Estimating pediatric inpatient medication use in the United States

Variation in Pediatric Asthmonia Diagnosis and Outcomes among Hospitalized Children

RATIONALE

Although <5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals asthma-pneumonia co-diagnosis is so common that the term "asthmonia" is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted healthcare costs and contribute to unnecessary antibiotic prescribing.

OBJECTIVE

To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals' asthmonia diagnosis rates and clinical outcomes.

METHODS

We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015-6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio (MOR) was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes.

RESULTS

Of 24606 asthma exacerbations, 19402 (78.9%) were diagnosed with asthma alone and 5204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (IQR:16.2-27.2%, range:8.4-55.9%). The MOR was 1.75 (95% CI:1.63-1.86). Compared to hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, non-teaching, rural hospitals with minimal subspecialty support (all p<0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic utilization, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission.

CONCLUSIONS

Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, non-teaching hospitals with minimal pediatric specialty support.

Antibiotic exposure in hospitalized pediatric patients in the United States: prevalence and length of stay

BACKGROUND

Hospital antibiotic use is rising. We aimed to evaluate the antibiotic-use prevalence and length of stay.

METHODS

We conducted a single-center retrospective study of patients < 18-years-old admitted to general pediatric services who received ≥ 1 antibiotic over six months. Demographics, culture results and antibiotic details were collected. The primary outcome was to identify the total number and classes of antibiotics prescribed during the admission. Secondary outcomes included length of stay (LOS), culture results, and the most commonly used antibiotics.

RESULTS

Forty-eight percent of patients received monotherapy (single class antibiotic). Cephalosporins (55%), vancomycin (35%), and clindamycin (22%) were prescribed more commonly than other antibiotic classes. Children were exposed up to 4 classes of antibiotics (range 1-4). A moderate correlation existed between the length of stay and the number of antibiotic classes used (R² = 0.38). Two or more classes of antibiotic use prolonged the length of stay. Cephalosporin use was associated with 35% reduced LOS (95 CI, 21%-57%), and penicillin use correlated with 38% more prolonged LOS (95 CI, 22%-66%).

CONCLUSIONS

Antibiotic use in pediatric hospitals was high, and children received multiple classes of antibiotics. Inappropriate antibiotic use and culture results may have an untoward effect on hospital length of stay.

Unnecessary antibiotic prescribing in children hospitalised for asthma exacerbation: a retrospective national cohort study

BACKGROUND

Antibiotic resistance represents a worldwide public health threat. Characterising prescribing patterns for conditions for which antibiotics have no role can inform antimicrobial stewardship efforts. Asthma is among the most common non-infectious diseases in children and results in 100 000 hospitalisations annually in the USA. We sought to identify the rate of antibiotic prescribing in children hospitalised for asthma exacerbations, and to characterise patient and hospital factors associated with receipt of antibiotics.

METHODS

Children and adolescents aged 2-17 years admitted to hospital between 1 October 2015 and 30 June 2018 with an asthma exacerbation were identified from the Premier Alliance Database. After excluding hospitalisations for which antibiotics appeared to have been justified, we assessed receipt and duration of antibiotic treatments during the hospital stay. We developed a hierarchical logistic regression model to identify patient and hospital factors associated with antibiotic treatment. For each hospital with at least 10 asthma cases we computed the percentage of cases receiving antibiotic treatment.

RESULTS

23 129 hospital stays met inclusion criteria; in 3329 (14%) of these, antibiotics were prescribed without clear indication. Hospital prescribing rates varied widely (range 0%-95%), with 25% of hospitals prescribing antibiotics at a rate of 27.5% or more. Patient factors most strongly associated with receipt of antibiotics included the presence of a complex chronic condition (OR: 2.4, 95% CI 2.1 to 2.9; p<0.0001) and admission to the intensive care unit compared with a general medical-surgical bed (OR: 1.6, 95% CI 1.5 to 1.9; p<0.0001). Hospitalisation at general hospitals with minimum paediatric specialty support conferred a nearly threefold higher odds of antibiotic treatment (OR: 2.9, 95% CI 1.5 to 5.6; p<0.0001).

CONCLUSIONS

These findings illustrate an opportunity to reduce unnecessary exposure to antibiotics in children hospitalised with asthma, particularly in general hospitals where three-quarters of children in the USA receive their hospital-based care.

Opioid response in paediatric cancer patients and the Val158Met polymorphism of the human catechol-O-methyltransferase (COMT) gene: an Italian study on 87 cancer children and a systematic review

Background

Genetic polymorphisms in genes involved in pain modulation have been reported to be associated to opioid efficacy and safety in different clinical settings.

Methods

The association between COMT Val158Met polymorphism (rs4680) and the inter-individual differences in the response to opioid analgesic therapy was investigated in a cohort of 87 Italian paediatric patients receiving opioids for cancer pain (STOP Pain study). Furthermore, a systematic review of the association between opioid response in cancer patients and the COMT polymorphism was performed in accordance with the Cochrane Handbook and the Prisma Statement.

Results

In the 87 paediatric patients, pain intensity (total time needed to reach the lowest possible level) was significantly higher for G/G than A/G and A/A carriers (p-value = 0.042). In the 60 patients treated only with morphine, the mean of total dose to reach the same pain intensity was significantly higher for G/G than A/G and A/A carriers (p-value = 0.010). Systematic review identified five studies on adults, reporting that opioid dose (mg after 24 h of treatment from the first pain measurement) was higher for G/G compared to A/G and A/A carriers.

Conclusions

Present research suggests that the A allele in COMT polymorphism could be a marker of opioid sensitivity in paediatric cancer patients (STOP Pain), as well as in adults (Systematic Review), indicating that the polymorphism impact could be not age-dependent in the cancer pain context.

Trial registration

Registration number: CRD42017057831.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5310-4) contains supplementary material, which is available to authorized users.

A survey of medicine use in children and adolescents in Austria

Aims of this survey were to evaluate prescription patterns for children and adolescents in primary and hospital care settings in Austria and to identify the medicines used most frequently in this population. Prescription data were assessed for the year 2014: for primary care, reimbursement data were obtained from Austrian health insurances; for hospital care, information on medicines dispensed to pediatric wards from hospital pharmacies. Frequencies of medicine use were analyzed by Anatomical Therapeutic Chemical classification system, age groups, and care setting. In primary care, anti-infectives (25%) and medicines for the respiratory system (14%) and for the nervous system (13%); in hospitals, anti-infectives (23%) and medicines for the nervous system (13%) and alimentary tract (12%) were prescribed most frequently. Amoxicillin/beta-lactamase inhibitor, ibuprofen, and paracetamol were the most frequent substances in both primary and hospital care settings. Based on the top 80% prescribed substances, a hit list of 150 pediatric medicines was defined for Austria.

CONCLUSION

This is the first representative and comprehensive survey of medicine use in children and adolescents in Austria, allowing comparison of prescription patterns to other European countries and assessing temporal trends in the future. Moreover, it serves as basis for planned measures to improve rational use of pediatric medicines. What is Known: • Large knowledge gaps exist for medicine use in children and adolescents concerning appropriate dosing, efficacy, and safety aspects. • Off-label medicine use is common in the treatment of children and adolescents. What is New: • We present a comprehensive survey of current prescription patterns for children and adolescents in Austria and define a hit list of pediatric medicines, as basis for developing an evidence-based information platform for health care professionals. • Anti-infectives, medicines for respiratory tract system, and pain medication are most frequently prescribed.

Association of Acute Kidney Injury With Concomitant Vancomycin and Piperacillin/Tazobactam Treatment Among Hospitalized Children

IMPORTANCE

β-Lactam antibiotics are often coadministered with intravenous (IV) vancomycin hydrochloride for children with suspected serious infections. For adults, the combination of IV vancomycin plus piperacillin sodium/tazobactam sodium is associated with a higher risk of acute kidney injury (AKI) compared with vancomycin plus 1 other β-lactam antibiotic. However, few studies have evaluated the safety of this combination for children.

OBJECTIVE

To assess the risk of AKI in children during concomitant therapy with vancomycin and 1 antipseudomonal β-lactam antibiotic throughout the first week of hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study focused on children hospitalized for 3 or more days who received IV vancomycin plus 1 other antipseudomonal β-lactam combination therapy at 1 of 6 large children's hospitals from January 1, 2007, through December 31, 2012. The study used the Pediatric Health Information System Plus database, which contains administrative and laboratory data from 6 pediatric hospitals in the United States. Patients with underlying kidney disease or abnormal serum creatinine levels on hospital days 0 to 2 were among those excluded. Patients 6 months to 18 years of age who were admitted through the emergency department of the hospital were included. Data were collected from July 2015 to March 2016. Data analysis took place from April 2016 through July 2017. (Exact dates are not available because the data collection and analysis processes were iterative.).

MAIN OUTCOMES AND MEASURES

The primary outcome was AKI on hospital days 3 to 7 and within 2 days of receiving combination therapy. Acute kidney injury was defined using KDIGO criteria and was based on changes in serum creatinine level from hospital days 0 to 2 through hospital days 3 to 7. Multiple logistic regression was performed using a discrete-time failure model to test the association between AKI and receipt of IV vancomycin plus piperacillin/tazobactam or vancomycin plus 1 other antipseudomonal β-lactam antibiotic.

RESULTS

A total of 1915 hospitalized children who received combination therapy were identified. Of the 1915 patients, a total of 866 (45.2%) were female and 1049 (54.8%) were male, 1049 (54.8%) were identified as white in race/ethnicity, and the median (interquartile range) age was 5.6 (2.1-12.7) years. Among the cohort who received IV vancomycin plus 1 other antipseudomonal β-lactam antibiotic, 157 patients (8.2%) had antibiotic-associated AKI. This number included 117 of 1009 patients (11.7%) who received IV vancomycin plus piperacillin/tazobactam combination therapy. After adjustment for age, intensive care unit level of care, receipt of nephrotoxins, and hospital, IV vancomycin plus piperacillin/tazobactam combination therapy was associated with higher odds of AKI each hospital day compared with vancomycin plus 1 other antipseudomonal β-lactam antibiotic combination (adjusted odds ratio, 3.40; 95% CI, 2.26-5.14).

CONCLUSIONS AND RELEVANCE

Coadministration of IV vancomycin and piperacillin/tazobactam may increase the risk of AKI in hospitalized children. Pediatricians must be cognizant of the potential added risk of this combination therapy when making empirical antibiotic choices.

Fatal Cardiac Arrest in 2 Children: Possible Role of Ondansetron

INTRODUCTION

Ondansetron is commonly used to treat vomiting in gastroenteritis, but has a United States Food and Drug Administration black box warning for risk of Q wave to T wave time interval (QT) prolongation. We report 2 pediatric cases of fatal refractory cardiac arrest after administration of ondansetron.

CASES

A 10-year-old previously healthy boy presented to the emergency room with gastroenteritis symptoms. After intravenous fluids, morphine, antibiotics, and 2 doses of ondansetron, the patient became unresponsive with agonal respirations and a wide complex tachycardia consistent with ventricular tachycardia. In a second case, an 86-day-old infant with previously unidentified congenital cardiomyopathy presented to our emergency department with gastroenteritis symptoms. The patient received ondansetron and subsequently experienced repeated bouts of supraventricular tachycardia which progressed to ventricular fibrillation. Resuscitation efforts failed in each case, and both patients expired.

DISCUSSION

Ondansetron can cause dose-dependent QT prolongation effects, which are more clinically relevant when other proarrhythmic elements are present. There is very limited published experience on use of ondansetron in children younger than 2 years. Our 2 cases join 2 previous case reports of death after ondansetron administration for gastroenteritis. The pharmacology of ondansetron's cardiac effects and drug-induced QT prolongation is discussed.

CONCLUSIONS

Patients may have hidden risk factors that, together with ondansetron, could result in a proarrhythmic state that could lead to adverse effects, such as arrhythmias. Administration of ondansetron should be individualized and used cautiously in patients with risk factors for arrhythmia.

Drug Utilisation Patterns in Children Admitted to a Paediatric General Medical Ward in Five Countries

Objective

To investigate and compare drug prescription patterns in children admitted to a paediatric general medical ward in five countries.

Methods

A prospective cohort study conducted on paediatric medical wards in the UK, Germany, Australia, Hong Kong (HK) and Malaysia. Data were collected over 3 months in each country except in Australia (1 month). All medications prescribed were classified according to the WHO Anatomical Therapeutic Chemical (ATC) classification. For each drug, frequency of prescriptions and patient exposures were calculated for ATC anatomical and therapeutic levels overall and by country.

Results

One thousand two hundred and seventy-eight patients were included (Australia 146, Germany 376, UK 313, HK 143 and Malaysia 300); 89.2 % of patients (1140) received medications, median 3 (interquartile range 2–5) drugs per patient. 5367 drugs were prescribed. The most frequently prescribed therapeutic groups in all countries were: systemic antibacterials (1355; 25.2 %), analgesics/non-steroidal anti-inflammatory drugs (NSAIDs) (1173; 21.8 %) and drugs for obstructive airway diseases (472; 8.8 %). Overall, 65.1 % (742) of patients received at least one systemic antibacterial, 63.7 % (726) received one or more analgesic/NSAIDs, and 23.6 % (269) received ‘drugs for obstructive airway diseases’. The number of patients exposed to these groups differed significantly between countries (p < 0.05). Paracetamol was the most frequently prescribed in all countries, but metamizole was only used in Germany. Morphine was mainly prescribed in the UK.

Conclusion

This study provides an overview of drug use patterns in five culturally and ethnically diverse countries. The most frequently used therapeutic groups were similar, but the proportion of patients treated differed between countries. Also within a therapeutic group the specific drug used varied between countries.

Polypharmacy in pediatric patients and opportunities for pharmacists' involvement

Rates of chronic conditions among pediatrics have been steadily increasing and medications used to treat these conditions have also shown a proportional increase. Most clinical trials focus on the safety of solitary medications in adult patients. However, data from these trials are often times extrapolated for use in pediatric patients who have different pharmacokinetic processes and physical profiles. As research increases and more drugs become available for pediatric use, the issue of polypharmacy becomes more of a concern. Polypharmacy is defined as the practice of administering or using multiple medications concurrently for the treatment of one to several medical disorders. With the increased rates of diagnosed complex disease states as prescribed mediations in pediatric patients, the prevalence and effect of polypharmacy in this patient population is largely a mystery. Polypharmacy falls within the realm of expertise of specialized pharmacists who can undertake medication therapy management services, medical chart reviews, and other services in pediatrics. Pharmacists have the time and knowledge to undertake pertinent interventions when managing polypharmacy and can play a major positive role in preventing adverse events. The aim of this paper is to review the literature on pediatric polypharmacy and provide insight into opportunities for pharmacists to help with management of polypharmacy. Information on adverse events, efficacy, and long-term outcomes with regard to growth and development of children subject to polypharmacy has yet to be published, leaving this realm of patient safety ripe for research.

Transforming the Premier Perspective Hospital Database into the Observational Medical Outcomes Partnership (OMOP) Common Data Model

Background:

The Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) has been implemented on various claims and electronic health record (EHR) databases, but has not been applied to a hospital transactional database. This study addresses the implementation of the OMOP CDM on the U.S. Premier Hospital database.

Methods:

We designed and implemented an extract, transform, load (ETL) process to convert the Premier hospital database into the OMOP CDM. Standard charge codes in Premier were mapped between the OMOP version 4.0 Vocabulary and standard charge descriptions. Visit logic was added to impute the visit dates. We tested the conversion by replicating a published study using the raw and transformed databases. The Premier hospital database was compared to a claims database, in regard to prevalence of disease.

Findings:

The data transformed into the CDM resulted in 1% of the data being discarded due to data errors in the raw data. A total of 91.4% of Premier standard charge codes were mapped successfully to a standard vocabulary. The results of the replication study resulted in a similar distribution of patient characteristics. The comparison to the claims data yields notable similarities and differences amongst conditions represented in both databases.

Discussion:

The transformation of the Premier database into the OMOP CDM version 4.0 adds value in conducting analyses due to successful mapping of the drugs and procedures. The addition of visit logic gives ordinality to drugs and procedures that wasn’t present prior to the transformation. Comparing conditions in Premier against a claims database can provide an understanding about Premier’s potential use in pharmacoepidemiology studies that are traditionally conducted via claims databases.

Conclusion and Next Steps:

The conversion of the Premier database into the OMOP CDM 4.0 was completed successfully. The next steps include refinement of vocabularies and mappings and continual maintenance of the transformed CDM.

Patterns of use and predictors of receipt of antibiotics in women undergoing cesarean delivery

OBJECTIVE

Perioperative antibiotics are recommended during cesarean delivery to reduce the risk of postoperative infections and resulting maternal morbidity. We examined the patterns of use and predictors of receipt of antibiotics in women undergoing cesarean delivery.

METHODS

We identified a national cohort of women who underwent a cesarean delivery between 2003 and 2010 using a commercial hospitalization database. Women who received antibiotics on the day of cesarean delivery were classified as having received perioperative antibiotics. Multivariable regression models were developed to account for patient, obstetric, physician, and hospital factors on receipt of antibiotics. Between-hospital variation was calculated using generalized linear mixed models.

RESULTS

Among 1,137,804 women who underwent cesarean delivery, 59.5% received perioperative antibiotics. The proportion of patients receiving antibiotics increased over time from 52.5% in 2003 to 63.1% in 2010 (P<.001) and varied significantly by geographic region. Women who did not labor were more likely to receive antibiotics than those who had a cesarean delivery after labor (66% compared with 44%, P<.001). Age, race, and insurance status were not major determinants of the use of perioperative antibiotics.

CONCLUSION

Among women undergoing cesarean delivery, compliance with the recommendation for universal perioperative antibiotic prophylaxis is poor. Coordinated efforts are needed to enhance use of guideline-based perioperative antibiotic prophylaxis for women undergoing cesarean delivery.

LEVEL OF EVIDENCE

III.

Management and outcomes of pneumonia among children with complex chronic conditions

INTRODUCTION

Although pneumonia is a common reason for pediatric hospitalization among children with complex chronic conditions (CCC), treatment and outcomes have not been well-described. We characterized the presentation, management and outcomes of pneumonia in children with and without CCC and described how antibiotic management and outcomes vary among subgroups of children with CCC.

METHODS

We conducted a cohort study of children <18 years with pneumonia across a large sample of US hospitals. Children were grouped according to CCC subgroups. Differences in disease management and outcomes were assessed using multivariable regression.

RESULTS

Of the 31,684 children in our cohort, 11.9% had CCC. Children with CCC were more likely to receive intensive investigations and therapies, were less likely to receive aminopenicillins or third generation cephalosporins and were more likely to receive antibiotics against methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and anaerobes. Compared with children without these conditions, children with CCC had significantly increased length of stay [relative risk 1.43, 95% confidence interval (CI) 1.39-1.48] and hospital costs (relative risk 1.38, 95% CI 1.33-1.43), with increased odds of antibiotic escalation (odds ratio 1.51, 95% CI 1.35-1.70), pneumonia complications (odds ratio 1.47, 95% CI 1.24-1.75) and readmission (odds ratio 4.0, 95% CI 3.2-5.0).

DISCUSSION

Children with CCC comprise a significant proportion of children hospitalized for pneumonia and are at substantially increased risk of adverse outcomes. They have high rates of treatment with broad spectrum antibiotics, both at the time of hospitalization and subsequently. Research is needed to inform decision-making and guideline development, with goals of reducing adverse outcomes and unnecessary variation in management among children with CCC.

Variation in resource utilization for the management of uncomplicated community-acquired pneumonia across community and children's hospitals

OBJECTIVE

To describe patterns of diagnostic testing and antibiotic management of uncomplicated pneumonia in general community hospitals and children's hospitals within hospitals and to determine the association between diagnostic testing and length of hospital stay.

STUDY DESIGN

We conducted a retrospective cohort study of children 1-17 years of age hospitalized with the diagnosis of pneumonia from 2007 to 2010 to hospitals contributing data to Perspective Database Warehouse, assessing patterns of diagnostic testing and antibiotic management. We constructed logistic regression models of log-transformed length of stay (LOS) and grouped treatment models to ascertain whether performance of blood cultures and viral respiratory testing were associated with LOS.

RESULTS

A total of 17 299 pneumonia cases occurred at 125 hospitals, with considerable variability in pneumonia management. Only 40 (0.2%) received ampicillin/penicillin G alone or in combination with other antibiotics, and 1318 (7.4%) received macrolide monotherapy as initial antibiotic management. Performance of blood culture and testing for respiratory viruses was associated with a statistically significant longer LOS, but these differences did not persist in grouped treatment models.

CONCLUSIONS

We observed greater rates of diagnostic testing in this cohort of structurally diverse hospitals than previously reported at freestanding children's hospitals, with extremely low rates of narrow-spectrum antibiotic use. Tailored antibiotic stewardship initiatives at these hospitals are needed to achieve adherence to national guideline recommendations.

Increasing Use of Computed Tomographic Perfusion and Computed Tomographic Angiograms in Acute Ischemic Stroke From 2006 to 2010

Background and Purpose—

Our objective was to study nationwide utilization trends of computed tomographic (CT) angiogram (CTA) and CT perfusion (CTP) in acute ischemic stroke and particularly in the context of use of reperfusion therapies.

Methods—

We reviewed the Premier Perspective Database for ischemic stroke–related hospitalizations of adult patients during a 5-year period, 2006 to 2010. Use of multimodal CT-based imaging and reperfusion therapies was determined through the procedure and billing codes. Logistic regression was used to identify predictors of utilization of imaging studies and reperfusion treatments.

Results—

An increasing proportion of ischemic strokes received CTA each year: 3.8% in 2006, 5.6% in 2007, 6.5% in 2008, 7.5% in 2009, and 9.1% in 2010 ( P <0.0001). The proportion of acute strokes that were imaged with CTP imaging also increased each year: 0.05% in 2006, 0.05% in 2007, 0.9% in 2008, 2.2% in 2009, and 2.9% in 2010 ( P <0.0001). Reperfusion treatment was more common among those who were imaged with CTA (13.0%) and CTP (17.6%) compared with those with CT head alone (4.0%; P <0.0001). Specifically, higher rates of recombinant tissue-type plasminogen activator were observed in CTA (10.2%) and CTP (11.4%) compared with those with CT head alone (3.8%; P <0.0001). Similarly, higher rates of mechanical embolectomy were observed in CTA (2.8%) and CTP (6.3%) compared with those with CT head alone (0.2%; P <0.0001).

Conclusions—

There was a marked increase in the rate of CTA and CTP studies in setting of acute ischemic stroke from 2006 to 2010, and both modalities were associated with increased reperfusion therapy use.

Pediatric health care quality measures: considerations for pharmacotherapy

Measuring the quality use of medicines can be conceptualized as a mechanism for understanding appropriate use, underuse, overuse, or misuse. For pediatric pharmacotherapy, measuring the quality use of medicines requires awareness of the differences in health care between children and adults and the differences in the quality and quantity of science that supports evidence-based practice in pediatric health care compared with adult health care. Here we use the Pediatric Quality Measures Program that arose from the Children's Health Insurance Program Reauthorization Act in the United States to illustrate the challenges in developing quality measures of pediatric pharmacotherapy. The challenges are primarily twofold: (i) weak evidence base for the specific pharmacotherapy in children and (ii) limited data to calculate the measure. A weak evidence base must often be weighed against the importance of the topic if the quality measure is intended to address a known quality of care or public health problem. Limited data because of insufficient amount or inappropriate type will affect implementation of the measure and its eventual usefulness. Methods to meet these challenges often depend on the priorities of and the tools available to end users. Health information technology is emerging as a tool to improve quality measurement but presents additional challenges.

Association of hospital and provider types on sickle cell disease outcomes

OBJECTIVES

Adolescents and young adults (A/YA) with sickle cell disease (SCD) are hospitalized in both children's and general hospitals. We determined the effect of hospital type and provider specialty on outcomes of hospitalized A/YA with SCD and acute chest syndrome (ACS).

METHODS

This retrospective cohort study used the 2007-2009 Premier Database, a large multi-institutional database, to identify 1476 patients ages 16 to 25 years with 2299 admissions with SCD and ACS discharged from 256 US hospitals from 2007 to 2009. Multilevel logistic regression and zero-truncated negative binomial regression were performed after adjustment for patient demographic, clinical, and hospital characteristics to test the association of hospital type and provider specialty on death, endotracheal intubation, simple or exchange transfusion, length of stay (LOS), and 30-day readmission.

RESULTS

Of all admissions, 14 died and 45% were intubated. General hospitals had 13 deaths and were associated with higher intubation rates (predicted probability [PP], 48% [95% confidence interval (CI), 43%-52%]) and longer LOS (predicted mean LOS, 7.6 days [95% CI, 7.2-7.9]) compared with children's hospitals (PP of intubation, 24% [95% CI, 5%-42%]; and predicted mean LOS, 6.8 days [95% CI, 5.6-5.8]). There was no difference by hospital type or provider specialty in PP of simple or exchange transfusion, or 30-day readmission.

CONCLUSIONS

General hospitals carry higher intubation risks for A/YA with SCD and ACS compared with children's hospitals. We need to better understand the drivers of these differences, including the role of staff expertise, hospital volume, and quality of ongoing SCD care.

Patterns of medication exposures in hospitalized pediatric patients with acute renal failure requiring intermittent or continuous hemodialysis

OBJECTIVES

Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications.

STUDY DESIGN

Retrospective cohort using the Pediatric Health Information System database.

SETTING

Forty freestanding children's hospitals throughout the United States.

PATIENTS

Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011.

INTERVENTION

A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database.

MAIN RESULTS

Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure.

CONCLUSIONS

Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.

Pragmatic estimates of the proportion of pediatric inpatients exposed to specific medications in the USA

PURPOSE

To provide pragmatic national estimates of the proportion of hospitalized pediatric patients exposed to specific drugs in the USA.

METHODS

We used Premier Perspective Database and the Pediatric Health Information System data including specific drug exposures of 1.15 million inpatients <18 years old in 411 general and 52 children's hospitals throughout the USA in 2006, extrapolating this information into the probability-based Kids' Inpatient Database, which has demographic and clinical characteristics but no drug exposure data. We used a multivariable stratified resampling (MSR) technique to estimate the proportion of drug exposure for the 700 most commonly used drugs and performed additional stability and sensitivity analyses for 19 drugs.

RESULTS

The estimated proportion of pediatric inpatients exposed to specific drugs in 2006 ranged from high levels such as that of acetaminophen (17.36; 95%CI: 17.32, 17.41) to rare exposures such as bosentan (0.0018; 95%CI: 0.0013, 0.0023). Additional analyses for 19 drugs revealed that the MSR estimates were close to estimates generated by multivariable multiple imputation, with a maximum absolute difference of 0.03 for acetaminophen (17.36 vs. 17.33) and famotidine (1.90 vs. 1.93), and that even with 50% of the hospitals removed at random, the proportion estimates did not vary by more than 2.5-fold at the upper 97.5 percentile.

CONCLUSIONS

These pragmatic national estimates of the proportion of pediatric inpatient drug exposures, generated using an MSR technique, provide a context for interpretation of drug-related adverse event reports and prioritization of pediatric pharmacology research.

Adverse Drug Reactions in Children--International Surveillance and Evaluation (ADVISE): a multicentre cohort study

BACKGROUND

A previous meta-analysis reported that 9.5% of hospitalized children suffered from an adverse drug reaction (ADR); however, reported incidences among studies varied.

OBJECTIVE

To enhance the knowledge of ADRs in paediatric hospitalized patients at a global level we investigated the incidence and characteristics of ADRs in hospitalized children in European and non-European countries.

METHODS

A prospective observational cohort study was conducted in academic and non-academic hospitals in five countries: Australia, Germany, Hong Kong, Malaysia and the UK. Children aged 0-18 years admitted during a 3-month period (between 1 October 2008 and 31 December 2009) were recruited. The main outcome measures were incidence, causality and outcome of ADRs.

RESULTS

A total of 1278 patients (1340 admissions) were included [Australia n = 146 (149 admissions), Germany n = 376 (407), Hong Kong n = 143 (149), Malaysia n = 300 (314) and the UK n = 313 (321)]. The median age was 2 years (interquartile range [IQR] 0-7). Patients received a total of 5367 drugs (median 3; IQR 2-5) and median length of hospital stay was 4 days (IQR 3-7). A total of 380 ADRs were identified in 211 patients. The resultant ADR incidence of 16.5% (95% CI 14.5, 18.7) varied significantly between countries (p < 0.001). The highest incidences were observed in Malaysia and the UK. 65.3% (n = 248) of ADRs were found to be probable, and 24% of the ADRs were serious, with one being fatal.

CONCLUSIONS

By comparing data from five countries in Europe, Asia and Australia we have shown that the incidence of ADRs in hospitalized children is at least as high as incidences published in adults. However, the variation between countries was mainly due to different populations and treatment strategies. Particular attention should be given to opioid use in hospitalized children.

Prevalence of moderate-severe pain in hospitalized children

BACKGROUND

  Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.

METHODS

  We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed.

RESULTS

  The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four.

CONCLUSIONS

  The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

Lasting developmental effects of neonatal fentanyl exposure in preweanling rats

The present study aimed to determine whether neonatal treatment with fentanyl has lasting effects on stressed developing brain. Six-day-old rats were assigned to one of three groups (10 males/group): (1) fentanyl (incision+fentanyl), (2) saline (incision+0.9% saline), and (3) unoperated (unoperated sham). Pups with a plantar paw incision received repetitive subcutaneous injections of fentanyl or vehicle through postnatal days (PNDs) 6 to 8. A nonoperated sham group served as nonstressed control. Studies included assessment of development from PND 6 to PND 21 (growth indices and behavioral testing). Fentanyl administered twice daily for three days after surgical incision had no impact on early growth and development, as measured on PND 9, but showed a lasting impact on later growth, enhanced behavioral development, and lower anxiety, as measured through PNDs 10–21. While this does not completely support a benefit from such treatment, our findings may contribute to support the neonatal use of fentanyl, when indicated, even in premature newborns.