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Objectives: Compare lifetime earning potential (LEP) for developmental and behavioral pediatrics (DBP) to general pediatrics and other pediatric subspecialties. Evaluate association between LEP for DBP and measures of workforce distribution., Methods: Using compensation and debt data from 2018 to 2019 and a net present value analysis, we estimated LEP for DBP compared to general pediatrics and other pediatric subspecialties. We evaluated potential effects of eliminating educational debt, shortening length of fellowship training, and implementing loan repayment or forgiveness programs for pediatric subspecialists. We evaluated the association between LEP for DBP and measures of workforce distribution, including distance to subspecialists, percentage of hospital referral regions (HRRs) with a subspecialist, ratio of subspecialists to regional child population, and fellowship fill rates., Results: LEP was lower for DBP than for general private practice pediatrics ($1.9 million less), general academic pediatrics ($1.1 million less), and all other pediatric subspecialties. LEP of DBP could be improved by shortening fellowship training or implementing loan repayment or forgiveness programs. LEP for subspecialists, including DBP, was associated with distance to subspecialists (-0.5 miles/$100,000 increase in LEP, 95% confidence interval [CI] -0.98 to -0.08), percentage of HRRs with a subspecialist (+1.1%/$100,000 increase in LEP, 95% CI 0.37-1.83), ratio of subspecialists to regional child population (+0.1 subspecialists/100,000 children/$100,000 increase in LEP, 95% CI 0.04-0.17), and average 2014 to 2018 fellowship fill rates (+1% spots filled/$100,000 increase in LEP, 95% CI 0.25-1.65)., Conclusions: DBP has the lowest LEP of all pediatric fields and this is associated with DBP workforce shortages. Interventions to improve LEP may promote workforce growth., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Examine the relationship between the gender distribution of the pediatric subspecialty workforce and lifetime earning potential., Methods: We estimated lifetime earning potential for pediatric academic subspecialists using mean debt and compensation data from national physician surveys for 2019 to 2020 and examined the relationship between the workforce gender composition and lifetime earning potential across the pediatric subspecialties using linear regression analysis., Results: Subspecialties with a higher proportion of women had lower lifetime earning potential (-$55,215 in lifetime earning potential/1% increase in the percentage of female subspecialists; P value .002, 95% CI -$24,429 to -$86,000). Similarly, a higher proportion of female first-year fellows was associated with lower lifetime earning potential (-$61,808 in lifetime earning potential/1% increase in the percentage of female first-year fellows; P value .026, 95% CI -$9,210 to -$114,405)., Conclusions: Consistent with patterns seen in other areas of adult medicine and surgery, pediatric subspecialties with higher proportions of women, such as adolescent medicine and endocrinology, tended to have lower lifetime earning potentials than subspecialties with higher proportions of men, such as cardiology and critical care. Lower earning subspecialties also tended to train higher proportions of women, suggesting that this trend may worsen over time as pediatrics in general and individual subspecialties in particular become increasingly female predominant., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention., Methods: Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals., Results: The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities., Conclusions: Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates., Methods: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering., Results: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits., Conclusions: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Adult patients are increasingly receiving care in pediatric emergency departments (PEDs), but little is known about the epidemiology of these visits. The goals of this study were to examine the characteristics of adult patients (≥21 years) treated in PEDs and to describe the variation in resource utilization across centers., Methods: We conducted a cross-sectional study examining visits to 30 PEDs (2012-2016) using the Pediatric Health Information System. Visits were categorized using All Patient Refined Diagnosis Related Groups and compared between age cohorts. We used multivariable logistic models to examine variation in demographics, utilization, testing, treatment, and disposition., Results: There were 12,958,626 visits to the 30 PEDs over 5 years; 70,636 (0.6%) were by adults. Compared with children, adult patients had more laboratory testing (49% vs 34%), diagnostic imaging (32% vs 29%), and procedures (48% vs 31%), and they were more often admitted (17% vs 11%) or transferred (21% vs 0.7%) (P < .001 for all). In multivariable analysis, older age, black race, Hispanic ethnicity, and private insurance were associated with decreased odds of admission in adults seen in PEDs. Across PEDs, the admission rates (7%-25%) and transfer rates (6%-46%) for adults varied., Conclusions: Adult patients cared for at PEDs have higher rates of testing, diagnostic imaging, procedures, and admission or transfer. There is wide variation in the care of adults in PEDs, highlighting the importance of further work to identify the optimal approach to adults who present for care in pediatric centers., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the characteristics of children who met the risk criteria for potential neurotoxicity defined by the US Food and Drug Administration (FDA; 2016 warning) in a procedural sedation (PS) service., Study Design: A single-center retrospective review of all infants and children aged <3 years receiving PS outside the operating room from 2014 to 2016. Demographics, duration of, and the reason for PS were analyzed., Results: A total of 2950 patients with 3653 sedation encounters were included. Median age was 19 (range, 11-26) months. Most PS (86.4%) were for magnetic resonance imaging (MRI). The median number of sedation procedures per patient was 1 (25th-75th: 1-7), and median duration of sedation was 72 minutes (25th-75th: 55-98 minutes). Forty patients (1.4%) required prolonged sedations >3 hours, in a single encounter (median, [25th-75th] of 196 minutes [185-214 minutes]), and 298 patients (10.1%) had multiple sedation exposures during the study period. Overall, 327 patients, 11.1% (95% confidence interval, 10.0%-12.3%) required repeated and/or prolonged sedation. The most common reasons for repeated or prolonged sedation were MRI of the brain and neurologic concerns., Conclusions: Multiple and prolonged PS commonly occurs outside the operating room in this young and potentially vulnerable population. Although certain imaging cannot be avoided, other cases may have the potential to be delayed until the child is >3 years old or to have alternate imaging that may not require prolonged PS. Family and provider awareness of the FDA warnings regarding potential neurotoxicity of sedation in all settings, both inside and outside the operating room, is critical., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS., Objective: To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization., Methods: Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded., Results: A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed., Conclusion: Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits., Methods: We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI., Results: Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74., Conclusions: Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to determine what characteristics of a primary care pediatric practice are associated with nonurgent use of the pediatric emergency department (PED)., Methods: Primary care practice characteristics were prospectively collected from 33 practices. Nonurgent and urgent visits to the PED for patients from these practices were analyzed retrospectively. A discriminant analysis classification model was used to identify practice characteristics that were associated with nonurgent versus urgent utilization of the PED., Results: Patients in the network of 33 practices accounted for 31 076 visits to the PED during the 12-month study period, 47% of which were classified as nonurgent. Based on the discriminant analysis classification model, discriminant patterns that predict the frequency of nonurgent utilization included the percentage of patients with Medicaid, total available sick slots to see patients per physician, closer distance to the PED, whether or not the nurse triage line notified all on-call physicians of disposition to the PED, whether it is practice policy to accept all walk-in sick visits, and ability of practice to have same-day turnaround of laboratory tests., Conclusions: Nonurgent utilization of the PED by patients in a specific primary care practice can be predicted based on discriminant practice characteristics, several of which may be modifiable. Use of these predictive rules can be used to optimize pediatric services and policy to help mitigate the high volume of PED nonurgent visitation. Focused interventions on practice characteristics of significance may help reduce PED overcrowding and improve continuity of care., (2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): Disposition of admission, transfer or deceased; Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine); Radiology or laboratory tests (excluding Rapid Strep); Fractures, dislocations, and febrile seizures. All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1-49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.

Background: Unintentional drownings cause over 600 deaths annually among children < or =5 years of age. Bathtubs are one of the leading sites for such drownings for children < or =2 years of age and especially for children 1 year or younger., Objective: To determine reported levels of supervision of children while they are in the bathtub., Methods: A face-to-face questionnaire was administered to a convenience sample of parents or guardians of children < or =5 years of age who presented to the emergency centers of 2 children's hospitals. The investigators developed a 17-point survey that included items related to general demographics and bathtub supervision. Parents and guardians were asked details concerning who supervised while the child was bathing, any unsupervised periods, length of unsupervised periods, and activities during any unsupervised periods., Results: A total of 259 families participated in the survey (16% Caucasian, 79% African American, 1% Hispanic, 3% Asian, and 1% biracial). The mean caregiver age was 29.1 years (SD 7.9). The mean age of the child was 30.5 months (SD 22). Overall, 31% of the respondents reported leaving their child unsupervised for some period of time in the bathtub. The mean age of children left alone was 37.5 months, with the youngest being 5 months old. Seventeen percent of children < or =24 months of age (N = 123, mean age 12.7 months) and 15% of children < or =12 months of age (N = 60, mean age 6.7 months) were reportedly at times left unsupervised in the bathtub. Common caregiver activities when leaving the child unsupervised included getting a towel or diapers, answering a phone, and cooking. A 5-month-old child was left unsupervised for >2 minutes, and an 8-month-old child was reportedly left unsupervised for >5 minutes to cook a meal. In addition, 20 of 259 respondents (7.7%) reported that their children bathed alone before the age of 5 years, and 4 respondents (1.5%) reported that their children bathed alone before the age of 2 years. Although most primary supervisors were adults, 5 children were at times supervised by children <10 years of age. No significant differences were seen based on the hospital, race, or educational level of the families., Conclusions: Many parents reported leaving their young children at times inadequately supervised in the bathtub. This occurred in children as young as 5 months of age. Given the potential risk of drowning when their children are inadequately supervised, parents should be advised concerning proper supervision in early anticipatory guidance.

This study evaluated the effects of initial wound orientation on the cosmetic outcome of facial lacerations repaired with histoacryl blue (HAB), a tissue adhesive, vs. conventional suturing. This was a retrospective analysis of patients from a prospective randomized clinical trial on the use of HAB. Children in the initial cohort who had facial lacerations and were also evaluated for cosmetic appearance at a 2-month follow-up appointment were eligible. Orientation along Langer's Lines, which define the functional anatomy of the underlying structures to the skin, was determined by two investigators blinded to the initial method of repair. Photographs of the wounds were reviewed and the wounds were categorized as being: Langer (+) (<20 degrees deviated from Langer's Lines) or Langer (-) (> or =20 degrees deviated from Langer's Lines). Photographic appearance at follow-up was evaluated using a 100-mm visual analog scale (0=best, 100=worst) by two plastic surgeons blinded to the method of repair. Sixty-one patients were enrolled in the initial cohort, with 55 (90%) evaluated at the 2-month follow-up. Forty-eight of the 55 (87%) had facial lacerations, therefore meeting present study criteria: [HAB (n=26), Suturing (n=22), Langer (+) (n=27), Langer (-) (n=21)]. Langer (+) patients were comparable to Langer (-) for demographics, wound characteristics, and method of repair. There was no difference in overall cosmetic appearance of facial wounds closed with HAB vs. conventional suturing. Follow-up appearance was significantly worse for sutured Langer (-) vs. Langer (+) wounds. In contrast, cosmetic appearance of lacerations closed by HAB were comparable between Langer (-) and Langer (+) wounds. In conclusion, initial wound orientation had a greater impact on the cosmetic appearance for lacerations closed by suturing compared to HAB. HAB may be the preferred method of cutaneous closure for facial lacerations oriented against Langer's Lines.