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Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time.This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission.Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer.Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.

OBJECTIVES To assess the prevalence of overweight or obesity among children with medical complexity (CMC), compared with children without medical complexity, and explore potentially modifiable mechanisms. METHODS This study involved a retrospective cohort of 41 905 children ages 2 to 18 seen in 2019 at a single academic medical center. The primary outcome was overweight or obesity, defined as a body mass index of ≥85% for age and sex. CMC was defined as ≥1 serious chronic condition in ≥1 system. Obesogenic conditions and medications were defined as those typically associated with excess weight gain. Multivariable logistic regression was used to adjust for common confounders. RESULTS Of the children in the cohort, 29.5% were CMC. Overweight or obesity prevalence was higher among CMC than non-CMC (31.9% vs 18.4%, P ≤.001, adjusted odds ratio [aOR] 1.27, 95% confidence interval [CI] 1.20–1.35). Among CMC, the risk for overweight or obesity was higher among children with metabolic conditions (aOR 2.09, 95% CI 1.88–2.32), gastrointestinal conditions (aOR 1.23 95% CI 1.06–1.41), malignancies (aOR 1.21 95% CI 1.07–1.38), and Spanish-speaking parents (aOR 1.47 95% CI 1.30–1.67). Among overweight or obese CMC, 91.6% had no obesogenic conditions, and only 8.5% had been seen by a registered dietitian in the previous year. CONCLUSIONS CMC are significantly more likely to be overweight or obese when compared with children without medical complexity. Although many CMC cases of overweight appear to be preventable, further research is necessary to determine if and how to prevent comorbid obesity among CMC.

Introduction The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD. Materials and Methods This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes. Results Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06). Conclusions Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

Introduction: Adult congenital heart disease (ACHD) patients may have shortened life expectancy due to complications of interventions and accrued comorbidities. Specialized ACHD care has become standard of care. The effect of regionalization on ACHD patient death is not known. Methods: The Office of Statewide Health Planning and Development database identified ACHD patients ≥ 18 years who died in California hospitals from 1995 - 2018. Specialized ACHD centers were self-designated, so high and low ACHD surgical volume centers were also compared. Results: Of 3,724 patients, when comparing by volume, more deaths occurred at low (85.2%) than high volume centers (14.8%); when comparing by specialization, more deaths occurred at non-ACHD (78.8%) than ACHD centers (21.2%). Moderate (9.4%) and high complexity (4.4%) lesions were rare. Common causes of death were sepsis (14.6%), myocardial infarction (9.3%), stroke (7.5%), and heart failure (7.1%). High volume centers were more likely the location of death than low volume centers for patients aged 18-64, with private insurance, and who lived >20 miles away (p Over 24 years, the proportion of patients dying at ACHD centers increased (Figure 1), while the proportion of patients dying at high volume centers decreased. Conclusion: ACHD patients who die at high surgical volume and ACHD self-designated centers are more likely to be young, have private insurance, be referred to centers far from home, and have higher socioeconomic status. These likely reflect disparities in access to specialized ACHD care. Despite regionalization with an increase in specialized ACHD centers over time, the majority of ACHD patients continue to die at non-specialized centers.

The COVID-19 pandemic prompted health systems to rapidly adopt telehealth for clinical care. We examined the impact of demography, subspecialty characteristics, and broadband availability on the utilization of telehealth in pediatric populations before and after the early period of the COVID-19 pandemic.Outpatients scheduled for subspecialty visits at sites affiliated with a single quaternary academic medical center between March-June 2019 and March-June 2020 were included. The contribution of demographic, socioeconomic, and broadband availability to visit completion and telehealth utilization were examined in multivariable regression analyses.Among visits scheduled in 2020 compared to 2019, in-person visits fell from 23,318 to 11,209, while telehealth visits increased from 150 to 7,675. Visits among established patients fell by 15% and new patients by 36% (P.0001). Multivariable analysis revealed that completed visits were reduced for Hispanic patients and those with reduced broadband; high income, private non-HMO insurance, and those requesting an interpreter were more likely to complete visits. Those with visits scheduled in 2020, established patients, those with reduced broadband, and patients older than 1 year were more likely to complete TH appointments. Cardiology, oncology, and pulmonology patients were less likely to complete scheduled TH appointments.Following COVID-19 onset, outpatient pediatric subspecialty visits shifted rapidly to telehealth. However, the impact of this shift on social disparities in outpatient utilization was mixed with variation among subspecialties. A growing reliance on telehealth will necessitate insights from other healthcare settings serving populations of diverse social and technological character.

Background: Gastrostomy tube (G-tube) placement for children with neurologic impairment with dysphagia has been suggested for pneumonia prevention. However, prior studies demonstrated an association between G-tube placement and increased risk of pneumonia. We evaluate the association between timing of G-tube placement and death or severe pneumonia in children with neurologic impairment. Methods: We included all children enrolled in California Children’s Services between July 1, 2009, and June 30, 2014, with neurologic impairment and 1 pneumonia hospitalization. Prior to analysis, children with new G-tubes and those without were 1:2 propensity score matched on sociodemographics, medical complexity, and severity of index hospitalization. We used a time-varying Cox proportional hazard model for subsequent death or composite outcome of death or severe pneumonia to compare those with new G-tubes vs those without, adjusting for covariates described above. Results: A total of 2490 children met eligibility criteria, of whom 219 (9%) died and 789 (32%) had severe pneumonia. Compared to children without G-tubes, children with new G-tubes had decreased risk of death (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.39-0.55) but increased risk of the composite outcome (HR 1.21, CI 1.14-1.27). Sensitivity analyses using varied time criteria for definitions of G-tube and outcome found that more recent G-tube placement had greater associated risk reduction for death but increased risk of severe pneumonia. Conclusion: Recent G-tube placement is associated with reduced risk of death but increased risk of severe pneumonia. Decisions to place G-tubes for pulmonary indications in children with neurologic impairment should weigh the impact of severe pneumonia on quality of life.

Introduction: Current research endorses regionalizing the care of infants with critical congenital heart disease (CCHD) to facilities with high levels of obstetrical, neonatal, and surgical volumes. California has a regionalization model that designates these facilities as accredited pediatric cardiac centers (PCCs). The impact of this system on the location of birth and cardiac surgeries for CCHD and for different social groups remains unexplored. Hypothesis: We hypothesize, there has been a trend toward increased accredited PCC utilization for birth and surgical intervention for CCHD in California with accompanying widening in social inequality. Methods: A retrospective, population-based analysis of CCHD hospitalizations between 1984-2018 using the California Office of Statewide Health Planning and Development’s discharge database was conducted. Demographic data and trends in location of birth and surgical procedures for CCHD from delivery to age 1 were evaluated in relation to hospital designation as an accredited PCC. Results: There were 15,091 live births with CCHD and 29,466 surgical admissions meeting inclusion criteria. Births at accredited PCCs increased from 17% in 1984 to 41% in 2018 while surgical admissions were largely above 80%. From 2015-2018, infants with CCHD, born outside an accredited PCC were more likely to have private HMO insurance and live 6-20 miles away. Patients with surgical admission to an accredited PCC were more likely to have private HMO insurance and reside in a zip code where the median income is >2x the federal poverty level. Conclusions: Significant gains have been made in the regionalization of care for infants with CCHD in California over 30 years. However, a substantial number of infants with CCHD do not receive care in accredited PCCs and social disparities in utilization remain. Increased efforts to reduce barriers to access, particularly those related to payer type and resident distance from PCCs are needed.

Background We report hospitalization patterns from 2000 to 2016 for young children (ages 0-5 years old) in California who underwent 1 of the 20 most common inpatient procedures that required general anesthesia and evaluate the estimated probability of treatment at a tertiary care children's hospital (CH) by year. Methods We hypothesized that children ≤5 years old increasingly undergo care at tertiary care CHs for common inpatient surgeries or other procedures that require general anesthesia. Data from the California Office of Statewide Health Planning and Development dataset were used to determine procedure, patient age, year of procedure, and hospital name. Hospitals were designated as either tertiary care CHs, children's units within general hospitals (CUGHs), or general hospitals (GHs) based on the California Children's Services Provider List. A tertiary care CH was defined using the California Children's Services definition as a referral hospital that provides comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age with a full range of medical and surgical care for severely ill children. We report the unadjusted percentage of patients treated at each hospital type and, after controlling for patient covariates and comorbidities, the estimated probability of undergoing care at a tertiary care CH from 2000 to 2016. Results There were 172,318 treatment episodes from 2000 to 2016. The estimated probability of undergoing care at a tertiary care CH increased from 63.4% (95% confidence interval [CI], 62.4%-64.4%) in 2000 to 78.3% (95% CI, 77.3%-79.4%) in 2016. Conclusions Children ≤5 years old undergoing common inpatient procedures that require general anesthesia increasingly receive care at tertiary care CHs in California.

Background Studies of adolescent and young adult (AYA) oncology end-of-life care utilization are critical because cancer is the leading cause of nonaccidental AYA death and end-of-life care contributes significantly to health care expenditures. This study was designed to determine the quantity of and disparities in inpatient utilization in the last year of life of AYAs with cancer. Methods The California Office of Statewide Health Planning and Development administrative discharge database, linked to death certificates, was used to perform a population-based analysis of cancer patients aged 15 to 39 years who died in 2000-2011. The number of hospital days and the inpatient costs were determined for each patient in the last year of his or her life, as were clinical and sociodemographic factors associated with high inpatient utilization. Admission patterns as death approached were also evaluated. Results The 12,883 patients were admitted for 40 days on average in the last year of life, and this cost $151,072 per patient in inpatient costs. As death approached, the admission rates and the percentage of all admissions occurring at nonspecialty centers increased. Five percent of patients used 20% of bed days in the last year (high utilizers). Factors associated with high utilization included younger age (15-30 years), Hispanic ethnicity, non-health maintenance organization insurance, and hematologic malignancies. Conclusions AYA oncology decedents were admitted for 40 days in their last year of life. Subgroups with high utilization had distinct sociodemographic and clinical characteristics, and nonspecialty center admissions increased as death approached. This demonstrates the need for palliative care at nonspecialty centers. Future studies need to determine whether these patterns are goal-concurrent, include high utilizers, and monitor the effects of health care reform. Cancer 2018;124:1819-27. © 2018 American Cancer Society.

BACKGROUND Private health insurance is associated with improved outcomes in patients with cancer. However, to the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE), which extended private insurance to young adults (to age 26 years) beginning in 2010, on the insurance status of young adults with cancer. METHODS The current study was a retrospective, population-based analysis of hospitalized young adult oncology patients (aged 22-30 years) in California during 2006 through 2014 (11,062 patients). Multivariable regression analyses examined factors associated with having private insurance. Results were presented as adjusted odds ratios and 95% confidence intervals. A difference-in-difference analysis examined the influence of the ACA-DCE on insurance coverage by race/ethnicity and federal poverty level. RESULTS Multivariable regression demonstrated that patients of black and Hispanic race/ethnicity were less likely to have private insurance before and after the ACA-DCE, compared with white patients. Younger age (22-25 years) was associated with having private insurance after implementation of the ACA-DCE (odds ratio, 1.20; 95% confidence interval, 1.06-1.35). In the difference-in-difference analysis, private insurance increased among white patients aged 22 to 25 years who were living in medium-income (2006-2009: 64.6% vs 2011-2014: 69.1%; P = .003) and high-income (80.4% vs 82%; P = .043) zip codes and among Asians aged 22 to 25 years living in high-income zip codes (73.2 vs 85.7%; P = .022). Private insurance decreased for all Hispanic patients aged 22 to 25 years between the 2 time periods. CONCLUSIONS The ACA-DCE provision increased insurance coverage, but not among all patients. Private insurance increased for white and Asian patients in higher income neighborhoods, potentially widening social disparities in private insurance coverage among young adults with cancer. Cancer 2017. © 2017 American Cancer Society.

Purpose: Cancer is the leading cause of nonaccidental death among adolescents and young adults (AYAs). High-intensity end-of-life care is expensive and may not be consistent with patient goals. However, the intensity of end-of-life care for AYA decedents with cancer—especially the effect of care received at specialty versus nonspecialty centers—remains understudied. Methods: We conducted a retrospective, population-based analysis with the California administrative discharge database that is linked to death certificates. The cohort included Californians age 15 to 39 years who died between 2000 and 2011 with cancer. Intense end-of-life interventions included readmission, admission to an intensive care unit, intubation in the last month of life, and in-hospital death. Specialty centers were defined as Children’s Oncology Group centers and National Cancer Institute–designated comprehensive cancer centers. Results: Of the 12,938 AYA cancer decedents, 59% received at least one intense end-of-life care intervention, and 30% received two or more. Patients treated at nonspecialty centers were more likely than those at specialty-care centers to receive two or more intense interventions (odds ratio [OR], 1.46; 95% CI, 1.32 to 1.62). Sociodemographic and clinical factors associated with two or more intense interventions included minority race/ethnicity (Black [OR, 1.35, 95% CI, 1.17 to 1.56]; Hispanic [OR, 1.24; 95% CI, 1.12 to 1.36]; non-Hispanic white: reference), younger age (15 to 21 years [OR, 1.36; 95% CI, 1.19 to 1.56; 22 to 29 years [OR,1.26; 95% CI,1.14 to 1.39]; ≥ 30 years: reference), and hematologic malignancies (OR, 1.53; 95% CI, 1.41 to 1.66; solid tumors: reference). Conclusion: Thirty percent of AYA cancer decedents received two or more high-intensity end-of-life interventions. In addition to sociodemographic and clinical characteristics, hospitalization in a nonspecialty center was associated with high-intensity end-of-life care. Additional research is needed to determine if these disparities are consistent with patient preference.

BACKGROUND Patients with a terminal illness should have access to their chosen location of death. Cancer is the leading cause of non-accidental death among adolescents and young adults (AYAs; those aged 15-39 years). Although surveys have suggested that a majority of these patients prefer a home death, to the authors' knowledge, little is known regarding their barriers to accessing their preferred location of death. As a first step, the authors sought to determine, across a large population, 20-year trends in the location of death among AYA patients with cancer. METHODS Using the Vital Statistics Death Certificate Database of the California Office of Statewide Health Planning and Development, the authors performed a retrospective, population-based analysis of California patients with cancer aged 15 to 39 years who died between 1989 and 2011. Sociodemographic and clinical factors associated with hospital death were examined using multivariable logistic regression. RESULTS Of 30,573 AYA oncology decedents, 57% died in a hospital, 33% died at home, and 10% died in other locations (eg, hospice facility or nursing facility). Between 1989 and 1994, hospital death rates decreased from 68.3% to 53.6% and at-home death rates increased from 16.8% to 35.5%. Between 1995 and 2011, these rates were stable. Those individuals who were more likely to die in a hospital were those aged

BACKGROUND Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers). METHODS A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived > 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors. CONCLUSIONS Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017;123:2516–23. © 2017 American Cancer Society.

We examined the use of Pediatric Cancer Specialty Centers (PCSCs) over time and the length of stay (LOS) in pediatric oncology patients with a diagnosis of febrile neutropenia. PCSCs were defined as Children's Oncology Group and California Children's Services designated centers. We performed a retrospective analysis on all discharges of pediatric (0 to 18) oncology patients with febrile neutropenia in California (1983 to 2011) using the private Office of Statewide Health Planning and Development database. We examined influence of age, sex, race/ethnicity, payer, income, distance, tumor type, and complications on utilization of PCSCs and LOS (SAS 9.2). Analysis of 24,559 pediatric oncology febrile neutropenia discharges showed hospitalizations in PCSCs increasing from 48% in 1983 to 94% in 2011. The adjusted regression analysis showed decreased PCSC utilization for ages 15 to 18, Hispanic patients, and those living40 miles away. The median PCSC LOS was 9 days compared with 7 days at a non-PCSC (P0.0001). Discharge from a PCSC was associated with a LOS8 days after controlling for complications. Inpatient PCSC care for febrile neutropenia in California has increased since 1983. Receiving care at a PCSC is influenced by age, tumor type, ethnicity, geography, and complications.

BACKGROUND: Children with neurologic impairment (NI) face high risk of recurrent severe pneumonia, with prevention strategies of unknown effectiveness. We evaluated the comparative effectiveness of secondary prevention strategies for severe pneumonia in children with NI. METHODS: We included children enrolled in California Children’s Services between July 1, 2009, and June 30, 2014, with NI and 1 pneumonia hospitalization. We examined associations between subsequent pneumonia hospitalization and expert-recommended prevention strategies: dental care, oral secretion management, gastric acid suppression, gastrostomy tube placement, chest physiotherapy, outpatient antibiotics before index hospitalization, and clinic visit before or after index hospitalization. We used a 1:2 propensity score matched model to adjust for covariates, including sociodemographics, medical complexity, and severity of index hospitalization. RESULTS: Among 3632 children with NI and index pneumonia hospitalization, 1362 (37.5%) had subsequent pneumonia hospitalization. Only dental care was associated with decreased risk of subsequent pneumonia hospitalization (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.49–0.85). Exposures associated with increased risk included gastrostomy tube placement (aOR: 2.15; 95% CI: 1.63–2.85), chest physiotherapy (aOR: 2.03; 95% CI: 1.29–3.20), outpatient antibiotics before hospitalization (aOR: 1.42; 95% CI: 1.06–1.92), clinic visit before (aOR: 1.30; 95% CI: 1.11–1.52), and after index hospitalization (aOR: 1.72; 95% CI: 1.35–2.20). CONCLUSIONS: Dental care was associated with decreased recurrence of severe pneumonia. Several strategies, including gastrostomy tube placement, were associated with increased recurrence, possibly due to unresolved confounding by indication. Our results support a clinical trial of dental care to prevent severe pneumonia in children with NI.

BACKGROUND: Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care. METHODS: We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ≥2 intensity markers (including hospital death). RESULTS: There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ≥2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ≥2 intensity markers. Hispanic and “other” race and/or ethnicity were associated with hospital death and ≥2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ≥2 intensity markers. CONCLUSIONS: Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.

Purpose Intensity of end-of-life care receives much attention in oncology because of concerns that high-intensity care is inconsistent with patient goals, leads to worse caregiver outcomes, and is expensive. Little is known about such care in those undergoing allogeneic hematopoietic cell transplantation (HCT), a population at high risk for morbidity and mortality. Patients and Methods We conducted a population-based analysis of patients who died between 2000 and 2013, within 1 year of undergoing an inpatient allogeneic HCT using California administrative data. Previously validated markers of intensity were examined and included: hospital death, intensive care unit (ICU) admission, and procedures such as intubation and cardiopulmonary resuscitation at end of life. Multivariable logistic regression models determined clinical and sociodemographic factors associated with: hospital death, a medically intense intervention (ICU admission, cardiopulmonary resuscitation, hemodialysis, intubation), and ≥ two intensity markers. Results Of the 2,135 patients in the study population, 377 were pediatric patients (age ≤ 21 years), 461 were young adults (age 22 to 39 years), and 1,297 were adults (age ≥ 40 years). The most common intensity markers were: hospital death (83%), ICU admission (49%), and intubation (45%). Medical intensity varied according to age, underlying diagnosis, and presence of comorbidities at time of HCT. Patients with higher-intensity end-of-life care included patients age 15 to 21 years and 30 to 59 years, patients with acute lymphoblastic leukemia, and those with comorbidities at time of HCT. Conclusion Patients dying within 1 year of inpatient allogeneic HCT are receiving medically intense end-of-life care with variations related to age, underlying diagnosis, and presence of comorbidities at time of HCT. Future studies need to determine if these patterns are consistent with patient and family goals.

Background American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD). Objectives This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011. Methods We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program. Results There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period. Conclusions California’s inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. Designation as a "specialty ACHD center" was defined on the basis of a national ACHD directory. A total of 4,611 ACHD procedures were identified. The proportion of procedures in patients with moderate and complex CHD delivered at specialty centers increased from 46% to 71% from 2000 to 2011. In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.

BACKGROUND: Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer. METHODS: By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death. RESULTS: The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ≥1 intensity indicator, 23% ≥2, and 22% ≥1 intense medical intervention. There was a bimodal association between age and intensity: ages CONCLUSIONS: Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.

Private health insurance is associated with improved outcomes in patients with cancer. However, to the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE), which extended private insurance to young adults (to age 26 years) beginning in 2010, on the insurance status of young adults with cancer.The current study was a retrospective, population-based analysis of hospitalized young adult oncology patients (aged 22-30 years) in California during 2006 through 2014 (11,062 patients). Multivariable regression analyses examined factors associated with having private insurance. Results were presented as adjusted odds ratios and 95% confidence intervals. A difference-in-difference analysis examined the influence of the ACA-DCE on insurance coverage by race/ethnicity and federal poverty level.Multivariable regression demonstrated that patients of black and Hispanic race/ethnicity were less likely to have private insurance before and after the ACA-DCE, compared with white patients. Younger age (22-25 years) was associated with having private insurance after implementation of the ACA-DCE (odds ratio, 1.20; 95% confidence interval, 1.06-1.35). In the difference-in-difference analysis, private insurance increased among white patients aged 22 to 25 years who were living in medium-income (2006-2009: 64.6% vs 2011-2014: 69.1%; P = .003) and high-income (80.4% vs 82%; P = .043) zip codes and among Asians aged 22 to 25 years living in high-income zip codes (73.2 vs 85.7%; P = .022). Private insurance decreased for all Hispanic patients aged 22 to 25 years between the 2 time periods.The ACA-DCE provision increased insurance coverage, but not among all patients. Private insurance increased for white and Asian patients in higher income neighborhoods, potentially widening social disparities in private insurance coverage among young adults with cancer. Cancer 2018;124:110-7. © 2017 American Cancer Society.

Summary Background Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems. Objectives To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care. Methods We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume. Results We reviewed 257 541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed

To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients.We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site.Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were3 times less likely to be treated at a PCSC.Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.

We performed a retrospective analysis of hospital discharges for children with autism, in comparison to children with cerebral palsy, Down syndrome, mental retardation/intellectual disability, and the general population. Hospitalizations for autism increased nearly threefold over 10 years, especially at the oldest ages, while hospitalizations for the other groups did not change. Leading discharge diagnoses for each age group in children with autism included mental health and nervous system disorders. Older age, Caucasian ethnicity, and living in a region with a high number of pediatric beds predicted hospitalizations associated with mental health diagnoses. These findings underscore the need for comprehensive clinical services that address the complex needs of children with autism to prevent costly hospitalizations.

BACKGROUND: Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care. METHODS: This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables. RESULTS: Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs. CONCLUSION: Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. LEVEL OF EVIDENCE: Therapeutic/care management, level III. Language: en

Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers).A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs).Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors.Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017;123:2516-23. © 2017 American Cancer Society.

This study examined patient, hospital, and county characteristics associated with hospitalization after emergency department visits for pediatric mental health problems.Retrospective analysis of emergency department encounters (N=324,997) of youths age five years to 17 years with psychiatric diagnoses was conducted with 2005-2009 California Office of Statewide Health Planning and Development emergency department statewide data.For youths with any psychiatric diagnosis, 23.4% of emergency department encounters resulted in hospitalization. In these cases, hospitalization largely was predicted by clinical need. Nonclinical factors that decreased the likelihood of hospitalization included demographic characteristics (such as younger age, lack of insurance, and rural residence) and resource characteristics (private hospital ownership, lack of psychiatric consultation in the emergency department, and lack of pediatric psychiatric beds). For youths with a significant psychiatric diagnosis plus a suicide attempt, 53.8% of emergency department encounters resulted in hospitalization. In these presumably more life-threatening cases, nonclinical factors that decreased the likelihood of hospitalization persisted: demographic characteristics (lack of insurance and rural residence) and resource characteristics (public hospital ownership, lack of psychiatric consultation, and lack of pediatric psychiatric beds).Mental health service delivery can improve only by addressing nonclinical demographic and resource obstacles that independently decrease the likelihood of hospitalization after an emergency department visit for a mental health issue; this is true even for the most severely ill youths-those with a suicide attempt as well as a serious psychiatric diagnosis.

Objectives: This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children. Methods: Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age. Results: Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06). Conclusions: Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care. Language: en

OBJECTIVE To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison. DESIGN Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression. SETTING United States, 1989–1999. PARTICIPANTS Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older. MEASUREMENTS AND MAIN RESULTS Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than nonblacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p

Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight1500 g or gestational age ≤32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD).This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011.We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program.There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period.California's inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

PURPOSE: The purpose of the study was to describe inpatient hospitalization patterns among detained and nondetained youth in a large, total population of hospitalized adolescents in California. METHODS: We examined the unmasked California Office of Statewide Health Planning and Development Patient Discharge Dataset from 1997 to 2011. We considered hospitalized youth aged 11-18 years "detained" if admitted to California hospitals from detention, transferred from hospital to detention, or both. We compared discharge diagnoses and length of stay between detained youth and their nondetained counterparts in the general population. RESULTS: There were 11,367 hospitalizations for detained youth. Hospitalizations differed for detained versus nondetained youth: 63% of all detained youth had a primary diagnosis of mental health disorder (compared with 19.8% of nondetained youth). Detained girls were disproportionately affected, with 74% hospitalized for a primary mental health diagnosis. Detained youth hospitalized for mental health disorder had an increased median length of stay compared with nondetained inpatient youth with mental illness (≥6 days vs. 5 days, respectively). This group difference was heightened in the presence of minority status, public insurance, and concurrent substance abuse. Hospitalized detained youth discharged to chemical dependency treatment facilities had the longest hospital stays (≥43 days). CONCLUSIONS: Detained juvenile offenders are hospitalized for very different reasons than the general adolescent population. Mental illness, often with comorbid substance abuse, requiring long inpatient stays, represents the major cause for hospitalization. These findings underscore the urgent need for effective, well-coordinated mental health services for youth before, during, and after detention. Language: en

Innovation of medical technology is a major driving force behind the increase in medical expenditures in developed countries. Previous studies identified that the diffusion of medical technology varied across countries according to the characteristics of regulatory policy and payment systems. Based on Roger's diffusion of innovation theory, this study purported to see how local practice norms, the evolving nature of diffusing technology, and local clinical needs in addition to differences in politico-economic systems would affect the process of innovation diffusion. Taking a case of coronary stenting, an innovative therapeutic technology in early 1990s, we provided a case study of hospital-based data between two teaching high-tech hospitals in Japan and the US for discussion. Stenting began to be widely used in both countries when complementary new technology modified its clinical efficacy, but the diffusion process still differed between the two hospitals due to (1) distinctive payment systems for hospitals and physicians, (2) practice norms in favor of percutaneous intervention rather than bypass surgery that was shaped by payment incentives and cultural attitudes, and (3) local patient's clinical characteristics that the technology had to be tailored for. The case study described the diffusion of stent technology as a dynamic process between patients, physicians, hospitals, health care systems, and technology under global and local conditions.

BACKGROUND. Studies from the early 1990s have documented greater intensity of treatment for patients with acute myocardial infarction (AMI) in the United States compared with Canada, with little difference in health outcomes. Little is known about whether treatments and outcomes are changing differently over time in the two countries, and whether the differences vary with patient age. METHODS. We conducted a retrospective cohort study of trends in cardiac procedure use, mortality, and recurrent AMI for patients 65 years or older hospitalized with AMI in the United States and Quebec. We examined Medicare claims and enrollment data from the United States (1.5 million) and provincial claims data from Quebec (35,000) between 1988 and 1994. RESULTS. Use of cardiac procedures grew more rapidly between 1988 and 1994 in the United States, particularly for patients 75 years or older; unlike in Quebec, these cardiac procedures were performed soon after AMI. Both countries experienced significant declines in 1-year mortality: the decline averaged 1.27% points per year in the United States and 1.05% points in Quebec (P = ns). For AMI patients 75 years or older, 30-day and 1-year mortality declined approximately twice as rapidly in the United States as in Quebec (P < 0.01). The decline in mortality in the United States relative to Canada was significantly greater among patients 75 years or older but not among those age 65 to 74 years. Readmission rates with recurrent AMI were almost unchanged. CONCLUSIONS. Over time, the use of cardiac procedures in elderly patients with AMI has risen more rapidly in the United States than in Quebec. These differences in procedure trends were associated with reductions in overall long-term AMI mortality in both countries.

Background The patterns of adoption of the implantable cardioverter defibrillator (ICD) and the outcomes of its use have not been well documented in general, unselected populations. The purpose of this study was to document the impact of the ICD in widespread clinical practice. Methods We identified ICD recipients by use of the hospital discharge databases of Medicare beneficiaries for 1987 through 1995 and of California residents for 1991 through 1995. The index admission for each patient was linked to previous and subsequent admissions and to mortality files to create a longitudinal patient profile. Results The rate of ICD implantations increased >10-fold between 1987 and 1995, as both the number of hospitals performing the procedure and the volume of ICD implantations per hospital rose. Mortality rates within 30 days of ICD implantation decreased from 6.0% to 1.9%, and mortality rates within 1 year fell from 19.3% to 11.4%. Surgical interventions to revise or replace the ICD within the first year remained about 5%, however, and cumulative expenditures at 1 year ($46,000-$51,000) changed very little. ICD implantation rates varied >3-fold among different regions of the United States. Conclusions ICD use has expanded markedly during the study period, with improved mortality rates, but medical expenditures and rates of surgical revision remain high for ICD recipients. (Am Heart J 2002;144:397-403.)

Background The use of coronary angiography and revascularization is lower than expected among black patients. It is uncertain whether use of other cardiac procedures also varies according to race and ethnicity and whether outcomes are affected. Methods We analyzed discharge abstracts from all nonfederal hospitals in California of patients hospitalized for a primary diagnosis of ventricular tachycardia or ventricular fibrillation between 1992 and 1994. We compared mortality rates and use of electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) procedures according to the race and ethnicity of the patient. Results Among 8713 patients admitted with ventricular tachycardia or ventricular fibrillation, 29% (n = 2508) had a subsequent EPS procedure, and 9% (n = 818) had an ICD implanted. After controlling for potential confounding factors, we found that black patients were significantly less likely than white patients to undergo EPS (odds ratio 0.72, CI 0.56-0.92) or ICD implantation (odds ratio 0.39, CI 0.25-0.60). Blacks discharged alive from the initial hospital admission had higher mortality rates over the next year than white patients, even after controlling for multiple confounding risk factors (risk ratio 1.18, CI 1.03-1.36). The use of EPS and ICD procedures was also significantly affected by several other factors, most notably by on-site procedure availability but also by age, sex, and insurance status. Conclusions In a large population of patients hospitalized for ventricular arrhythmia, blacks had significantly lower rates of utilization for EPS and ICD procedures and higher subsequent mortality rates. (Am Heart J 2002;144:431-9.)

Purpose The implantable cardioverter defibrillator has been assessed in randomized trials, but the generalizability of trial results to broader clinical settings is unclear. Our purpose was to evaluate the outcomes and costs of defibrillator use in an unselected population. Subjects and methods We identified 125,892 Medicare patients who were discharged between 1987 and 1995 after hospitalization with a primary diagnosis of ventricular tachycardia or ventricular fibrillation, 7789 of whom (6.2%) received a defibrillator. We used a multivariable propensity score that included patient and hospital characteristics to match pairs of patients, in which one patient received a defibrillator and the other did not. We compared mortality and costs in these 7612 matched pairs during 8 years of follow-up. Results Patients who received a defibrillator were more likely to be younger, white, male, and urban dwelling, and to have ischemic heart disease, heart failure, or a history of ventricular fibrillation. In the matched-pairs analysis, those who received a defibrillator had significantly lower mortality: 11% versus 19% at 1 year (odds ratio [OR] = 0.57; 95% confidence interval [CI]: 0.51 to 0.63), 20% versus 30% at 2 years (OR = 0.66; 95% CI: 0.60 to 0.72), and 28% versus 39% at 3 years (OR = 0.70; 95% CI: 0.63 to 0.77). These patients also had lower mortality at 8 years ( P = 0.0001), although this advantage over patients who received medical treatment only decreased over time. Expenditures among defibrillator recipients were consistently higher, with a cost-effectiveness ratio of $78,400 per life-year gained. Conclusion The use of implantable defibrillators was associated with significantly lower mortality and higher costs, whereas the cost-effectiveness was higher than many, but not all, generally accepted therapies.

10574 Background: There is growing evidence that adult oncology patients who know they are dying choose less intense care. Further, high intensity care is associated with worse caregiver outcomes. Little is known about pediatric oncology end-of-life care intensity. Methods: Using the California Office of Statewide Health Planning and Development administrative database linked to death certificates, we performed a retrospective population based analysis of cancer patients aged 0-21 who died between 2000 and 2011. The frequency of previously defined end-of-life intensity markers (hospital death, intense medical interventions, IV chemotherapy, and gastrostomy and tracheostomy tube placement) were calculated and multivariable logistic regression was used to determine clinical and sociodemographic factors associated with > 2 intensity markers (as above), intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis), and hospital death. Results: The 3,732 pediatric cancer decedents were 34% non-Hispanic whites and 45% Hispanic; 41% had hematologic malignancies and 59% solid tumors. The most prevalent intensity markers included: hospital death (63%) and ICU admission (20%). 65% had > 1 intensity marker, 23% > 2, and 22% > 1 intense medical intervention. There was a bimodal association between age and intensity: the youngest patients (age < 5) and adolescent patients (age 15-21) were more likely to receive intense care: < 5y (intense medical intervention: OR = 1.42; 95% CI, 1.1-1.9; hospital death: OR = 1.72; 95% CI, 1.4-2.2; > 2 markers: OR = 1.37, 95% CI 1.1-1.8); 15-21y (intense medical: OR = 1.48; 95% CI, 1.2-1.9; hospital death: OR = 1.39; 95% CI, 1.1-1.7; > 2 markers: OR = 1.35, 1.1-1.7) (references: 5-9y). Other factors associated with intensity included, hematologic malignancies, minority status, and death between 2008 and 2011 vs. < 2008. Conclusions: Nearly two-thirds of the pediatric cancer decedents had ≥1 marker of intense care and disparities exist. Patients < 5 and adolescents were more likely to receive intense end-of-life care. Further research needs to determine if these rates and variation are consistent with patient goals and factors associated with goal concurrent care.

6561 Background: Private health insurance is associated with improved outcomes in cancer patients. We know little, however, about the impact of the ACA-DCE, which extended private insurance to young adults (up to age 26) beginning in 2010, on the insurance status of young adults with cancer. This study sought to determine the effect of the ACA-DCE on having private insurance coverage among hospitalized young adult oncology patients. Methods: We performed a retrospective, population-based analysis of hospitalized young adult oncology patients (22-30 years-old) in California during 2006-2014 (n = 11,062) using the Office of Statewide Health Planning and Development database. Multivariable regression analyses examined the social and clinical predictors of having private insurance. Results are presented as adjusted odds ratios (OR) and 95% confidence intervals (CIs). A difference-in-difference analysis examined the influence of the ACA-DCE on insurance coverage by race/ethnicity and zip code federal poverty level. Results: Multivariable regression demonstrated patients of black and Hispanic race/ethnicity were less likely to have private insurance both before and after the ACA-DCE, compared to non-Hispanic white patients. Younger age (22-25 years) was associated with having private insurance after the ACA-DCE implementation (OR 1.18, CI 1.05-1.33; reference, 27-30 years). In the difference-in-difference analysis, private insurance increased among non-Hispanic whites aged 22-25 living in medium- (2006-2009: 64.6% versus (vs) 2011-2014: 69.1%; p = 0.003) and high-income zip codes (80.4% vs 82%; p = 0.043) and among Asian patients aged 22-25 living in high-income zip codes (73.2 vs 85.7%; p = 0.022). Private insurance decreased for all Hispanic patients aged 22-25 between the two time periods. Conclusions: The ACA-DCE provision was an important first step in increasing coverage, but it was not universal and generated disparity in coverage as gains occurred for non-Hispanic white and Asian patients living in higher income zip codes. This policy change was shown to increase coverage for a traditionally underinsured population and attention should now focus on those remaining uninsured.

The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) do not capture complications arising after discharge. This study sought to quantify the bias related to omission of readmissions for PSI-qualifying conditions. Using 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data, the study team examined the change in PSI rates when including readmissions in the numerator, hospitals performing in the extreme deciles, and longitudinal performance. Including 7-day readmissions resulted in a 0.3% to 8.9% increase in average hospital PSI rates. Hospital PSI rates with and without PSI-qualifying 30-day readmissions were highly correlated for point estimates and within-hospital longitudinal change. Most hospitals remained in the same relative performance decile. Longer length of stay, public payer, and discharge to skilled nursing facilities were associated with a higher risk of readmission for a PSI-qualifying event. Failure to include readmissions in calculating PSIs is unlikely to lead to erroneous conclusions.

Objective To quantify the limitations associated with restricting readmission metrics to same-hospital only readmission. Design Using 2000–2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file, we identified the proportion of 7-, 15- and 30-day readmissions occurring to the same hospital as the initial admission using All-cause Readmission (ACR) and 3M Corporation Potentially Preventable Readmissions (PPR) Metric. We examined the correlation between performance using same and different hospital readmission, the percent of hospitals remaining in the extreme deciles when utilizing different metrics, agreement in identifying outliers and differences in longitudinal performance. Using logistic regression, we examined the factors associated with admission to the same hospital. Results 68% of 30-day ACR and 70% of 30-day PPR occurred to the same hospital. Abdominopelvic procedures had higher proportions of same-hospital readmissions (87.4–88.9%), cardiac surgery had lower (72.5–74.9%) and medical DRGs were lower than surgical DRGs (67.1 vs. 71.1%). Correlation and agreement in identifying high- and low-performing hospitals was weak to moderate, except for 7-day metrics where agreement was stronger ( r = 0.23–0.80, Kappa = 0.38–0.76). Agreement for within-hospital significant ( P < 0.05) longitudinal change was weak (Kappa = 0.05–0.11). Beyond all patient refined-diagnostic related groups, payer was the most predictive factor with Medicare and MediCal patients having a higher likelihood of same-hospital readmission (OR 1.62, 1.73). Conclusions Same-hospital readmission metrics are limited for all tested applications. Caution should be used when conducting research, quality improvement or comparative applications that do not account for readmissions to other hospitals.

Readmission rates have come to the forefront as measures of interest for assessing several dimensions of health care quality. Readmissions related to infections and other complications of care may reflect overall aspects of hospital quality—while evidence is mixed, several studies have linked hospital quality deficits to higher readmission rates (Ashton et al. 1997; Benbassat and Taragin 2000). Lower readmission rates may also signal more successful care transitions, or higher quality of outpatient chronic disease care. Readmissions are costly and may also provide an indication of care inefficiency in some cases (Friedman and Basu 2004; Jencks, Williams, and Coleman 2009). Efforts have begun to integrate readmission measures into policy frameworks. The National Quality Forum has endorsed four readmission measures for comparative reporting, including All-Cause Readmissions and condition-specific readmission measures (National Quality Forum 2011). The Patient Protection and Affordable Care Act also contains provisions to measure and reduce readmissions in an effort to improve quality and reduce costs (2010). A number of ways of measuring readmissions have been proposed. These metrics differ in various ways, along a couple of key dimensions. First, the time period over which readmissions are measured ranges widely, with some metrics capturing readmissions within 7 days of the first admission and others going as far as 90 days. Thirty-day rates are the most common. Some metrics focus on readmissions for any cause (“all-cause readmissions”), but other metrics attempt to exclude subsequent admissions likely to be planned or unrelated to the initial admission (Halfon et al. 2006; Goldfield et al. 2008). Some metrics count all readmissions that occur for a given patient, while others count only whether a patient has at least one readmission in a given time period. Finally, the risk adjustment approaches employed in different metrics also vary. Each of these definitional differences has the potential to affect the conclusions drawn from readmission metrics. However, there is currently no quantitative assessment of the impact of these differences. Effective efforts to reduce readmissions and to develop fair reimbursement policies related to readmissions will require reliable and well-understood metrics, and an important step toward having such a metric set is understanding how variations in metrics affect assessment of hospital performance. This study aimed to quantify the differences in measured hospital performance when applying three commonly used readmission metrics.

132 Background: Cancer is the leading cause of non-accidental death amongst adolescents and young adults (AYA), aged 15-39, in the U.S. It is critical to understand end of life (EOL) care of AYA cancer decedents, including use of medically intense interventions like intubation. Although desired by some, most patients prefer a natural death. We sought to determine rates of medically intense interventions at end of life for AYA cancer decedents and associated factors. Methods: Using the California Office of Statewide Health Planning and Development private administrative database linked to death certificates, we performed a retrospective population based analysis of patients aged 15-39 with cancer who died between 2000-2010. We used previously defined administrative codes indicative of intense EOL care: intubation, CPR, hospital re-admission, and ICU admission in the last 30 days of life, and location of death. The frequencies of each intense item were calculated and multivariate logistic regression was used to determine clinical (including treatment at specialty center vs non) and socio-demographic factors associated with each item and receipt of ≥ 2 items. Results: The 8,978 AYA cancer decedents were 46% non-Hispanic white, 29% Hispanic, 10% non-Hispanic black, 11% Asian; 21% had hematologic malignancies, 70% had solid tumors, and 9% had secondary neoplasms; 58% were hospitalized only at non-specialty centers in the last 6 months of life. 62% received ≥ 1 medically intense EOL care intervention, and 32% received > 2. Factors associated with > 2 intense EOL care interventions were: non-Hispanic black (OR 1.38, 95% CI 1.16-1.65), Hispanics (1.19, 1.06-1.35), Asians (1.30, 1.10-1.52); those sometimes (2.19, 1.87-2.56) or never (1.44, 1.26-1.65) seen at specialty centers; hematologic malignancies (1.77, 1.57-2.00 ref grp: solid tumors) whereas secondary malignancies were not associated with > 2 intense markers (0.68, 0.56-0.83). Conclusions: Nearly two-thirds of the AYA cancer decedents received medically intense EOL interventions and disparities exist in receipt of such care. Further research needs to determine if the disparities are due to healthcare system, patient preference, or other factors.

126 Background: Cancer is the leading cause of non-accidental death among adolescents and young adults (AYA) in the US. The last year of life involves significant inpatient resources for older patients. We sought to determine the quantity and pattern of inpatient care for AYA cancer decedents in the last year of life to learn their healthcare system impact and groups to target for intervention. Methods: Using the California Office of Statewide Health Planning and Development private administrative database linked to death certificates, we performed a retrospective cross-sectional population-based analysis of patients aged 15-39 with cancer who died between 2000-2011. We calculated the number of admissions, hospital days, and percent of the cohort admitted each day in the last year of life. We determined the bed-day distribution across the population and the clinical and socio-demographic factors associated with high inpatient utilization. Results: The 9562 AYA cancer decedents were 45% non-Hispanic white, 30% Hispanic; 20% had hematologic malignancies, 70% had solid tumors. They were hospitalized, on average, 4.3 times and 40.6 days in the last year of life, increasing 3 months before death. Bed day occupation was skewed: 5% of the patients occupied 20% of the bed days and 18% occupied 50%. Factors associated with increased odds of being a top 5% utilizer were being Hispanic (OR: 1.48, 95% CI: 1.15-1.90, ref: non-Hispanic white), and having Acute Myelogenous Leukemia (AML) (2.7, 1.74-0.67, ref: Acute Lymphoblastic Leukemia (ALL). Factors associated with decreased odds were rural residence (0.39, 0.23-0.67, ref: urban), HMO insurance (0.58, 0.38-0.88, ref: private non-HMO), no hospitalizations at specialty centers (0.72, 0.53-0.97, ref: specialty center only), and having lymphoma or a solid tumor (ORs 0.035-0.39, CI range 0.005-0.56, ref: ALL). Conclusions: AYAs dying of cancer spent 40.6 days in the hospital in their last year of life (more than 1 in 9 days) with higher rates for Hispanics, AML patients, those with urban residence, and those hospitalized at specialty centers. Further research needs to determine what is driving these patterns, if they are preventable, and if they align with patient and family wishes.