Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia

OBJECTIVES

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED.

METHODS

Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy.

RESULTS

A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy.

CONCLUSIONS

Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding

The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric "boarding"). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital's approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.

Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems

OBJECTIVES

Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.

METHODS

As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.

RESULTS

Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.

CONCLUSIONS

The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty

PURPOSE

Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery.

METHODS

This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification.

FINDINGS

Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects.

CONCLUSIONS

Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.

Clinician-Spoken Plain Language in Health Care Encounters: A Qualitative Analysis to Assess Measurable Elements

PURPOSE

Good communication and use of plain language in health care encounters improves outcomes, including emotional health, symptom resolution, and functional status. Yet there is limited research on how to measure and report spoken plain language, which is the use of familiar, clear language. The authors aimed to describe key, measurable elements of spoken plain language that can be assessed and reported back to clinicians for self-reflection.

METHOD

The authors conducted secondary analysis of transcripts from recorded encounters between breast cancer surgeons and patients with early-stage breast cancer. Two coders used a hybrid qualitative analysis with a framework based on US Federal Plain Language Guidelines. To develop major themes, they examined (1) alignment with the Guidelines and (2) code frequencies within and across transcripts. They also noted minor themes.

RESULTS

From 74 transcripts featuring 13 surgeons, the authors identified two major themes representing measurable elements of spoken plain language: (1) clinicians had a propensity to use both explained and unexplained medical terms, and (2) clinicians delivered information using either short turns (one unit of someone speaking) with one topic or long turns with multiple topics. There were three minor themes that were not indicative of whether or not clinicians used spoken plain language. First, clinicians regularly used absolute risk communication techniques. Second, question-asking techniques varied and included open-ended, close-ended, and comprehension checks. Third, some clinicians used imagery to describe complex topics.

CONCLUSIONS

Clinicians' propensity to use medical terms with and without explanation and parse encounters into shorter or longer turns are measurable elements of spoken plain language. These findings will support further research on the development of a tool that can be used in medical education and other settings. This tool could provide direct and specific feedback to improve the plain language practices of clinicians in training and beyond.

Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020-2040

Pediatric hospital medicine (PHM) established a new model of care for hospitalized children in the United States nearly 3 decades ago. In that time, the field experienced rapid growth while distinguishing itself through contributions to medical education, quality improvement, clinical and health services research, patient safety, and health system leadership. Hospital systems have also invested in using in-house pediatricians to manage various inpatient care settings as patient acuity has accelerated. National PHM leaders advocated for board certification in 2014, and the first certification examination was administered by the American Board of Pediatrics in 2019. In this article, we describe the development of the subspecialty, including evolving definitions and responsibilities of pediatric hospitalists. Although PHM was not included in the model forecasting future pediatric subspecialties through 2040 in this supplement because of limited historical data, in this article, we consider the current and future states of the workforce in relation to children's health needs. Expected challenges include potential alterations to residency curriculum, changes in the number of fellowship positions, expanding professional roles, concerns related to job sustainability and burnout, and closures of pediatric inpatient units in community hospitals. We simultaneously forecast growing demand in the PHM workforce arising from the increasing prevalence of children with medical complexity and increasing comanagement of hospitalized children between pediatric hospitalists and other subspecialists. As such, our forecast incorporates a degree of uncertainty and points to the need for ongoing investments in future research to monitor and evaluate the size, scope, and needs of pediatric hospitalists and the PHM workforce.

Pediatric Hospitalization Trends at Children's and General Hospitals, 2000-2019

This study examines whether pediatric inpatient care has been redistributed from general hospitals into children’s hospitals.

Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity

OBJECTIVE

Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality.

METHODS

In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider.

RESULTS

Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS.

CONCLUSIONS

Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.

Association Between Educational Resources and Pediatric Fellows' Mental Health Attitudes and Self-Reported Competence

BACKGROUND/OBJECTIVES

Children with chronic medical conditions (CCMC) have high rates of mental health (MH) conditions. This study examines associations between MH educational resources during fellowship and 3 dependent variables: fellows' interest, perceived responsibility, and self-reported competence in assessing MH concerns of CCMC.

METHODS

Subspecialty fellows taking the American Board of Pediatrics in-training examinations in February 2020 were invited to participate in a survey inquiring about MH educational resources. Logistic regression examined associations between MH educational resources and the 3 dependent variables, adjusting for demographics and program-level characteristics.

RESULTS

Of the 97.7% (4216) fellows who responded, 3870 were included in analyses. About 37.5% reported formal MH teaching sessions; 36.7% reported on-site MH professionals engaged in teaching; 41.6% reported co-assessing patients with MH specialists; and 28.3% reported performance evaluation of their MH skills. All 4 resources were significantly and positively associated with self-reported competence in adjusted analyses, with odds ratios (OR) ranging from 1.28 (95% confidence interval (95% CI): 1.03-1.58) for formal teaching sessions to 2.14 (95% CI: 1.73-2.65) for performance evaluation. Resources were positively associated with the dependent variables in a "dose-response" pattern. Respondents who reported having all 4 educational resources compared to zero resources had an OR of 2.20 (95% CI: 1.74-2.78) for high MH interest, 3.18 (95% CI: 2.45-4.12) for high perceived responsibility, and 4.38 (95% CI: 3.43-5.60) for high self-reported competence CONCLUSIONS: Access to mental health educational resources was associated with higher interest, perceived responsibility, and self-reported competence; investing in these resources may improve fellows' skills in addressing the emotional needs of CCMC.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update

BACKGROUND

General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals.

OBJECTIVE

Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings.

DESIGNS, SETTING, AND PARTICIPANTS

This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays.

INTERVENTION

Not applicable.

MAIN OUTCOME AND MEASURES

Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates.

RESULTS

There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

Importance

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood.

Objective

To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity.

Design, Setting, and Participants

This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023.

Exposures

Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals.

Main Outcomes and Measures

The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009.

Results

The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year.

Conclusions and Relevance

Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure

BACKGROUND

Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience.

METHODS

Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated.

RESULTS

The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery.

CONCLUSIONS

A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.

The association of regional perinatal risk factors and neonatal intensive care capacity for Military Health System-insured newborns

OBJECTIVE

To characterize hospitals where military-insured newborns received care and test the association of regional perinatal risk with neonatal intensive care unit (NICU) capacity.

STUDY DESIGN

We identified birth hospitals for live newborns October 2015-December 2018 (n = 296,568) and assigned newborns to health service areas (HSAs). Perinatal risk factors and the number of neonatal special care beds and neonatologists were calculated at HSA levels. Cross-sectional correlation analyses assessed perinatal risk factors and capacity across HSAs.

RESULTS

27.0% (n = 10) of military birth hospitals had special care beds (intermediate and intensive) compared with 44.3% of civilian hospitals (n = 1224; p < 0.05). The number of special care beds and neonatologists per newborn varied more than twofold across regions and were only weakly associated with the proportion of higher risk newborns (R2 < 0.05).

CONCLUSIONS

The lack of meaningful association of regional perinatal risk with NICU capacity poses challenges for effective specialized care among military-associated newborns.

Urban-rural disparities in interfacility transfers for children during COVID-19

PURPOSE

We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling.

FINDINGS

Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168.

CONCLUSIONS

Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.

Characterization of Birth Hospitalizations in the United States

OBJECTIVES

A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations.

METHODS

We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression).

RESULTS

In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million).

CONCLUSIONS

Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Importance

Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.

Objectives

To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals.

Design, Setting, and Participants

Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.

Exposures

Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.

Main Outcomes and Measures

Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals.

Results

Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations.

Conclusions and Relevance

Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding

PURPOSE

Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE.

METHODS

A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically.

RESULTS

Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers.

DISCUSSION

I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.

Direct Admission to Hospital for Children in the United States

One in four unscheduled hospital admissions for children and adolescents in the United States occurs via direct admission, defined as hospital admission without first receiving care in the hospital's emergency department. The purpose of this policy statement is to present recommendations to optimize the quality and safety of this hospital admission approach for children. Recommendations included in this policy statement provide guidance related to: (i) direct admission written guidelines, (ii) clear systems of communication between members of the health care team and with families of children requiring admission, (iii) triage systems to identify patient acuity and disease severity, (iv) identification of hospital resources needed to support direct admission systems of care, (v) consideration of patient populations that may be at increased risk of adverse outcomes during the hospital admission process, (vi) addressing the relevance of local factors and resources, and (vii) ongoing evaluation of direct admission processes and outcomes. The recommendations included in this policy statement are intended to support the implementation of safe direct admission processes and to foster awareness of outcomes associated with this common portal of hospital admission.

Hospitalists' Perceptions of Pediatric Mental Health Boarding: Quality of Care and Moral Distress

BACKGROUND

Acute care hospitals increasingly provide care for youth experiencing mental health crises while they await transfer for psychiatric hospitalization. To inform quality improvement efforts, we aimed to characterize hospitalists' perceptions of health care quality during pediatric mental health boarding and their experiences of moral distress in caring for this population.

METHODS

In March 2021, we conducted a web-based survey of hospitalists who participate in the Pediatric Research in Inpatient Settings (PRIS) network. Closed- and open-ended questions queried the quality of care provided to youth during boarding and clinician experience of moral distress in caring for these youth. We iteratively coded qualitative data for emergent themes. Moral distress was measured using 11 items from the Measure of Moral Distress for Health Care Professionals (MMD-HP), which categorizes sources of moral distress into system-, team-, and patient-level factors.

RESULTS

Eighty-eight of 111 PRIS site leaders (79%) and 76 of 383 other PRIS members (20%) responded, representing 12 community hospitals, 38 freestanding children's hospitals, and 35 children's hospitals in adult centers. Emergent themes related to health care quality included the following: access to psychiatric services; safety; standardized workflows; clinician training; compassion/patient engagement; and collaboration and disposition planning. Hospitals often lacked desired resources, resulting in poor perceived therapeutic value of care, limited patient engagement, and provider moral distress. Four of the 5 highest MMD-HP item scores were related to system-level factors.

CONCLUSION

Hospitalists identified several foci for quality improvement and described significant moral distress in caring for youth experiencing boarding, particularly related to health system factors.

Multistakeholder Perspectives on Interventions to Support Youth During Mental Health Boarding

OBJECTIVE

To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care.

STUDY DESIGN

This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method.

RESULTS

Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important.

CONCLUSIONS

Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts.

Collaborative to Increase Lethal Means Counseling for Caregivers of Youth With Suicidality

BACKGROUND

The number of youth presenting to hospitals with suicidality and/or self-harm has increased substantially in recent years. We implemented a multihospital quality improvement (QI) collaborative from February 1, 2018 to January 31, 2019, aiming for an absolute increase in hospitals' mean rate of caregiver lethal means counseling (LMC) of 10 percentage points (from a baseline mean performance of 68% to 78%) by the end of the collaborative, and to evaluate the effectiveness of the collaborative on LMC, adjusting for secular trends.

METHODS

This 8 hospital collaborative used a structured process of alternating learning sessions and action periods to improve LMC across hospitals. Electronic medical record documentation of caregiver LMC was evaluated during 3 phases: precollaborative, active QI collaborative, and postcollaborative. We used statistical process control to evaluate changes in LMC monthly. Following collaborative completion, interrupted time series analyses were used to evaluate changes in the level and trend and slope of LMC, adjusting for covariates.

RESULTS

In the study, 4208 children and adolescents were included-1314 (31.2%) precollaborative, 1335 (31.7%) during the active QI collaborative, and 1559 (37.0%) postcollaborative. Statistical process control analyses demonstrated that LMC increased from a hospital-level mean of 68% precollaborative to 75% (February 2018) and then 86% (October 2018) during the collaborative. In interrupted time series analyses, there were no significant differences in LMC during and following the collaborative beyond those expected based on pre-collaborative trends.

CONCLUSIONS

LMC increased during the collaborative, but the increase did not exceed expected trends. Interventions developed by participating hospitals may be beneficial to others aiming to improve LMC for caregivers of hospitalized youth with suicidality.

Preparedness of Pediatric Subspecialty Fellows to Address Emotional and Mental Health Needs Among Children With Chronic Medical Conditions

This survey study investigates pediatric subspecialty fellows’ attitudes about and perceived competence in addressing emotional and mental health needs of pediatric patients with chronic medical conditions.

Healthcare quality during pediatric mental health boarding: A qualitative analysis

BACKGROUND

Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period.

OBJECTIVE

This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts.

DESIGN, SETTING, & PARTICIPANTS

We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development.

RESULTS

Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress.

CONCLUSION

This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population.

Suicide and Self-Harm in Youth Presenting to a US Rural Hospital During COVID-19

OBJECTIVE

Rural-residing children in the United States experience higher suicide mortality than urban-residing children but are underrepresented in research. We examined changes in emergency department (ED) utilization and subsequent hospitalization for suicide or self-harm in a rural hospital after the coronavirus disease 2019 pandemic onset.

METHODS

This retrospective cohort study involved children aged 5 to 17 years visiting a rural, Northeastern hospital from January 1, 2017 to May 31, 2021. We used autoregressive integrated moving average modeling, an interrupted time series analysis, to examine monthly changes after the pandemic onset (March 2020) in ED visits with a primary mental health diagnosis, number of mental health visits with a suicide or self-harm diagnosis, proportion of patients with suicide or self-harm admitted to hospital, and length of stay for suicide or self-harm.

RESULTS

Prepandemic, there was an average of 20.6 visits per month for mental health conditions, with 23.3 visits per month postpandemic (P = .16). Monthly visits for suicide or self-harm were greater in the postpandemic (15.6 visits per month) versus prepandemic months (11.4 visits per month, P < .01). In autoregressive integrated moving average modeling, pandemic onset related to an additional 0.83 (95% confidence interval: 0.31 to 1.36) primary mental health visits with suicide or self-harm diagnoses per month. Of these visits, there was an immediate, absolute increase of 39.6% (95% confidence interval: 26.0% to 53.1%) in the proportion resulting in admission; admission rates declined in subsequent months. Pandemic onset was not associated with significant changes in the number of visits for mental health conditions or length of stay.

CONCLUSIONS

Pediatric ED visits for suicide or self-harm increased at a significant rate during the coronavirus disease 2019 pandemic and a greater proportion resulted in hospitalization, highlighting the acute mental health needs of rural-residing children.

Association of Behavioral and Mental Health Professionals in Continuity Clinic with Resident-Reported Competence

OBJECTIVE

To assess whether residents who trained with a colocated or integrated behavioral/mental health professional (B/MHP) reported greater competence in the assessment and management of behavioral/mental health (B/MH) conditions than those who trained without an onsite B/MHP. We hypothesized that having an onsite B/MHP would be associated with greater self-reported competence, especially if integrated into clinic.

STUDY DESIGN

Cross-sectional survey of applicants for the initial American Board of Pediatrics (ABP) certifying examination. The independent variable was training in a continuity clinic with no onsite B/MHP, a colocated B/MHP, or an integrated B/MHP. Outcome variables were self-reported competence in 7 B/MH assessment skills and 9 treatment skills, summarized as 2 composite measures. Competence was rated on a 5-point scale; high competence was defined as mean scores ≥4. Logistic regression assessed relationships between independent and outcome variables adjusting for covariates including individual and residency program characteristics.

RESULTS

Of 1503 eligible respondents, 645 (42.9%) reported no onsite B/MHP, 390 (26.0%) a colocated B/MHP, and 468 (31.1%) an integrated B/MHP. In multivariable models, respondents with a colocated B/MHP reported greater levels of B/MH assessment competence (aOR 1.40, 95% CI1.06-1.86) and treatment competence (aOR 1.45, 95% CI 1.03-2.05) compared with those with no B/MHP. Respondents with an integrated B/MHP similarly reported greater odds of assessment (aOR 1.33, 95%CI 1.02-1.74) and treatment competence (aOR 1.53, 95% CI 1.10-2.13) than the reference group.

CONCLUSIONS

Although specific mechanisms were not tested, training with an onsite B/MHP within a continuity clinic may improve pediatric trainees' competence for addressing B/MH conditions.

Prevalence of Children With Medical Complexity and Associations With Health Care Utilization and In-Hospital Mortality

Importance

Children with medical complexity (CMC) have substantial health care needs and frequently experience poor health care quality. Understanding the population prevalence and associated health care needs can inform clinical and public health initiatives.

Objective

To estimate the prevalence of CMC using open-source pediatric algorithms, evaluate performance of these algorithms in predicting health care utilization and in-hospital mortality, and identify associations between medical complexity as defined by these algorithms and clinical outcomes.

Design, Setting, and Participants

This retrospective cohort study used all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 through 2017. Children and adolescents younger than 18 years residing in these states were included if they had 12 months or longer of enrollment in a participating health care plan. Analyses were conducted from March 12, 2021, to January 7, 2022.

Exposures

The pediatric Complex Chronic Condition Classification System, Pediatric Medical Complexity Algorithm, and Children With Disabilities Algorithm were applied to 3 years of data to identify children with complex and disabling conditions, first in their original form and then using more conservative criteria that required multiple health care claims or involvement of 3 or more body systems.

Main Outcomes and Measures

Primary outcomes, examined over 2 years, included in-hospital mortality and a composite measure of health care services, including specialized therapies, specialized medical equipment, and inpatient care. Outcomes were modeled using logistic regression. Model performance was evaluated using C statistics, sensitivity, and specificity.

Results

Of 1 936 957 children, 48.4% were female, 87.8% resided in urban core areas, and 45.1% had government-sponsored insurance as their only primary payer. Depending on the algorithm and coding criteria applied, 0.67% to 11.44% were identified as CMC. All 3 algorithms had adequate discriminative ability, sensitivity, and specificity to predict in-hospital mortality and composite health care services (C statistic = 0.76 [95% CI, 0.73-0.80] to 0.81 [95% CI, 0.78-0.84] for mortality and 0.77 [95% CI, 0.76-0.77] to 0.80 [95% CI, 0.79-0.80] for composite health care services). Across algorithms, CMC had significantly greater odds of mortality (adjusted odds ratio [aOR], 9.97; 95% CI, 7.70-12.89; to aOR, 69.35; 95% CI, 52.52-91.57) and composite health care services (aOR, 4.59; 95% CI, 4.44-4.73; to aOR, 18.87; 95% CI, 17.87-19.93) than children not identified as CMC.

Conclusions and Relevance

In this study, open-source algorithms identified different cohorts of CMC in terms of prevalence and magnitude of risk, but all predicted increased health care utilization and in-hospital mortality. These results can inform research, programs, and policies for CMC.

Psychotropic Polypharmacy and Antipsychotics in Children: A Survey of Caregiver's Perspectives

OBJECTIVE

We examined caregiver's knowledge, attitudes, and concerns about their child's psychotropic medication regimen and the potential side effects, describe how they seek information regarding treatment, and ascertain their perspectives toward deprescribing.

METHODS

We surveyed 48 caregivers of children 6-17 years old treated with two or more psychotropic medications or an antipsychotic medication, analyzing outcomes using descriptive statistics.

RESULTS

Almost all (N = 44, 92%) participants reported feeling very knowledgeable about why medications were prescribed, but only one-third (N = 16, 33%) reported feeling very knowledgeable about potential problems with long-term use or polypharmacy. Half of respondents (N = 24, 50%) reported asking their provider about reducing/stopping medications due to concerns about harmful effects, and nearly half (N = 20, 42%) reported stopping medications earlier than recommended.

CONCLUSIONS

Interventions to engage caregivers in shared decision-making about complex medication regimens and to support prescribers to safely deprescribe psychotropic medications are needed to address caregivers' concerns regarding psychotropic medication use.

Understanding trust between pediatric hospitalists and outpatient clinicians during hospital admissions: A multisite qualitative analysis

BACKGROUND

During transitions between sites of care, clinicians must build trust with colleagues to make decisions that ensure safe, high-quality care.

OBJECTIVES

This study explored factors that could influence trust between outpatient clinicians and pediatric hospitalists when children are referred for hospital admission.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an analysis of 41 semistructured interviews with outpatient clinicians and pediatric hospitalists from May 2020 through October 2021 across three healthcare systems participating in a multisite comparative effectiveness study of pediatric direct and emergency department admissions.

INTERVENTION, MAIN OUTCOMES, AND MEASURES

Qualitative interviews. A conceptual model for trust between outpatient clinicians and pediatric hospitalists during hospital admission referral. Interviews were professionally transcribed, verified for accuracy, and analyzed using a combination of inductive and deductive.

RESULTS

We identified two primary domains: (1) interpersonal trust and (2) trust-by-proxy. Interpersonal trust included five relational factors that influenced collaboration between clinicians: antecedent relationships, confidence in others clinical abilities, understanding others' practice culture, recognition of available resources, and power dynamic. An individual clinicians' assessment of risk and past clinical experiences also influenced trust during clinical decision-making. Trust-by-proxy represented system-level factors that could influence trust, independent of any pre-existing relationships, including communication infrastructure, guidelines and protocols, the organizational culture, and professional courtesy.

CONCLUSION

Interpersonal and system-level factors influence trust between outpatient clinicians and hospitalists during decision-making encounters. System-level factors may serve as a proxy for trust when clinicians do not have pre-existing interpersonal relationships. These factors could be explored as an explicit target of interventions to improve interdisciplinary collaboration and decision-making between hospitalists and primary care clinicians.

Common Diagnoses and Costs in Pediatric Hospitalization in the US

This cross-sectional study ranks the prevalent diagnoses among hospitalized children and related costs by hospital type.

Frequency and Duration of Boarding for Pediatric Mental Health Conditions at Acute Care Hospitals in the US

This study estimates the frequency and duration of boarding for pediatric mental health conditions at US acute care hospitals and describes hospital resources available to support youths during boarding.

Responsibilities and Interests of Pediatricians Practicing Hospital Medicine in the United States

BACKGROUND AND OBJECTIVES

In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests.

METHODS

Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification.

RESULTS

The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68).

CONCLUSIONS

Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

A Systematic Review and Meta-Analysis of Patient Decision Aids for Socially Disadvantaged Populations: Update from the International Patient Decision Aid Standards (IPDAS)

BACKGROUND

The effectiveness of patient decision aids (PtDAs) and other shared decision-making (SDM) interventions for socially disadvantaged populations has not been well studied.

PURPOSE

To assess whether PtDAs and other SDM interventions improve outcomes or decrease health inequalities among socially disadvantaged populations and determine the critical features of successful interventions.

DATA SOURCES

MEDLINE, CINAHL, Cochrane, PsycINFO, and Web of Science from inception to October 2019. Cochrane systematic reviews on PtDAs.

STUDY SELECTION

Randomized controlled trials of PtDAs and SDM interventions that included socially disadvantaged populations.

DATA EXTRACTION

Independent double data extraction using a standardized form and the Template for Intervention Description and Replication checklist.

DATA SYNTHESIS

Twenty-five PtDA and 13 other SDM intervention trials met our inclusion criteria. Compared with usual care, PtDAs improved knowledge (mean difference = 13.91, 95% confidence interval [CI] 9.01, 18.82 [I2 = 96%]) and patient-clinician communication (relative risk = 1.62, 95% CI 1.42, 1.84 [I2 = 0%]). PtDAs reduced decisional conflict (mean difference = -9.59; 95% CI -18.94, -0.24 [I2 = 84%]) and the proportion undecided (relative risk = 0.39; 95% CI 0.28, 0.53 [I2 = 75%]). PtDAs did not affect anxiety (standardized mean difference = 0.02, 95% CI -0.22, 0.26 [I2 = 70%]). Only 1 trial looked at clinical outcomes (hemoglobin A1C). Five of the 12 PtDA studies that compared outcomes by disadvantaged standing found that outcomes improved more for socially disadvantaged participants. No evidence indicated which intervention characteristics were most effective. Results were similar for SDM intervention trials.

LIMITATIONS

Sixteen PtDA studies had an overall unclear risk of bias. Heterogeneity was high for most outcomes. Most studies only had short-term follow-up.

CONCLUSIONS

PtDAs led to better outcomes among socially disadvantaged populations but did not reduce health inequalities. We could not determine which intervention features were most effective.[Box: see text].

Where Do Future Pediatricians Learn Behavioral and Mental Health Skills?

OBJECTIVE

This national study identified the rotations in which pediatric residents received training in the assessment and treatment of behavioral/mental health (B/MH) problems, and examined associations between learning B/MH skills during multiple clinical rotations and resident-reported interest in B/MH issues.

METHODS

Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam (62.4% response rate; 1555 eligible respondents). Respondents reported their overall interest in B/MH issues, and specified where they had received training in 7 B.M. assessment skills and 8 treatment skills. Logistic regression models were estimated to identify associations between learning B/MH assessment and treatment skills in multiple clinical rotations and resident-reported B/MH interest, adjusting for respondent characteristics.

RESULTS

Respondents reported continuity clinic as the predominant site of B/MH learning, followed by development-behavioral and adolescent rotations. Multisite learning varied across B/MH skills, ranging from 45.1 % (n = 678) for using rating scales to titrate medications to 82.1% (n = 1234) for eliciting parent concerns. 946 (63.2%) reported having overall interest in B/MH issues. Adjusting for respondent characteristics, learning the majority of B/MH skills in >1 rotation was associated with an increased odds of B/MH interest for both assessment and treatment domains (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI] 1.16-1.83 for assessment skills and aOR = 1.36, 95% CI 1.09-1.69 for treatment skills).

CONCLUSIONS

The majority of residents report learning B/MH skills in continuity clinic, with substantial variation in the proportion learning these skills in more than one rotation. Teaching B/MH skills during multiple clinical rotations may enhance resident interest in B/MH care delivery for children.

Infant Mortality Associated With Prenatal Opioid Exposure

IMPORTANCE

Knowledge of health outcomes among opioid-exposed infants is limited, particularly for those not diagnosed with neonatal opioid withdrawal syndrome (NOWS).

OBJECTIVES

To describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of NOWS compared with infants without opioid exposure.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of maternal-infant dyads was conducted, linking health care claims with vital records for births from January 1, 2010, to December 31, 2014, with follow-up of infants until age 1 year (through 2015). Maternal-infant dyads were included if the infant was born in Texas at 22 to 43 weeks' gestational age to a woman aged 15 to 44 years insured by Texas Medicaid. Data analysis was performed from May 2019 to October 2020.

EXPOSURE

The primary exposure was prenatal opioid exposure, with infants stratified by the presence or absence of a diagnosis of NOWS during the birth hospitalization.

MAIN OUTCOMES AND MEASURES

Risk of infant mortality (death at age <365 days) was examined using Kaplan-Meier and log-rank tests. A series of logistic regression models was estimated to determine associations between prenatal opioid exposure and mortality, adjusting for maternal and neonatal characteristics and clustering infants at the maternal level to account for statistical dependence owing to multiple births during the study period.

RESULTS

Among 1 129 032 maternal-infant dyads, 7207 had prenatal opioid exposure, including 4238 diagnosed with NOWS (mean [SD] birth weight, 2851 [624] g) and 2969 not diagnosed with NOWS (mean [SD] birth weight, 2971 [639] g). Infant mortality was 20 per 1000 live births for opioid-exposed infants not diagnosed with NOWS, 11 per 1000 live births for infants with NOWS, and 6 per 1000 live births in the reference group (P < .001). After adjusting for maternal and neonatal characteristics, mortality in infants with a NOWS diagnosis was not significantly different from the reference population (odds ratio, 0.82; 95% CI, 0.58-1.14). In contrast, the odds of mortality in opioid-exposed infants not diagnosed with NOWS was 72% greater than the reference population (odds ratio, 1.72; 95% CI, 1.25-2.37).

CONCLUSIONS AND RELEVANCE

In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.

Comparative effectiveness of direct admission and admission through emergency departments for children: a randomized stepped wedge study protocol

BACKGROUND

Approximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital's ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.

METHODS/DESIGN

We will conduct a stepped wedge cluster randomized controlled trial at 3 structurally and geographically diverse hospitals. A total of 70 primary and urgent care practice sites in the hospitals' catchment areas will be randomized to a time point when they will begin participation in the multi-stakeholder informed direct admission program. This crossover will be unidirectional and occur at 4 time points, 6 months apart, over a 24-month implementation period. Our primary outcome will be the timeliness of clinical care provision. Secondary outcomes include (i) parent-reported experience of care, (ii) unanticipated transfer to the intensive care unit within 6 h of hospital admission, and (iii) rapid response calls within 6 h of hospital admission. We anticipate that 190 children and adolescents will be directly admitted, with 1506 admitted through EDs. Analyses will compare the effectiveness of direct admission to admission through the ED and will evaluate the causal effect of implementing a direct admission program using linear regression with random effects for referring practice clusters and time period fixed effects. We will further examine the heterogeneity of treatment effects based on hypotheses specified a priori. In addition, we will conduct a mixed-methods process evaluation to assess reach, effectiveness, adoption, implementation, and maintenance of our direct admission intervention.

DISCUSSION

Our study represents the first randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients. Our scientific approach, pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04192799 . Registered on December 10, 2019).

Pediatric Mental Health Boarding

CONTEXT

The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care.

OBJECTIVE

To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors.

DATA SOURCES

Medline and PsycINFO.

STUDY SELECTION

All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age.

DATA EXTRACTION

Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality.

RESULTS

Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children's hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely.

LIMITATIONS

Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented.

CONCLUSIONS

Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

International Experience of US Pediatricians and Level of Comfort Caring for Immigrant Children and Children Traveling Internationally

OBJECTIVE

To determine whether international experience is associated with greater comfort in providing care to US children who are immigrants, refugees, and traveling internationally.

STUDY DESIGN

Following enrollment into the 2018 American Board of Pediatrics Maintenance of Certification program, general pediatricians and subspecialists received a voluntary, online survey with questions about their experience and self-reported comfort caring for immigrant, refugee, and internationally traveling children and previous international experiences. Using multivariable logistic regression, we examined how previous international experiences, and other personal characteristics, were associated with self-reported comfort.

RESULTS

A total of 5461 eligible participants completed the survey; 76.3%, (n = 4168) reported caring for immigrant children, 35.8% (n = 1957) cared for refugee children, and 79.8% (n = 4358) cared for children traveling internationally. High levels of comfort caring for immigrant children were reported by 68.5% (n = 3739), for refugee children by 50.1% (n = 2738), and for children traveling internationally by 72.7% (n = 3968). One-third of respondents (34.1%, n = 1866) reported past international experiences. In multivariable analysis, respondents with previous international experience and of Hispanic origin were significantly more likely to report high levels of comfort caring for all 3 populations.

CONCLUSIONS

The majority of pediatricians report caring for children in the US who are immigrants, refugees, and traveling internationally, and previous international experience was associated with greater comfort with care. Training programs and professional organizations should consider ways to encourage a more diverse workforce and to support all pediatricians in achieving the skills and confidence required to care for children in our highly mobilized society.

Competency of Future Pediatricians Caring for Children With Behavioral and Mental Health Problems

BACKGROUND AND OBJECTIVES

There is an urgent need to prepare pediatricians to care for children with behavioral and mental health (B/MH) conditions. In this study, we evaluate the perceived competence of pediatric residents and recent graduates in the assessment and treatment of B/MH conditions, characterize variation in competence across residency programs, and identify program characteristics associated with high competence.

METHODS

Cross-sectional survey of applicants for the initial certifying examination in pediatrics. Questions were focused on (1) who should be competent in B/MH skills, (2) institutional support around B/MH training, and (3) perceived competence in 7 B/MH assessment skills and 9 treatment skills. Competence was rated on a 5-point scale, and high levels of assessment and treatment competence were defined as scores of ≥4. Composite measures for B/MH assessment and treatment were calculated as mean scores for each domain. We examined variation in residents' self-reported competence across programs and used linear regression to identify factors associated with high levels of competence at the program level.

RESULTS

Of applicants, 62.3% responded to the survey (n = 2086). Of these, 32.8% (n = 595) reported high competence in assessment skills and 18.9% (n = 337) in treatment skills. There were large variations in reported competence across programs. Respondents from smaller programs (<30 trainees) reported higher competence in assessment and treatment than those from large programs (P < .001).

CONCLUSIONS

Current and recent pediatric trainees do not report high levels of perceived competence in the assessment and treatment of children with B/MH conditions. The substantial variation across programs indicates that the pediatric community should create standards for B/MH training.

Factors Influencing Career Longevity in Pediatric Hospital Medicine

BACKGROUND AND OBJECTIVES

Pediatric hospital medicine (PHM) is a growing field recently approved by the American Board of Pediatrics as a subspecialty. Understanding factors associated with hospitalist retention is important for workforce planning. Our objective for this study was to examine the proportion of pediatric hospitalists who remained in PHM over a 5-year period and identify factors associated with retention.

METHODS

We used 2012 and 2016 data from the American Academy of Pediatrics' Pediatrician Life and Career Experience Study. Retention was defined as being a self-reported hospitalist on both surveys. χ² tests were used to examine relationships between retention and variables within 3 categories: demographics, position-related factors, and factors related to stress and satisfaction. A multivariable logistic regression was used to further assess relationships between select factors and retention.

RESULTS

In 2012, 206 of 1804 survey respondents were hospitalists (11%); 180 of these 206 individuals responded again in 2016, and 122 (68%) remained hospitalists. In the multivariable analysis, individuals earning ≥$175 000 were more likely than those earning less (adjusted odds ratio [aOR] = 3.93; 95% confidence interval [CI]: 1.26-12.25) and those more satisfied with their job were more likely than those less satisfied (aOR = 3.28; 95% CI: 1.22-8.80) to remain hospitalists. Respondents with more concern about educational debt were less likely than those less concerned to remain hospitalists over 5 years (aOR = 0.42; 95% CI: 0.20-0.90).

CONCLUSIONS

Two-thirds of early- to mid-career hospitalists remained in PHM 5 years later. Financial factors and job satisfaction appear to play an important role in retention; consideration should be given to the impact of these factors on the PHM workforce.