Pediatric high-impact conditions in the United States: retrospective analysis of hospitalizations and associated resource use

Profiling Pediatric Potentially Avoidable Transfers Using Procedure and Diagnosis Codes

OBJECTIVES

While hospital-hospital transfers of pediatric patients are often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PATs) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric interfacility transfers with early discharges.

METHODS

We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PATs defined as patient transfers with a discharge home within 24 hours without receiving any specialized procedures or diagnoses.

RESULTS

Of the 2,415 pediatric transfers, 31.4% were discharged home within 24 hours. Among transferred patients with early discharges, 356 patients (14.7% of total patient transfers) received no specialized procedures or diagnoses. Direct admissions were categorized as PATs 1.9-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.1%, 17.3%, and 27.3%, respectively. Respiratory infections, asthma, and ill-defined conditions (eg, fever, nausea with vomiting) were the most common PAT diagnoses.

CONCLUSIONS

Early discharges and PATs are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PATs, with a focus on direct admissions given the high frequency of PATs among direct admissions to both the pediatric ICU and non-ICU.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions

BACKGROUND

Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions.

METHODS

This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs.

RESULTS

There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01).

CONCLUSIONS

CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

Is Unplanned PICU Readmission a Proper Quality Indicator? A Systematic Review and Meta-analysis

CONTEXT

Unplanned PICU readmissions within 48 hours of discharge (to home or a different hospital setting) are considered a quality metric of critical care.

OBJECTIVE

We sought to determine identifiable risk factors associated with early unplanned PICU readmissions.

DATA SOURCES

A comprehensive search of Medline, Embase, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to July 16, 2018.

STUDY SELECTION

Observational studies of early unplanned PICU readmissions (<48 hours) in children (<18 years of age) published in any language were included.

DATA EXTRACTION

Two reviewers selected and appraised studies independently and abstracted data. A meta-analysis was performed by using the random-effects model.

RESULTS

We included 11 observational studies in which 128 974 children (mean age: 5 years) were evaluated. The presence of complex chronic diseases (odds ratio 2.42; 95% confidence interval 1.06 to 5.55; I ² 79.90%) and moderate to severe disability (odds ratio 2.85; 95% confidence interval 2.40 to 3.40; I ² 11.20%) had the highest odds of early unplanned PICU readmission. Other significant risk factors included an unplanned index admission, initial admission to a general medical ward, spring season, respiratory diagnoses, and longer initial PICU stay. Readmission was less likely after trauma- and surgery-related index admissions, after direct admission from home, or during the summer season. Modifiable risk factors, such as evening or weekend discharge, revealed no statistically significant association. Included studies were retrospective, which limited our ability to account for all potential confounders and establish causality.

CONCLUSIONS

Many risk factors for early unplanned PICU readmission are not modifiable, which brings into question the usefulness of this quality measure.

Variations in pediatric hospitalization in seven European countries

OBJECTIVE

To compare rates of pediatric hospital utilization across seven European countries.

METHODS

Secondary data from WHO's European Hospital Morbidity Database from 2009 to 2012. Cross- country comparison of rates of admissions and bed days per 100 person-years by clinical service. We tabulated counts of admissions and bed days by principal diagnosis and age group for Ireland, Austria, Hungary, Belgium, Spain, Germany, and France. ICD 9 or ICD 10 or ISHMT diagnosis codes were allocated to clinical services. Normal newborn admissions were excluded from the analysis. Simple linear regression models, weighted by pediatric population size, were constructed to estimate the relationships between health care utilization and factors that may influence variation in care.

RESULTS

Hospital admission across the seven countries ranged from 9.41 (Spain) to 19.59 (Germany) admissions per 100 person-years. Bed days ranged from a low of 52.50 (Spain) to 135.44 (Germany) per 100 person-years. General pediatrics and neonatology led in clinical volume across all countries. Infectious disease admissions were the third most common. Bed supply and nurse supply were positively associated with health care utilization. Out-of-pocket payment was inversely associated with health care utilization CONCLUSIONS: A wide range of utilization of pediatric inpatient care was observed across seven European countries that have universal coverage. Variation in the provision of effective, supply-sensitive, and preference-sensitive care may explain some of the variations. Our study shows that it is probable that preventable hospital admissions are occurring in the pediatric population.

Resource Use and Outcomes for Children Hospitalized With Severe Sepsis or Septic Shock

OBJECTIVE

To describe patient and hospital characteristics associated with in-hospital mortality, length of stay (LOS), and charges for children with severe sepsis or septic shock who often require specialized organ-supportive technology to enhance outcomes, availability of which might vary across hospitals.

DESIGN

Retrospective study among children hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. Multivariate regression methods identified factors associated with mortality, LOS, and charges.

MEASUREMENTS AND MAIN RESULTS

Of an estimated 11 972 hospitalizations for pediatric severe sepsis or septic shock, most hospitalizations (85%) were to urban teaching hospitals. Hospitalizations were more frequent among neonates and older adolescents than other age groups. Mortality was 17%, average LOS was 24 days, and average hospital charges were US$314 950. Higher mortality was associated with neonates, cumulative organ dysfunction, more comorbidities, and cardiopulmonary resuscitation. Longer hospitalization and higher charges were associated with neonates, more comorbidities, higher illness severity, invasive medical technology, and urban hospitals.

CONCLUSIONS

Efforts to mitigate the substantial in-hospital mortality and resource use observed in pediatric severe sepsis or septic shock should be age-specific and focused on the influence of comorbidities and organ dysfunction on outcomes. Future research should elucidate reasons for higher resource use at urban hospitals.

Analysis of the cost of care for children and adolescents with medical complex chronic conditions

This paper aimed to identify the use of technology and to analyze the cost of hospital care for children and adolescents with medical complex chronic conditions at a public federal hospital specialized in high-complexity pediatric care, and was performed concomitantly with a prospective cohort study conducted over a one-year period. It included 146 patients with complex medical chronic conditions and 37 non-chronic patients. The analysis showed that most patients had, on average, two hospitalizations a year and were diagnosed with diseases related to at least two organic systems. Catheters, drains and gastrostomy were the most common technologies used. Median direct costs of patients with medically complex chronic conditions were higher than those of non-chronic patients when comparing the use of technology. The study shows high hospitalization cost to these patients. Technology use and hospitalization care costs documentation yields more data to support decision-makers in the planning, managing, and financing of pediatric health policies.

Postextubation Dysphagia in Pediatric Populations: Incidence, Risk Factors, and Outcomes

OBJECTIVE

To assess incidence, risk factors for, and impact on outcomes of postextubation dysphagia. We hypothesized that the incidence of postextubation dysphagia in pediatric patients would approximate or exceed that in adults, that age and duration of intubation would increase odds for postextubation dysphagia, and that the presence of postextubation dysphagia would negatively impact patient outcomes.

STUDY DESIGN

We performed a retrospective, observational cohort study of patients aged 0-16 years admitted between 2011 and 2017. Patients were included if they were extubated in the intensive care unit and fed orally within 72 hours. Records were reviewed to determine dysphagia status and assess the impact of patient factors on odds of postextubation dysphagia. The impact of postextubation dysphagia on patient outcomes was then assessed.

RESULTS

Following application of inclusion and exclusion criteria, the sample size was 372 patients. Postextubation dysphagia was observed in 29% of patients. For every hour of intubation, odds of postextubation dysphagia increased by 1.7% (P < .0001). Age of <25 months increased odds of postextubation dysphagia more than 2-fold (P < .05). When we controlled for age, diagnosis, number of complex chronic conditions, and dysphagia status, patients with dysphagia had an increase in total length of stay of 10.95 days (P < .0001). Postextubation dysphagia increased odds of gastrostomy or nasogastric tube at time of discharge (aOR 22.22, P < .0001).

CONCLUSIONS

This study found that postextubation dysphagia is associated with increased time between extubation and discharge and with odds of gastrostomy or nasogastric tube at time of discharge.

Pediatric Inpatient-Status Volume and Cost at Children's and Nonchildren's Hospitals in the United States: 2000-2009

OBJECTIVES

The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs.

METHODS

A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database. Weighted discharge data were used to generate national estimates for a comparison of inpatient volume, cost, and complexity at CHs and nonchildren's hospitals (NCHs). Linear regression was used to assess how complexity, payer mix, and hospital-level characteristics affected inflation-adjusted costs.

RESULTS

Between 2000 and 2009, the number of discharges per 1000 children increased from 6.3 to 7.7 at CHs and dropped from 55.4 to 53.3 at NCHs. The proportion of discharges at CHs grew by 6.8% between 2006 and 2009 alone. In 2009, CHs were responsible for 12.6% (95% confidence interval: 10.4%-14.9%) of pediatric discharges and 14.7% of major therapeutic procedures, yet they accounted for 23.0% of inpatient costs. Costs per discharge were significantly higher at CHs than at NCHs for all years (P < .001); however, the increase in costs seen over time was not significant. Care complexity increased during the study period at both CHs and NCH, but it could not be used to fully account for the difference in costs.

CONCLUSIONS

National trends reveal a small rise in both the proportion of inpatient discharges and the hospital costs at CHs, with costs being significantly higher at CHs than at NCHs. Research into factors influencing costs and the role of CHs is needed to inform policy and contain costs.

Trends in common surgical procedures at children's and nonchildren's hospitals between 2000 and 2009

PURPOSE

Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH.

METHODS

We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE). Trends in case volume and costs were examined at CH versus NCH.

RESULTS

The proportion of surgical care at CH increased for all procedures from 2000 to 2009. TA and CHOLE demonstrated higher costs per case at CH. Positive growth over time in cost per case at CH was seen for AP and FP, with the cost per case of FP increasing by 21% between 2006 and 2009.

CONCLUSIONS

The proportion of surgeries performed at CH is continuing to grow alongside proportionate increases in costs, however costs for certain procedures are higher at CH than NCH. Further investigation is needed to explore cost containment at CH while still maintaining specialized, high quality surgical care.

LEVEL OF EVIDENCE

Level III.

PICU Provider Supply and Demand: A National Survey

OBJECTIVES

To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs.

DESIGN

National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017.

SETTING

Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners.

SUBJECTS

PICU physician medical directors and nurse practitioners.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care.

CONCLUSIONS

Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.

Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care

Objective:

To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners.

Methods:

A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used.

Results:

Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners.

Conclusion:

Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

Profiling Interfacility Transfers for Hospitalized Pediatric Patients

BACKGROUND AND OBJECTIVE

The hospital-to-hospital transfer of pediatric patients is a common practice that is poorly understood. To better understand this practice, we examined a national database to profile pediatric interfacility transfers.

METHODS

We used the 2012 Kids' Inpatient Database to examine characteristics of hospitalized pediatric patients (<21 years; excluding pregnancy diagnoses) with a transfer admission source. We performed descriptive statistics to compare patient characteristics, utilization, and hospital characteristics between those admitted by transfer versus routine admission. We constructed a multivariable logistic regression model to identify patient characteristics associated with being admitted by transfer versus routine admission.

RESULTS

Of the 5.95 million nonpregnancy hospitalizations in the United States in 2012, 4.4% were admitted by transfer from another hospital. Excluding neonatal hospitalizations, this rate increased to 9.4% of the 2.10 million nonneonatal, nonpregnancy hospitalizations. Eighty-six percent of transfers were to urban teaching hospitals. The most common transfer diagnoses to all hospitals nationally were mood disorder (8.9%), other perinatal conditions (8.7%), prematurity (4.8%), asthma (4.2%), and bronchiolitis (3.8%). In adjusted analysis, factors associated with higher odds of being admitted by transfer included having a neonatal principal diagnosis, male gender, white race, nonprivate insurance, rural residence, higher illness severity, and weekend admission.

CONCLUSIONS

Interfacility transfers are relatively common among hospitalized pediatric patients. Higher odds of admission by transfer are associated not only with higher illness severity but also with principal diagnosis, insurance status, and race. Further studies are needed to identify the etiologies and clinical impacts of identified transfer differences.

Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals

BACKGROUND

Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH.

METHODS

Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs.

RESULTS

NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status.

CONCLUSIONS

Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.

Variation and Trends in Charges for Pediatric Care in Massachusetts Emergency Departments, 2000-2011

OBJECTIVES

Emergency department (ED) utilization by children is common and growing more expensive. Tracking trends and variability in ED charges is essential for policymakers who strive to improve the efficiency of the health care system and for payers who prepare health care budget forecasts. Our objective was to examine trends and variability in ED charges for pediatric patients across Massachusetts.

METHODS

This was a comprehensive analysis of the statewide database containing all the visits of children aged 0 to 18 years evaluated in any of the state's EDs from 2000 to 2011, excluding patients with chronic medical conditions and those whose visits resulted in hospital admission. A validated system designed to specifically classify pediatric emergency patients into major diagnostic groups was used. Mean charges as well as interhospital variability of charges over time were examined for the most common diagnostic groups.

RESULTS

Seventy-six hospitals provided emergency care in Massachusetts during the study period, with 6,249,923 pediatric patients treated and discharged. Statewide charges significantly increased from 2000 until 2007/2008, before plateauing or decreasing through 2011. There was no evidence that interhospital variability changed over time. With the exception of academic teaching status, no hospital-level factors emerged as consistent predictors of charges.

CONCLUSIONS

Charges for common pediatric emergency conditions varied widely across Massachusetts EDs, and hospital-level factors by and large could not consistently explain the variability. Although a plateau (and in some cases decrease) of statewide pediatric emergency health care charges was observed after 2007, no evidence was found that interhospital variability decreased. These data may be useful in the ongoing effort to reform the economics of health care delivery systems.

Retrospective Evaluation of the Epidemiology and Practice Variation of Dexmedetomidine Use in Invasively Ventilated Pediatric Intensive Care Admissions, 2007-2013

OBJECTIVES

The study assessed dexmedetomidine utilization and practice variation over time in ventilated pediatric intensive care unit (PICU) patients; and evaluated differences in hospital outcomes between high- and low-dexmedetomidine utilization hospitals.

STUDY DESIGN

This serial cross-sectional analysis used administrative data from PICU admissions in the pediatric health information system (37 US tertiary care pediatric hospitals). Included admissions from 2007 to 2013 had simultaneous dexmedetomidine and invasive mechanical ventilation charges, <18 years of age, excluding neonates. Patient and hospital characteristics were compared as well as hospital-level severity-adjusted indexed length of stay (LOS), charges, and mortality.

RESULTS

The utilization of dexmedetomidine increased from 6.2 to 38.2 per 100 ventilated PICU patients among pediatric hospitals. Utilization ranged from 3.8 to 62.8 per 100 in 2013. Few differences in patient demographics and no differences in hospital-level volume/severity of illness measures between high- and low-utilization hospitals occurred. No differences in hospital-level, severity-adjusted indexed outcomes (LOS, charges, and mortality) were found.

CONCLUSION

Wide practice variation in utilization of dexmedetomidine for ventilated PICU patients existed even as use has increased sixfold. Higher utilization was not associated with increased hospital charges or reduced hospital LOS. Further work should define the expected outcome benefits of dexmedetomidine and its appropriate use.

Factors associated with high resource utilization in pediatric skin and soft tissue infection hospitalizations

OBJECTIVE

To describe factors associated with prolonged lengths of stay (LOS) and increased charges for pediatric skin and soft tissue infection (SSTI) hospitalizations.

METHODS

This study was a cross-sectional analysis of pediatric SSTI hospital discharges in 2009 within the Healthcare Cost and Utilization Project Kids' Inpatient Database. Outcomes were prolonged LOS (>75th percentile) and increased hospital charges (>75th percentile). Multivariate logistic regression controlling for patient and hospital level factors was conducted for 2009 data to assess associations among variables.

RESULTS

The 75th percentile for LOS was 3 days. Infants had higher odds of prolonged LOS than other age groups (<1 year: 1; 1-4 years: 0.70 [95% confidence interval (CI): 0.64-0.76]; 5-12 years: 0.69 [95% CI: 0.63-0.76]; 13-18 years: 1.01 [95% CI: 0.91-1.10]), as did all minority groups compared with white subjects (black subjects: 1.23 [95% CI: 1.09-1.38]; Hispanic subjects: 1.33 [95% CI: 1.20-1.47]; and other races: 1.30 [95% CI: 1.12-1.50]). Public payers compared with private payers (odds ratio: 1.17 [95% CI: 1.10-1.26]) also had increased odds of prolonged LOS. The 75th percentile for charges was $14 317. The adolescent-aged category had higher odds of charges >75th percentile compared with the age category <1 year (odds ratio: 1.54 [95% CI: 1.36-1.74]). All racial/ethnic minorities had higher odds of charges >75th percentile compared with white subjects (black subjects: 1.38 [95% CI: 1.17-1.62]; Hispanic subjects: 1.90 [95% CI: 1.59-2.26]; and other races: 1.26 [95% CI: 1.06-1.50]).

CONCLUSIONS

Vulnerable populations, including infants, racial/ethnic minorities, and publicly insured children, had higher odds of increased resource utilization during hospitalizations for SSTIs. The findings of this study provide potential targets for future preventive and public health interventions.

Caregiver Asthma Knowledge, Aptitude, and Practice in High Healthcare Utilizing Children: Effect of an Educational Intervention

Factors underlying high healthcare utilization among Hispanic and African American (AA) children with asthma are not well known. We hypothesized that low parental knowledge and suboptimal practices are associated with high healthcare utlization and sought to elucidate these factors and identify ethnicity-specific differences. We also hypothesized that a targeted educational intervention will decrease emergency department (ED) visits and hospitalizations. A 57-item questionnaire investigating asthma knowledge, aptitude, and practice was administered during a hospitalization to 268 caregivers (158 Hispanic and 110 AA) of high healthcare utilizer children. Responses were compared between ethnicities. Participants were randomized into an education group and a control group to investigate the impact of an in-hospital educational intervention on future ED visits and hospitalizations. More than 80% of caregivers knew that asthma is associated with muscle constriction and mucus production. Overall, 66.7%-86.9% of caregivers found preventive steps including allergen avoidance, regular primary care physician (PCP) follow-up, and medication adherence helpful, but only 45.2% reported adherence to controller medications. Similarly, caregivers found management steps, including albuterol use, avoidance of ineffective medications, and need to contact PCP helpful but 33% Hispanic caregivers contacted their child's PCP at the time of the exacerbation leading the current hospitalization, compared with 17% AA caregivers (P=0.006). Moreover, 40% and 30% Hispanic and 27% and 18% AA caregivers felt stressed and helpless, respectively, about their child's asthma. Despite high baseline levels of knowledge, there were fewer ED visits in the education group (1.56±1.94) compared with the control group (2.05±2.32) (P=0.02) 2 years after the intervention. Although Hispanic and AA caregivers of children with high healthcare utilization were knowledgeable of asthma pathophysiology, and preventive and management steps, they reported being stressed and helpless and were unable to implement the steps at the time of an exacerbation, seeking care at the ED rather than contacting their PCP. The high health utilizers who underwent a targeted educational intervention had fewer ED visits 2 years following the intervention.