Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

Adherence with post-hospitalization follow-up after pediatric critical illness due to respiratory failure

BACKGROUND

Adherence with follow-up appointments after a pediatric intensive care unit (PICU) admission is likely a key component in managing post-PICU sequalae. However, prior work on PICU follow-up adherence is limited. The objective of this study is to identify hospitalization characteristics, discharge child health metrics, and follow-up characteristics associated with full adherence with recommended follow-up at a quaternary care center after a PICU admission due to respiratory failure.

METHODS

We conducted a retrospective cohort study of patients ≤ 18 years with respiratory failure admitted between 1/2013-12/2014 to a quaternary care PICU. Post-hospitalization full adherence with recommended follow-up in the two years post discharge (1/2013-3/2017) at the quaternary care center was quantified and compared by demographics, baseline child health metrics, hospitalization characteristics, discharge child health metrics, and follow-up characteristics in bivariate and multivariate analyses. Patients were dichotomized into being non-adherent with follow-up (patients who attended less than 100% of recommended appointments at the quaternary care center) and fully adherent (patients who attended 100% of recommended appointments at the quaternary care center).

RESULTS

Of 155 patients alive at hospital discharge, 140 (90.3%) were recommended to follow-up at the quaternary care center. Of the 140 patients with recommended follow-up at the quaternary care center, 32.1% were non-adherent with follow-up and 67.9% were fully adherent. In a multivariable logistic regression model, each additional recommended unique follow-up appointment was associated with lower odds of being fully adherent with follow-up (OR 0.74, 95% CI 0.60-0.91, p = 0.005), and each 10% increase in the proportion of appointments scheduled before discharge was associated with higher odds of being fully adherent with follow-up (OR 1.02, 95% CI 1.01-1.03, p = 0.004).

CONCLUSIONS

After admission for acute respiratory failure, only two-thirds of children were fully adherent with recommended follow-up at a quaternary care center. Our findings suggest that limiting the recommended follow-up to only key essential healthcare providers and working to schedule as many appointments as possible before discharge could improve follow-up adherence. However, a better understanding of the factors that lead to non-adherence with follow-up appointments is needed to inform broader system-level approaches could help improve PICU follow-up adherence.

Frequency and Correlates of Pediatric High-Flow Nasal Cannula Use for Bronchiolitis, Asthma, and Pneumonia

BACKGROUND

Heated humidified high-flow nasal cannula (HFNC) is a respiratory support device historically used in pediatrics for infants with bronchiolitis. No large-scale analysis has determined the current frequency or demographic distribution of HFNC use in children. The objective of this study was to determine the frequency and correlates of HFNC use in children presenting to the hospital for asthma, bronchiolitis, or pneumonia.

METHODS

This longitudinal observational study was based on electronic health record data from a large regional health information exchange, the Indiana Network for Patient Care (INPC). Subjects were age 0-18 y with recorded hospital encounters at an INPC hospital between 2010-2019 with International Classification of Diseases codes for bronchiolitis, asthma, or pneumonia. Annual proportions of HFNC use among all hospital encounters were assessed using generalized additive models. Log-binomial regression models were used to identify correlates of incident HFNC use and determine risk ratios of specific subjects receiving HFNC.

RESULTS

The study sample included 242,381 unique subjects with 412,712 hospital encounters between 2010-2019. The 10-y period prevalence of HFNC use was 2.54% (6,155/242,381) involving 7,974 encounters. Hospital encounters utilizing HFNC increased by 400%, from 326 in 2010 to 1,310 in 2019. This increase was evenly distributed across all 3 diagnostic categories (bronchiolitis, asthma, and pneumonia). Sex, race, age, and ethnicity all significantly influenced the risk of HFNC use. Over the 10-y period, the percentage of all hospital encounters using HFNC increased from 1.11% in 2010 to 3.15% in 2018. Subjects with multiple diagnoses had significantly higher risk of receiving HFNC.

CONCLUSIONS

The use of HFNC in children presenting to the hospital with common respiratory diseases has increased substantially over the past decade and is no longer confined to treating infants with bronchiolitis. Demographic and diagnostic factors significantly influenced the frequency of HFNC use.

Severe Blunt Liver Injury Complicated by Delayed Massive Hemobilia in a Toddler: A Case Report and Literature Review

Introduction

Unintentional injuries remain a leading cause of disability among children. Although most of the pediatric patients suffering blunt liver injury can be successfully treated with non-operative therapy, the diagnosis and management of delayed life-threatening hemobilia following severe blunt liver injury, especially in the pediatric population, remain a challenge for clinicians.

Case Presentation

A previously healthy 2-year-old girl suffered a severe blunt liver injury related to an electric bike, which was inadvertently activated by herself. She initially received non-operative therapy and was in a stable condition in the first 2 weeks. On the 16th and 22nd postinjury days, the patient presented with life-threatening massive hemobilia, which was confirmed via repeat emergent gastroscopy and hepatic arterial angiography. An emergency selective transarterial embolization of the involved branch of the left hepatic artery was successfully performed. The patient recovered uneventfully, and long-term follow-up was needed owing to a mild dilatation of the left intrahepatic bile duct.

Discussion

Incidental injury in children should be considered as a major public health issue and preventive measures should be taken to reduce its occurrence. Delayed massive hemobilia after severe blunt liver trauma is rare, and its accurate and timely diagnosis via emergency hepatic arterial angiography and selective angioembolization may allow prompt and optimal management to achieve good outcomes in the pediatric population.

Ten year trends in hospital encounters for pediatric asthma: an Indiana experience

INTRODUCTION

Pediatric asthma is a common cause of emergency department visits, hospital admissions, and mortality. Population incidence studies have historically used large-scale survey data. We measured these epidemiologic trends using a health information exchange.

METHODS

In this retrospective cohort study, we used electronic health record data from a regional health information exchange to study clinical trends in pediatric patients presenting to the hospital for asthma in the State of Indiana. Data was obtained from 2010 to 2019 and included all patients ages 2-18 years. Study participants were identified using international classification of disease codes. The measured outcomes were number of hospital encounters per year, percentage of admissions per year, and mortality rates.

RESULTS

Data included 50,393 unique patients and 88,772 unique encounters, with 57% male patients. Over the ten-year period, hospital encounters ranged from 5000 to 8000 per year with no change in trajectory. Between 2010 and 2012, the percent of encounters admitted to the hospital was ∼30%. This decreased to ∼20-25% for 2015-2019. Patient mortality rates increased from 1 to 3 per 1000 patient encounters in 2010-2014 to between 5 and 7 per 1000 patient encounters from 2016 to 2019. White patients had a significantly higher admission percentage compared to other racial groups, but no difference in mortality rate.

CONCLUSIONS

Asthma continues to be a common condition requiring hospital care for pediatric patients. Regional health information exchanges can enable public health researchers to follow asthma trends in near real time, and have potential for informing patient-level public health interventions.

Factors Associated with Pediatric Burn Clinic Follow-up after Emergency Department Discharge

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within one week. A total of 196 patients (Mage=5.5 years; 54% male) were included in analyses. Average percent total body surface area was 1.9 (SD=1.5%). One-third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (OR=1.00; 95% CI: [.99-1.00], p=.045), patients with superficial burns (OR=9.37; 95% CI: [2.50-35.16], p=.001), patients with smaller percent total body surface area (OR=1.37; 95% CI: [1.07-1.76], p=.014), and patients with Medicaid insurance (OR=.22; 95% CI: [.09-.57], p=.002) or uninsured/unknown insurance (OR=.07; 95% CI: [.02-.26], p=.000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates

PURPOSE

The factors affecting outpatient follow-up (OFU) after pediatric surgery have not been well studied. We evaluate factors impacting OFU and the effect of OFU in pediatric surgical patients.

METHODS

A retrospective review of all pediatric patients operated on by the Division of Pediatric Surgery from February 1st to September 30th, 2017, and subsequently discharged was performed.

RESULTS

1242 patients were identified. Overall OFU was 69.6%. Language and distance between patient residence and the hospital had no impact on OFU. Inpatient surgical patients followed-up at a higher rate than ambulatory surgical patients (72.7% vs 64.8%, p < 0.01). Out-of-system transfers had the lowest OFU rate at 52.8% (p < 0.001). Insurance type and patient age had a significant impact on OFU rates. Thirty-day ED visit and readmission rates were significantly lower in those patients with OFU than in those without (8.8% vs 12.7%, p = 0.04 and 3.7% to 11.0%, p < 0.001, respectively). OFU was more beneficial in patients with inpatient procedures or longer hospitalization lengths of stay than in the cohort of ambulatory patients.

CONCLUSIONS

Socioeconomic status, hospital presentation, and procedural complexity influenced rates of OFU. OFU was associated with significant reductions in 30-day ED visits and readmissions, and this benefit was more pronounced for complex procedures or patients.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

Level III.