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Objective: Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP). Design: A retrospective cross-sectional analysis. Setting: The 1997 to 2019 Kids' Inpatient Databases (KID). Patients: Children 3 years old and younger who underwent CL/P repair. Main Outcome Measure(s): Complications and mortality. Results: A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P <.001) and higher rates of complications and mortality (12.8% vs 2.9%, P <.001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P <.001). Conclusions: CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Reducing pediatric readmissions has become a national priority; however, the use of readmission rates as a quality metric remains controversial. The goal of this study was to examine short-term stability and long-term changes in hospital readmission rates. METHODS: Data from the Pediatric Health Information System were used to compare annual 30-day risk-adjusted readmission rates (RARRs) in 47 US children's hospitals from 2016 to 2017 (short-term) and 2016 to 2019 (long-term). Pearson correlation coefficients and weighted Cohen's Kappa statistics were used to measure correlation and agreement across years for hospital-level RARRs and performance quartiles. RESULTS: Median (IQR) 30-day RARRs remained stable from 7.7% (7.0-8.3) in 2016 to 7.6% (7.0-8.1) in 2019. Individual hospital RARRs in 2016 were strongly correlated with the same hospital's 2017 rate (R² = 0.89 [95% confidence interval (CI) 0.80-0.94]) and moderately correlated with those in 2019 (R² = 0.49 [95%CI 0.23-0.68]). Short-term RARRs (2016 vs 2017) were more highly correlated for medical conditions than surgical conditions, but correlations between long-term medical and surgical RARRs (2016 vs 2019) were similar. Agreement between RARRs was higher when comparing short-term changes (0.73 [95%CI 0.59-0.86]) than long-term changes (0.45 [95%CI 0.27-0.63]). From 2016 to 2019, RARRs increased by ≥1% in 7 (15%) hospitals and decreased by ≥1% in 6 (13%) hospitals. Only 7 (15%) hospitals experienced reductions in RARRs over the short and long-term. CONCLUSIONS: Hospital-level performance on RARRs remained stable with high agreement over the short-term suggesting stability of readmission measures. There was little evidence of sustained improvement in hospital-level performance over multiple years. [ABSTRACT FROM AUTHOR]

School-based telehealth (SBTH) offers an opportunity to overcome traditional barriers to providing comprehensive asthma care for children. Guided by an implementation science framework considering factors internal and external to the school setting, we characterized barriers and facilitators to asthma care within an existing SBTH program available in over 50 under-resourced South Carolina schools. This cross-sectional study assessed barriers and facilitators to SBTH asthma care delivery using web-based surveys of school nurses, specifically addressing school implementation of telehealth methods. Surveys evaluated practices and nurse and school-specific factors related to telehealth implementation including perceived barriers, organizational readiness and self-efficacy. Utilizers were schools who completed 1–10 average visits per month while non-utilizers completed less than 1 average visit per month. Descriptive statistics were performed to characterize perceptions in utilizers versus non-utilizers. Of 53 surveys distributed, 36 were completed (68% response rate). Commonly cited barriers included inadequate time due to competing tasks in both utilizers (65%) and non-utilizers (74%) as well as lack of caregiver involvement in care planning (94% of utilizers and 84% of non-utilizers). Of those utilizing specific, relevant telehealth services, schools scored high in perceptions of organizational readiness (n = 24, mean: 24.5/30), self-efficacy (n = 26, mean: 3.6/5) and comfort with identifying students eligible for SBTH (n = 26, mean: 3.5/5). We identified inadequate nurse time and challenges engaging caregivers as key barriers to implementation of a school-based telehealth asthma program providing care to an under-resourced population. Addressing these barriers when expanding telehealth services may promote utilization of telehealth. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Asthma is one of the most common chronic conditions of childhood, conferring an immense burden on children and their caregivers. School-based telehealth approaches for asthma care provide the opportunity to deliver convenient, cost-effective care to more children in the school setting. Our study objective was to characterize school-based telehealth asthma program delivery experiences and examine barriers and facilitators to telehealth program implementation. Interviews were conducted with telehealth program staff and school stakeholders in nine schools engaged in a school-based telehealth asthma program. A structured interview guide was designed using the Exploration, Adoption/Preparation, Implementation, Sustainment (EPIS) framework. A template analysis qualitative approach was used to identify themes related to implementation processes. Interviews identified key telehealth implementation strategies including building relationships, marketing and provision of technical assistance, education and support to aid program delivery. Key facilitators to successful program implementation included strong partnerships between the telehealth and school teams, a shared commitment to enhancing access to asthma care for children, and strong nurse leadership. Primary barriers to implementation included lack of family/caregiver involvement and competing demands for nurses. This study identified barriers and facilitators to implementing a school-based telehealth asthma program that can be used to guide education, training and support strategies to enhance program delivery. Recommended implementation strategies include building strong program-school partnerships, creating a shared vision to improve access to care, and building engagement in families and communities while supporting nurse leaders and family involvement with training and resources. These results can help guide future telehealth interventions. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To analyze the trend of sleep surgeries in pediatric patients with Down syndrome (DS) and obstructive sleep apnea (OSA), and to compare this to nonsyndromic (NS) children with OSA.Study Design: Retrospective cohort database analysis.Methods: Analysis of the 1997 to 2012 editions of the Kid's Inpatient Database was conducted. Using International Classification of Diseases, Ninth Revision codes, all patients with OSA were identified, and subsequently, subgroups of NS children and children with DS were identified. Trends of the number and types of sleep surgeries were analyzed.Results: A total of 48,301 and 2,991 sleep surgeries were identified in the NS and DS groups, respectively, during the study period. Tonsillectomy with adenoidectomy was the most common procedure in both groups, but the proportion of tonsillectomy with adenoidectomy decreased over time (P < .01). The proportion of palatal surgery and tracheostomy also decreased significantly, whereas there was an increase in the proportion of lingual tonsillectomies, tongue-base reduction procedures, and supraglottoplasties performed in both groups over time. The relative rates of change in these procedures were higher in the DS population.Conclusions: Tonsillectomy with adenoidectomy remains the most commonly performed procedure, although there was a significant increase in other sleep surgeries performed (lingual tonsillectomy, tongue-base reduction, and supraglottoplasty) between the two study periods, especially in children with DS.Level Of Evidence: 2c. Laryngoscope, 1963-1969, 2018. [ABSTRACT FROM AUTHOR]

Objective To describe the cost, length of stay, and incidence of postoperative hemorrhage associated with Down syndrome (DS) patients undergoing tonsillectomy in a national sample of inpatient children. Study Design This study uses a national cross-sectional cohort to analyze children with and without DS undergoing tonsillectomy with or without adenoidectomy. Setting 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database. Subjects and Methods The database was analyzed for postoperative hemorrhage and respiratory compromise, length of stay, and total charges of hospital stay. These outcomes were compared between patients with DS vs patients without DS. Results In total, 7512 patients were identified who underwent tonsillectomy: 7159 patients without DS and 353 patients with DS. The non-DS group was younger with a median age of 3 years (range, 0-18) compared with a DS median age of 4 years (range, 0-20), P = .004. The DS group had a significant increase in postoperative hemorrhage compared with non-DS (10 [2.8%] vs 87 [1.2%], respectively), P = .024. However, the DS and non-DS groups were comparable for respiratory complications (5 [1.4%] vs 106 [1.5%], respectively), P = .922. Median length of stay was significantly increased in the DS group (1 [interquartile range (IQR), 1-3]) compared with the non-DS group (1 [IQR, 1-2]), P < .001. Median charges for hospital stay totaled $17,451 (IQR, $11,901-$24,949) for the DS group compared with $14,395 (IQR, $9739-$21,890) for the non-DS group, P < .001. Conclusion Across the United States, children with DS hospitalized for tonsillectomy have an increased length of stay and cost of care. These data also suggest an increased risk of postoperative hemorrhage during the initial admission without an increased risk of respiratory complications. [ABSTRACT FROM AUTHOR]

Objective To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals. Study design A total of 1?719?617 hospitalizations for 1?531?828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions. Results The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year). Conclusions Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs. [ABSTRACT FROM AUTHOR]

Objective: To determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children. Design: Retrospective cohort with two year pairs. Setting/Participants: 2007–2009 South Carolina Medicaid recipients with persistent asthma age 2–18. M ain Exposure: C ontrol ler-to-total ast hma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0–1 (1 = ideal, 0 = no controller). Outcome Measures: 2008 and 2009 asthma related ED visits, hospitalizations, and a combined outcome of ED visit or hospitalization in the subsequent 3, 6, and 12 month time periods. Results: 19,512 patients were included. Mean age 8.9 years, 58% male, and 55% black. The ratio significantly predicted ED visits and hospitalizations over subsequent 3, 6, and 12 month time periods. The cut-point that maximized the ability to predict visits ranged from 0.4–0.6. A cutpoint of 0.5 was used in the final models. After controlling for age, race, gender, and rurality, patients with a ratio <0.5 were significantly more likely to have a subsequent emergent healthcare visit (OR 1.5–2.0). The ratio retained its predictive ability in both year-pairs for all three outcome variables, in all three time periods, with the exception of the 2008 ratio not predicting 2009 3-month and 6-month hospitalizations. Conclusions: The asthma medication ratio is a significant predictor of ED visits and hospitalizations in children. Using a cutoff of <0.5 to signal at-risk patients may be an effective way for populations who would benefit from increased use of controller medications to reduce future emergent asthma visits. [ABSTRACT FROM AUTHOR]

Background: Recommended care prior to discharge from an asthma hospitalization includes prescribing controller medications, providing asthma education, and scheduling a follow-up appointment. Objective:To identify factors associated with receipt of recommended preventive care among children hospitalized for asthma. Methods: Retrospective chart review of patients 2-18 years with primary diagnosis of asthma admitted to MUSC Children’s Hospital in 2005. Gender, race, age (2-6 yrs v. 7-18 yrs), primary payer, and season of admission were recorded. Outcome variables were: prescription for inhaled corticosteroids (ICS), asthma education, and scheduling a follow-up appointment. Results: Of the 146 subjects analyzed, 59% were male, 69% non-white, 64% 2-6 years old, 73% Medicaid/other, and 66% were admitted between Oct-March. 73% were prescribed ICS, 71% got asthma education, and 66% had a follow-up appointment scheduled. Bivariate analyses showed that 2-6 year olds were less likely to get ICS (65% v. 88% p < .01) and asthma education (64% v. 84% p < .05). Multivariable analyses demonstrated that younger children were less likely to get ICS (OR= 0.27 95% CI 0.10 - 0.70), younger children were less likely to get asthma education (OR 0.29 95% CI 0.11- 0.74), and commercial payer patients were less likely to get follow-up appointments scheduled (OR 0.39 95% CI 0.18 -0.87) (all models, p < .05). Conclusions: Among children hospitalized for asthma at our institution, younger patients are significantly less likely to receive inhaled steroids and asthma education. Targeting younger asthmatics may be a way to efficiently and effectively improve delivery of recommended preventive care in the hospital. [ABSTRACT FROM PUBLISHER]

Objective. To determine national estimates of computerized physician order entry (CPOE) use for 2003 in hospitals that care for children. Design. Retrospective cohort analysis. Results. Six percent of the hospitals used CPOE (119 out of 2145). Children's hospitals are more likely to use CPOE than a children's unit (odds ratio [OR] = 6; 95% confidence interval [CI] = 1.5-23.9). Private forprofit hospitals are more likely to use CPOE than public hospitals (OR = 26.5; 95% CI = 3.1-224.8). Urban teaching hospitals are more likely to use CPOE than rural hospitals (OR = 3.9; 95% CI = 1.7-8.8). Hospitals in the Northeast, Midwest, and South are more likely to use CPOE than hospitals in the West (OR = 11.2, 95% CI = 4.8-26.5; OR = 4.2, 95% CI = 1.7-10.5; OR = 3.1, 95% CI = 1.5-6.3, respectively). Conclusions. In 2003, 6% of the hospitals that care for children reported using CPOE. Early adoption of CPOE was associated with children's hospitals, private hospitals, urban-teaching hospitals, and hospitals outside of the western region. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVE: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves. METHODS: We performed a cross-sectional analysis of 64 children's hospitals from the Children's Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression. RESULTS: We examined a total of 1416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%-19.6%); the mean PPR rate was 4.9% (range 2.9%-6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63-1.23), compared with 0.95 (range 0.65-1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR. CONCLUSIONS: High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties. [ABSTRACT FROM AUTHOR]

Dyspnea is an unpredictable and distressing symptom of chronic obstructive pulmonary disease (COPD). Dyspnea is challenging to measure due to the heterogeneity of COPD and recall bias associated with retrospective reports. Ecological Momentary Assessment (EMA) is a technique used to collect symptoms in real-time within a natural environment, useful for monitoring symptom trends and risks of exacerbation in COPD. EMA can be integrated into mobile health (mHealth) platforms for repeated data collection and used alongside physiological measures and behavioral activity monitors. The purpose of this paper is to discuss the use of mHealth and EMA for dyspnea measurement, consider clinical implications of EMA in COPD management, and identify needs for future research in this area., Competing Interests: Dr Marta Walentynowicz reports grants from Research Foundation Flanders, during the conduct of the study. The authors report no other conflicts of interest in this work., (© 2024 Miller et al.)