asthma and $86.22 (7.8%) for patients with dehydration. During the same period, length of stay and total cost rose in HMO 2. CONCLUSIONS. Introduction of a hospitalist system in one health maintenance organization resulted in earlier discharges and reduced costs for children with asthma and dehydration compared with another one, with the largest reductions occurring in reducing some 2-day hospitalizations to 1 day. These findings suggest that hospitalists can increase efficiency and reduce costs for children with common pediatric conditions. [ABSTRACT FROM AUTHOR]

Objectives . To determine parents' awareness of and compliance with air pollution advisories, and to compare the awareness and compliance of parents' of asthmatics to that of other parents. Methods . Responses of 240 parents surveyed at pediatric clinic visits were compared. Results . A total of 88% of parents were aware of air pollution advisories; 71% reduced pollution and 55% restricted children's play “sometimes” because of advisories. However, only 7% complied with more than one third of the advisories issued. More parents of asthmatics reported awareness of alerts ( p = 0.002), reducing pollution ( p = 0.005), or restricting play “sometimes” in response to advisories ( p = 0.007). Conclusions . Most parents report awareness of and some compliance with air pollution advisories. Parents of asthmatics are more aware and somewhat more compliant than other parents. [ABSTRACT FROM AUTHOR]

Objective. Pediatric hospitalist systems are being implemented widely. Their implementation may be influenced by physician attitudes, which may vary according to practice type (eg, community or hospital-based practice) and personal characteristics (eg, age and practice location). Little evidence exists to describe factors relevant to pediatric systems. The objective of this study was to determine physicians' attitudes regarding hospitalists and associated physician and practice characteristics. Methods. We used a cross-sectional survey of all physicians with admitting privileges at a tertiary-care, pediatric, teaching hospital in the Intermountain West in April 2002. Outcomes included survey responses indicating attitudes toward the effects of the hospitalist system on quality of care, patient satisfaction, and teaching. Results. A total of 313 of 368 physicians (85%) responded, 191 of whom (61%) were community physicians; 224 respondents (72%) spent the majority of their time in outpatient care. Community physicians more often characterized inpatient care as an inefficient use of time (45% vs 25%) but were less likely to think that hospitalists would improve the quality of care (49% vs 68%) or increase patient satisfaction (10% vs 30%). In multivariate models examining predictors of overall attitudes toward hospitalists, being a community physician (6.4 points more negative) and admitting patients at >1 hospital (3.3 points more negative) were associated with less favorable attitudes. Being <40 years of age (4.5 points more positive) and practicing >13 miles from the hospital (4.3 points more positive) were associated with more positive attitudes. Conclusions. Attitudes regarding hospitalist systems differ between physician groups and are influenced by practice characteristics. Understanding these differences and tailoring hospitalist systems to address them will be important as pediatric hospitalist systems are implemented nationwide. [ABSTRACT FROM AUTHOR]

Objective. Pediatric teaching hospitals provide particular expertise in caring for children with complex or severe illnesses, yet most patients within teaching hospitals have common pediatric conditions. No study has determined whether children with common conditions remain hospitalized at teaching institutions longer than at nonteaching institutions. The objective of this study was to compare length of stay (LOS) for common pediatric conditions between teaching and nonteaching hospitals. Methods. This study uses Massachusetts's hospital data for all discharged children ages 0 to 17 years for 1995 and 1996. Discharges were included when tile principal diagnosis indicated asthma, bacterial pneumonia, convulsions, dehydration, failure to thrive, gastroenteritis, or urinary tract infections. Hospitals were classified as either teaching or nonteaching using the 1995-1996 American Hospital Association Guide. Children were identified as having a chronic condition when any discharge diagnosis was 1 of those on a previously published catalog of chronic childhood illnesses. The analysis tested the association of hospital type with LOS, controlling for chronic conditions, insurance type, age, race, diagnosis, mortality, and disposition using multivariate linear regression. Results. Of 17 890 discharges for a common pediatric condition during the study period, 523% were from teaching hospitals. Twelve percent of common condition discharges also had a chronic disease diagnosis; 75.1% of these were discharged from a teaching hospital. LOS from nonteaching hospitals was shorter than from teaching hospitals (2.42 days vs 3.20 days). Although LOS for stays with a chronic diagnosis were longer than those without (4.75 days vs 2.56 days), controlling for chronic illness and other covariates did not eliminate... [ABSTRACT FROM AUTHOR]

Pertussis cases have been increasing in the United States for the past 40 years. Polymerase chain reaction (PCR) testing is now the preferred method of diagnosis, but little is known about duration of PCR positivity. We conducted a pilot study using serial B pertussis PCR testing to determine duration of PCR positivity. Kaplan-Meier survival analysis suggested a median duration of 58 days (interquartile range, 40–110 days). [ABSTRACT FROM PUBLISHER]

The authors reflect on the use of proper health care measures to reduce pediatric readmission. According to the authors, hospitals for children are not included under the U.S. Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program (HRRP). They inform that the U.S. Centers for Medicaid and Medicare Service should develop programs to reduce readmission of children.

The article examines the development of hospitalists and its effects on the doctor-patient relationship (DPR). The six fundamental elements of the ideal DPR are explained. It is noted that while the majority of hospitalist systems are voluntary, some have proposed mandatory systems. The significance of the development of hospitalists is mentioned.

Context Methods Results Conclusions Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care – Triple Aim ‐ and improving the work life of the care providers – Quadruple Aim ‐. Reinforcing the recently defined Fifth Aim as equity through “health democracy” to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care – Triple Aim ‐ and improving the work life of the care providers – Quadruple Aim ‐. Reinforcing the recently defined Fifth Aim as equity through “health democracy” to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care – Triple Aim ‐ and improving the work life of the care providers, including clinicians and staff – Quadruple Aim ‐. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term.A conceptual framework to provide additional ethical guardrails for health systems.Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through “health democracy” to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment.As social tension and environmental changes seem to continue to impact the structure of our society this “Hexagonal Aim” taken together might provide additional ethical guiderails as we set our healthcare goals. [ABSTRACT FROM AUTHOR]

Background Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care. Methods We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter. Results UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization. Conclusions Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes. METHODS: This multicenter retrospective cohort study included children ≥2 months and <18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed "all related revisits." RESULTS: Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46). CONCLUSIONS: Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. Methods: The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. Discussion: The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. Trial registration: Clinicaltrials.gov, NCT05141396, registered 12/02/2021. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We implemented a computerized protocol for low tidal volume ventilation (LTVV) to improve management and outcomes of mechanically ventilated patients with, and without, the acute respiratory distress syndrome (ARDS). DESIGN: Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial. SETTING: Twelve hospitals in an integrated healthcare system over a 2-year period. PATIENTS: Patients greater than or equal to 18 years old who had initiation of mechanical ventilation in the emergency department or ICU. We excluded patients who died or transitioned to comfort care on the day of admission to the ICU. We defined a subgroup of patients with ARDS for analysis. INTERVENTIONS: Implementation of ventilator protocols for LTVV in the ICU. MEASUREMENTS AND MAIN RESULTS: Our primary clinical outcome was ventilator-free days (VFDs) to day 28. Our primary process outcome was median initial set tidal volume. We included 8,692 mechanically ventilated patients, 3,282 (38%) of whom had ARDS. After implementation, set tidal volume reported as mL/kg predicted body weight decreased from median 6.1 mL/kg (interquartile range [IQR], 6.0–6.8 mL/kg) to 6.0 mL/kg (IQR, 6.0–6.6 mL/kg) (p = 0.009). The percent of patients receiving LTVV (tidal volume ≤ 6.5 mL/kg) increased from 69.8% (n = 1,721) to 72.5% (n = 1,846) (p = 0.036) after implementation. The percent of patients receiving greater than 8 mL/kg initial set tidal volume was reduced from 9.0% (n = 222) to 6.7% (n = 174) (p = 0.005) after implementation. Among patients with ARDS, day 1 positive end-expiratory pressure increased from 6.7 to 8.0 cm H2O (p < 0.001). We observed no difference in VFD (adjusted odds ratio, 1.06; 95% CI, 0.91–1.24; p = 0.44), or in secondary outcomes of length of stay or mortality, either within the main cohort or the subgroup of patients with ARDS. CONCLUSIONS: We observed improved adherence to optimal ventilator management with implementation of a computerized protocol and reduction in the number of patients receiving tidal volumes greater than 8 mL/kg. We did not observe improvement in clinical outcomes. [ABSTRACT FROM AUTHOR]

The article presents information on a research which investigated the impact of fundoplication on reflux related hospital admissions for children with neurological impairment. Study participants, selected from 42 children's hospitals in the U.S., were children with neurological impairment born between 2000 and 2005. Primary outcome measure included the incident rate ratio for reflux related hospital admissions. Presented in details are the research findings.

The characteristics of seizures and epilepsy in infants who have had an apparent life-threatening event have been poorly defined. Our objective was to characterize in depth the cohort of patients with apparent life-threatening events who developed seizures. We collected data from infants hospitalized for an apparent life-threatening event, and evaluated patients for subsequent seizures or chronic epilepsy. Of 471 patients with an apparent life-threatening event, 25 (5.3%) had seizures and 17 (3.6%) developed chronic epilepsy. There was no increased risk for febrile seizures. Abnormal brain magnetic resonance imaging results and developmental delay were only found in those patients who developed chronic epilepsy. Of those who developed chronic epilepsy, 47% were diagnosed with seizures within 1 week of their apparent life-threatening event. The discharge diagnosis at the time of the apparent life-threatening event was poorly predictive of those who developed seizures. In most cases the cause of chronic epilepsy was unknown, although cortical dysplasias made up a significant percentage (12%). [ABSTRACT FROM AUTHOR]

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS.This was a retrospective cohort study. Hospital administrative data were collected from 38 children's hospitals in the United States for the years 2003-2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186 856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning. [ABSTRACT FROM AUTHOR]

Background Studies on the implementation of antibiotic stewardship programs (ASPs) in small hospitals are limited. Accreditation organizations now require all hospitals to have ASPs. Methods The objective of this cluster-randomized intervention was to assess the effectiveness of implementing ASPs in Intermountain Healthcare’s 15 small hospitals. Each hospital was randomized to 1 of 3 ASPs of escalating intensity. Program 1 hospitals were provided basic antibiotic stewardship education and tools, access to an infectious disease hotline, and antibiotic utilization data. Program 2 hospitals received those interventions plus advanced education, audit and feedback for select antibiotics, and locally controlled antibiotic restrictions. Program 3 hospitals received program 2 interventions plus audit and feedback on the majority of antibiotics, and an infectious diseases–trained clinician approved restricted antibiotics and reviewed microbiology results. Changes in total and broad-spectrum antibiotic use within programs (intervention versus baseline) and the difference between programs in the magnitude of change in antibiotic use (eg, program 3 vs 1) were evaluated with mixed models. Results Program 3 hospitals showed reductions in total (rate ratio, 0.89; confidence interval,.80–.99) and broad-spectrum (0.76;.63–.91) antibiotic use when the intervention period was compared with the baseline period. Program 1 and 2 hospitals did not experience a reduction in antibiotic use. Comparison of the magnitude of effects between programs showed a similar trend favoring program 3, but this was not statistically significant. Conclusions Only the most intensive ASP intervention was associated with reduction in total and broad-spectrum antibiotic use when compared with baseline. Clinical Trials Registration NCT03245879 [ABSTRACT FROM AUTHOR]

BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. METHODS: We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time. RESULTS: Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations. CONCLUSIONS: AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions. [ABSTRACT FROM AUTHOR]

Purpose The advent of genomic diagnostic technologies such as next-generation sequencing has recently enabled the use of genomic information to guide targeted treatment in patients with cancer, an approach known as precision medicine. However, clinical outcomes, including survival and the cost of health care associated with precision cancer medicine, have been challenging to measure and remain largely unreported. Patients and Methods We conducted a matched cohort study of 72 patients with metastatic cancer of diverse subtypes in the setting of a large, integrated health care delivery system. We analyzed the outcomes of 36 patients who received genomic testing and targeted therapy (precision cancer medicine) between July 1,2013, and January 31,2015, compared with 36 historical control patients who received standard chemotherapy (n = 29) or best supportive care (n = 7). Results The average progression-free survival was 22.9 weeks for the precision medicine group and 12.0 weeks for the control group (P = .002) with a hazard ratio of 0.47 (95% CI, 0.29 to 0.75) when matching on age, sex, histologic diagnosis, and previous lines of treatment. In a subset analysis of patients who received all care within the Intermountain Healthcare system (n = 44), per patient charges per week were $4,665 in the precision treatment group and $5,000 in the control group (P = .126). Conclusion These findings suggest that precision cancer medicine may improve survival for patients with refractory cancer without increasing health care costs. Although the results of this study warrant further validation, this precision medicine approach may be a viable option for patients with advanced cancer. [ABSTRACT FROM AUTHOR]

Introduction: Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting. Methods: We collected retrospective data from 28 UC clinics and 22 hospitals in the Intermountain Healthcare system between years 2008-2013. Adult patients (≥18 years) were included if they had a unique UC visit and HR or SBP data. Three endpoints following UC visit were assessed: emergency department (ED) visit within three days, hospitalization within three days, and death within seven days. We analyzed associations between age, SBP, HR and endpoints using local regression with a binomial likelihood. Five age groups were chosen from previously published national surveys. Vital sign (VS) distributions were determined for each age group, and the central tendency was compared against previously published norms (90-120mmHg for SBP and 60-1 00bpm for HR.) Results: A total of 1,720,207 encounters (714,339 unique patients) met the inclusion criteria; 51,446 encounters (2.99%) had ED visit within three days; 12,397 (0.72%) experienced hospitalization within three days; 302 (0.02%) died within seven days of UC visit. Heart rate and SBP combined with advanced age predicted the probability of ED visit (p<0.0001) and hospitalization (p<0.0001) following UC visit. Significant associations between advancing age and death (p<0.0001), and VS and death (p<0.0001) were observed. Odds ratios of risk were highest for elderly patients with lower SBP or higher HR. Observed distributions of SBP were higher than published normal ranges for all age groups. Conclusion: Among adults seeking care in the UC, associations between HR and SBP and likelihood of ED visits and hospitalization were more pronounced with advancing age. Death following UC visit had a more limited association with advancing age or the VS evaluated. Rapidly increasing risk below SBP of 100-110 mmHg in older patients suggests that accepted normal ranges for SBP may need to be redefined for patients treated in the UC clinic. [ABSTRACT FROM AUTHOR]

Objective To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A). Methods Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1–18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits. Results Data from 39,906 children aged 1–18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR = 1.64 95% CI 1.47–1.84), Hispanic race (OR = 1.36 95% CI 1.13–1.64), and increased severity of illness (SOI) (OR = 11.29 95% CI 2.69–47.4 for SOI = 3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU ( p < 0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage. Conclusion Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. METHODS: We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits]. We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series. RESULTS: Of 111 813 children who underwent tonsillectomy, 54 043 and 57 770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001] in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% [P < .001) because of an increase in revisits for pain. Hospital-level results were similar. CONCLUSIONS: The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain. [ABSTRACT FROM AUTHOR]

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics’ Quality Improvement Innovation Networks and the Section on Hospital Medicine. [ABSTRACT FROM AUTHOR]

Children with inherited leukodystrophies have high hospitalization rates, often associated with infection. We studied whether potentially modifiable risk factors (preexisting indwelling central intravenous access, urinary catheter, hardware, or mechanical ventilation; and influenza vaccine) were associated with infection-related hospitalization in children with leukodystrophy. Central intravenous access was associated with sepsis (odds ratio [ OR] 9.8); urinary catheter was associated with urinary tract infections ( OR 9.0); lack of seasonal vaccination was associated with influenza ( OR 6.4); and mechanical ventilation was associated with pneumonia ( OR 2.7). We conclude that potentially modifiable risk factors are significantly associated with infection and hospitalization in children with leukodystrophies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe the quality of care for routine tonsillectomy at US children's hospitals. METHODS: We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital. RESULTS: Of 139 715 children who underwent same-day tonsillectomy, 10 868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P< .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%). CONCLUSIONS: Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to characterize variation in hospital resource utilization and readmission for diabetic ketoacidosis (DKA) across US children's hospitals. METHODS: The study sample included a retrospective cohort of children aged 2 to 18 years with a diagnosis of DKA at 38 children's hospitals between 2004 and 2009. The main outcomes were resource utilization as determined by total standardized cost per hospitalization, overall and non-ICU length of stay (LOS), and readmission for DKA within 30 and 365 days. RESULTS: There were 24 890 DKA admissions, and 20.3% of these were readmissions within 1 year. The mean hospital-level total standardized cost was $7142 (range $4125-$11 916). The mean hospital-level LOS was 2.5 days (1.5-3.7), and the non-ICU portion was 1.9 days (0.7-2.7). The mean hospital-level readmission within 365 days was 18.7% (6.5%-41.1%) and within 30 days was 2.5% (0.0%-7.1%). Hospital bed days overall, and in particular the non-ICU portion, accounted for the majority of the total standardized cost per hospitalization (overall 57%; non-ICU 36%) and explained most of the variation in resource use. Even after adjusting for difference in patient characteristics across hospitals, widespread differences existed across hospitals in total standardized cost, LOS, and readmission rates (P < .001). CONCLUSIONS: Readmission for DKA within a year of hospitalization is common. US children's hospitals vary widely in resource use, hospital LOS, and readmission rates for patients with DKA. Our study highlights the need for additional research to understand these differences and to identify the most cost-effective strategies for managing diabetes across the continuum of care. Pediatrics 2013;132:229-236 [ABSTRACT FROM AUTHOR]

Objectives We sought to determine the yield of cardiac testing and to identify predictors of cardiac disease in infants with an apparent life-threatening event (ALTE). Design Retrospective longitudinal cohort study. Setting Paediatric hospital providing primary and tertiary care that is part of an integrated healthcare system. Patients Infants hospitalised for an ALTE from 1999 to 2003. Main exposures Cardiac testing used at time of ALTE and results, and clinical risk factors for cardiac disease. Outcome measures Short-term (during hospitalisation) and long-term (through November 2009) follow-up for any diagnosis of significant cardiac anatomic or rhythm abnormality. Results Study criteria were met by 485 infants (mean age 1.9, SD±2.2 months; 49% boys). Cardiac testing was performed on 219 (45%) patients during ALTE hospitalisation, identifying two patients with significant cardiac disease (cardiomyopathy, ventricular preexcitation). During 7.7 years of follow-up, three additional significant cardiac diagnoses (ventricular pre-excitation, frequent ventricular ectopy, moderate aortic stenosis) were identified. All cardiac tests had low positive predictive value (PPV). Significant cardiac disease was associated with prematurity (22% vs 80%, p=0.002), but not age, gender, prior ALTE or rescue breaths. Conclusions This longitudinal study of an ALTE cohort revealed significant cardiac disease in <1% of patients. Prematurity was the only clinical predictor identified. ECG was sensitive for identifying significant cardiac disease, but routine testing warrants further investigation because of the low PPV. [ABSTRACT FROM AUTHOR]

Objective To describe patient demographics, interventions, and outcomes in hospitalized children with macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis (JIA). Methods We performed a retrospective cohort study using data recorded in the Pediatric Health Information System (PHIS) database from October 1, 2006 to September 30, 2010. Participants had International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for MAS and either SLE or JIA. The primary outcome was hospital mortality (for the index admission). Secondary outcomes included intensive care unit (ICU) admission, critical care interventions, and medication use. Results A total of 121 children at 28 children's hospitals met the inclusion criteria, including 19 children with SLE and 102 children with JIA. The index admission mortality rate was 7% (8 of 121 patients). ICU admission (33%), mechanical ventilation (26%), and inotrope/vasopressor therapy (26%) were common. Compared to children with JIA, those with SLE had a similar mortality rate (6% versus 11%, respectively; exact P = 0.6). More patients with SLE than those with JIA received ICU care (63% versus 27%; P = 0.002), received mechanical ventilation (53% versus 21%; P = 0.003), and had cardiovascular dysfunction (47% versus 23% received inotrope/vasopressor therapy; P = 0.02). Children with SLE and those with JIA received cyclosporine at similar rates, but more children with SLE received cyclophosphamide and mycophenolate mofetil, and more children with JIA received interleukin-1 antagonists. Conclusion Organ system dysfunction is common in children with rheumatic diseases complicated by MAS, and more organ system support is required in children with underlying SLE than in children with JIA. Current treatment of pediatric MAS varies based on the underlying rheumatic disease. [ABSTRACT FROM AUTHOR]