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Razzaghi H, Forrest CB, Hirabayashi K, Wu Q, Allen AJ, Rao S, Chen Y, Bunnell HT, Chrischilles EA, Cowell LG, Cummins MR, Hanauer DA, Higginbotham M, Horne BD, Horowitz CR, Jhaveri R, Kim S, Mishkin A, Muszynski JA, Naggie S, Pajor NM, Paranjape A, Schwenk HT, Sills MR, Tedla YG, Williams DA, Bailey LC. Vaccine Effectiveness Against Long COVID in Children. Pediatrics 2024; 153:e2023064446. [PMID: 38225804 PMCID: PMC10979300 DOI: 10.1542/peds.2023-064446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVES Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years. METHODS This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination. RESULTS The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months. CONCLUSIONS This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data.
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Affiliation(s)
- Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics
| | - Kathryn Hirabayashi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Qiong Wu
- Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrea J. Allen
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Yong Chen
- Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - H. Timothy Bunnell
- Biomedical Research Informatics Center, Nemours Children’s Health, Wilmington, Delaware
| | | | - Lindsay G. Cowell
- Peter O’Donnell Jr School of Public Health; Department of Immunology, School of Biomedical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - David A. Hanauer
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Miranda Higginbotham
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin D. Horne
- Intermountain Heart Institute, Intermountain Health, Salt Lake City, Utah
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Susan Kim
- Division of Rheumatology, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California
| | - Aaron Mishkin
- Section of Infectious Diseases, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Susanna Naggie
- Division of Infectious Diseases, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anuradha Paranjape
- Section of Infectious Diseases, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Hayden T. Schwenk
- Division of Pediatric Infectious Diseases, Stanford School of Medicine, Palo Alto, California
| | | | - Yacob G. Tedla
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - L. Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics
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Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse. Child Abuse Negl 2024; 149:106648. [PMID: 38262182 DOI: 10.1016/j.chiabu.2024.106648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
IMPORTANCE Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.
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Affiliation(s)
- Denise C Abdoo
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America.
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Matt Hall
- Children's Hospital Association, United States of America
| | - Daniel M Lindberg
- University of Colorado Anschutz Medical Campus, Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, United States of America
| | - James Anderst
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri- Kansas City School of Medicine, Kansas City, MO, United States of America
| | - Joanne N Wood
- Division of General Pediatrics, PolicyLab and Clinical Futures, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States of America
| | | | - Margaret Tashijan
- University of Colorado School of Medicine, Children's Hospital Colorado, United States of America
| | - Marion R Sills
- University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, United States of America
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Bensken WP, Koroukian SM, McGrath BM, Alberti PM, Cottrell EK, Sills MR. Unwinding of Continuous Medicaid Coverage Among Patients at Community Health Centers. JAMA Health Forum 2024; 5:e234622. [PMID: 38180766 PMCID: PMC10770764 DOI: 10.1001/jamahealthforum.2023.4622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/26/2023] [Indexed: 01/06/2024] Open
Abstract
This retrospective cohort study uses data from the Accelerating Data Value Across a National Community Health Center Network to assess patterns of Medicaid disenrollment during the first 6 months after the end of continuous enrollment.
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Affiliation(s)
- Wyatt P. Bensken
- Department of Research, OCHIN, Portland, Oregon
- Quantitative Sciences Core, OCHIN, Portland, Oregon
- Social Policy Program, OCHIN, Portland, Oregon
- Case Western Reserve University, Cleveland, Ohio
| | | | - Brenda M. McGrath
- Department of Research, OCHIN, Portland, Oregon
- Quantitative Sciences Core, OCHIN, Portland, Oregon
| | - Philip M. Alberti
- AAMC Center for Health Justice, Association of American Medical Colleges, Washington, DC
| | - Erika K. Cottrell
- Department of Research, OCHIN, Portland, Oregon
- Social Policy Program, OCHIN, Portland, Oregon
- Oregon Health and Science University, Portland, Oregon
| | - Marion R. Sills
- Department of Research, OCHIN, Portland, Oregon
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Parikh K, Lopez MA, Hall M, Bettenhausen J, Sills MR, Hoffmann J, Morse R, Shah SS, Noelke C, Kaiser SV. Child Opportunity Index and Rehospitalization for Ambulatory Care Sensitive Conditions at US Children's Hospitals. Hosp Pediatr 2023; 13:1028-1037. [PMID: 37823239 DOI: 10.1542/hpeds.2023-007279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations. METHODS Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions. RESULTS The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75]). CONCLUSIONS Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations.
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Affiliation(s)
- Kavita Parikh
- Division of Hospital Medicine, Children's National Hospital, Washington, DC
| | - Michelle A Lopez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jessica Bettenhausen
- Division of Pediatric Hospital Medicine, Children's Mercy - Kansas City, Kansas City, Missouri University of Missouri - Kansas City, Kansas City, Missouri
| | - Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rustin Morse
- The Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Clemens Noelke
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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Razzaghi H, Forrest CB, Hirabayashi K, Wu Q, Allen A, Rao S, Chen Y, Bunnell HT, Chrischilles EA, Cowell LG, Cummins MR, Hanauer DA, Higginbotham M, Horne BD, Horowitz CR, Jhaveri R, Kim S, Mishkin A, Muszynski JA, Naggie S, Pajor NM, Paranjape A, Schwenk HT, Sills MR, Tedla YG, Williams DA, Bailey C. Vaccine Effectiveness Against Long COVID in Children: A Report from the RECOVER EHR Cohort. medRxiv 2023:2023.09.27.23296100. [PMID: 37808803 PMCID: PMC10557822 DOI: 10.1101/2023.09.27.23296100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Objective Vaccination reduces the risk of acute COVID-19 in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5-17 years. Methods This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record (EHR) Program for visits between vaccine availability, and October 29, 2022. Conditional logistic regression was used to estimate VE against long COVID with matching on age group (5-11, 12-17) and time period and adjustment for sex, ethnicity, health system, comorbidity burden, and pre-exposure health care utilization. We examined both probable (symptom-based) and diagnosed long COVID in the year following vaccination. Results The vaccination rate was 56% in the cohort of 1,037,936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, while diagnosed long COVID was 0.7%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5 - 44.5) against probable long COVID and 41.7% (15.0 - 60.0) against diagnosed long COVID. VE was higher for adolescents 50.3% [36.3 - 61.0]) than children aged 5-11 (23.8% [4.9 - 39.0]). VE was higher at 6 months (61.4% [51.0 - 69.6]) but decreased to 10.6% (-26.8 - 37.0%) at 18-months. Discussion This large retrospective study shows a moderate protective effect of SARS-CoV-2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including EHR sources and prospective data. Article Summary Vaccination against COVID-19 has a protective effect against long COVID in children and adolescents. The effect wanes over time but remains significant at 12 months. What’s Known on This Subject Vaccines reduce the risk and severity of COVID-19 in children. There is evidence for reduced long COVID risk in adults who are vaccinated, but little information about similar effects for children and adolescents, who have distinct forms of long COVID. What This Study Adds Using electronic health records from US health systems, we examined large cohorts of vaccinated and unvaccinated patients <18 years old and show that vaccination against COVID-19 is associated with reduced risk of long COVID for at least 12 months. Contributors’ Statement Drs. Hanieh Razzaghi and Charles Bailey conceptualized and designed the study, supervised analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript.Drs. Christopher Forrest and Yong Chen designed the study and critically reviewed and revised the manuscript.Ms. Kathryn Hirabayashi, Ms. Andrea Allen, and Dr. Qiong Wu conducted analyses, and critically reviewed and revised the manuscript.Drs. Suchitra Rao, H Timothy Bunnell, Elizabeth A. Chrischilles, Lindsay G. Cowell, Mollie R. Cummins, David A. Hanauer, Benjamin D. Horne, Carol R. Horowitz, Ravi Jhaveri, Susan Kim, Aaron Mishkin, Jennifer A. Muszynski, Susanna Nagie, Nathan M. Pajor, Anuradha Paranjape, Hayden T. Schwenk, Marion R. Sills, Yacob G. Tedla, David A. Williams, and Ms. Miranda Higginbotham critically reviewed and revised the manuscript.All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Authorship statement Authorship has been determined according to ICMJE recommendations.
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Ozkaynak M, Amura CR, Sills MR, Topoz I. Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department. J Asthma 2023:1-11. [PMID: 36562525 DOI: 10.1080/02770903.2022.2162412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evaluate a nurse-initiated quality improvement (QI) intervention aimed at enhancing asthma treatment in a pediatric emergency department (ED), utilizing outcomes and workflow. METHODS We evaluated the impact of QI interventions for pediatric patients presenting to the ED with asthma with pre-post analysis. A pediatric asthma score (PAS) of >8 indicated moderate to severe asthma. This secondary analysis of the electronic health record (EHR), evaluated on 1) patient outcomes (time to clinical treatment, ED length of stay [EDLOS], admissions and discharges home), 2) clinical workflow. RESULTS We compared 886 visits occurring between 01/01/2015 and 09/27/2015 (pre-implementation period) with 752 visits between 01/01/2016 and 09/27/2016 (post-implementation). Time to first documentation of PAS was decreased post-intervention (p<.001) by >30 min (75 ± 57 to 39 ± 54 min). There were significant decreases in time to treatment with both steroid and bronchodilator administration (both p<.001). EDLOS did not significantly change. Based on acuity level, those discharged home from the ED with high acuity (PAS score ≥8), had a significant decrease in time to initial PAS, steroid and bronchodilator use and EDLOS. Of those with high acuity who were admitted to the hospital, there was a difference pre- to post-implementation, in time to first PAS (p<.05), but not to treatment. Workflow visualization provided additional insights and detailed (task level) comparisons of the timing of ED activities. CONCLUSIONS Nurse-initiated ED interventions, can significantly improve the timeliness of pediatric asthma evaluation and treatment. Examining workflow along with the outcomes, can better inform QI evaluations and clinical management.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Claudia R Amura
- College of Nursing, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Marion R Sills
- School of Medicine, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Irina Topoz
- School of Medicine, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
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Wells JM, Rodean J, Cook L, Sills MR, Neuman MI, Kornblith AE, Jain S, Hirsch AW, Goyal MK, Fleegler EW, DeLaroche AM, Aronson PL, Leonard JC. Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19. Pediatrics 2022; 150:188520. [PMID: 35836331 DOI: 10.1542/peds.2021-054545] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods. RESULTS Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%). CONCLUSIONS Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.
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Affiliation(s)
- Jordee M Wells
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Lawrence Cook
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Marion R Sills
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron E Kornblith
- Departments of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, California
| | - Shobhit Jain
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, District of Columbia
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy M DeLaroche
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Kaiser SV, Hall M, Bettenhausen JL, Sills MR, Hoffmann JA, Noelke C, Morse RB, Lopez MA, Parikh K. Neighborhood Child Opportunity and Emergency Department Utilization. Pediatrics 2022; 150:189362. [PMID: 36052604 DOI: 10.1542/peds.2021-056098] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED The Child Opportunity Index measures the structural neighborhood context that may influence a child's healthy development. We examined relationships between the Child Opportunity Index and emergency department utilization. BACKGROUND AND OBJECTIVES The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample. METHODS This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission. RESULTS We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]). CONCLUSIONS Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California.,Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | | | - Jessica L Bettenhausen
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Clemens Noelke
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Rustin B Morse
- Nationwide Children's Hospital, Center for Clinical Excellence, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, College of Medicine, Columbus, OH
| | - Michelle A Lopez
- Department of Pediatrics.,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Kavita Parikh
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
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Fritz CQ, Fleegler EW, DeSouza H, Richardson T, Kaiser SV, Sills MR, Cooper JN, Parikh K, Puls HT, DeLaroche AM, Hogan AH, Pantell MS, Kornblith AE, Heller KR, Bigham MT, Goyal M. Child Opportunity Index and Changes in Pediatric Acute Care Utilization in the COVID-19 Pandemic. Pediatrics 2022; 149:185223. [PMID: 35233618 DOI: 10.1542/peds.2021-053706] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Pediatric acute care utilization decreased dramatically during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between the Child Opportunity Index (COI), a multidimensional neighborhood measure of childhood opportunity, and changes in acute care utilization at US pediatric hospitals during the COVID-19 pandemic compared with the previous 3 years. METHODS This observational study used administrative data across 41 US-based pediatric hospitals. Children aged 0 to 17 years with emergency department (ED) encounters during the study period were included. The COVID-19 pandemic time period (March 15, 2020-March 14, 2021) was the primary exposure. The primary outcome was the relative volume drop in ED encounters and observation/inpatient admissions through the ED by COI quintile. RESULTS Of 12 138 750 encounters, 3 705 320 (30.5%) were among the very low COI quintile. Overall, there was a 46.8% relative volume reduction in the pandemic period compared with the prepandmic period. This drop in volume occurred disproportionately among the very low COI quintile (51.1%) compared with the very high COI quintile (42.8%). The majority of clinical diagnosis groups demonstrated larger relative volume drops among the very low COI quintile. CONCLUSIONS Acute care utilization decreased the most among children from very low COI neighborhoods, narrowing previously described acute care utilization disparities. Additional study of patient perspectives on health care needs and access during this period is required to understand these changes.
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Affiliation(s)
- Cristin Q Fritz
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric W Fleegler
- Department of Pediatrics, Boston Children's Hospitaland Harvard Medical School, Boston, Massachusetts
| | | | | | - Sunitha V Kaiser
- Departments of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, California.,Philip R. Lee Institute of Health Policy Studies, San Francisco, California
| | - Marion R Sills
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | | | - Kavita Parikh
- Department of Pediatrics, Children's National Hospitaland The George Washington University, Washington, District of Columbia
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Alex H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Matthew S Pantell
- Department of Pediatric Hospital Medicine, University of California, San Francisco, California
| | - Aaron E Kornblith
- Division of Emergency Medicine, Department of Pediatrics, University of California, San Francisco, California
| | - Kayla R Heller
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael T Bigham
- Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Monika Goyal
- Department of Pediatrics, Children's National Hospitaland The George Washington University, Washington, District of Columbia
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10
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Parikh K, Hall M, Kaiser SV, Hogan AH, Bettenhausen JL, Lopez MA, Sills MR. Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma. J Pediatr 2021; 238:290-295.e1. [PMID: 34284032 DOI: 10.1016/j.jpeds.2021.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept. STUDY DESIGN This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18 years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range = 0-100) when there was statistical evidence that the percentages were different. RESULTS Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P = .46). CONCLUSIONS The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.
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Affiliation(s)
- Kavita Parikh
- Division of Hospital Medicine, Children's National Hospital and George Washington University School of Medicine, Washington, DC.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, CA; Department of Clinical Epidemiology and Biostatistics, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, San Francisco, CA
| | - Alexander H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, CT; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
| | - Jessica L Bettenhausen
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy, Kansas City, MO; University of Missouri, Kansas City, Kansas City, MO
| | - Michelle A Lopez
- Section of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX; Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX
| | - Marion R Sills
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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11
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Sills MR, Ozkaynak M, Jang H. Predicting hospitalization of pediatric asthma patients in emergency departments using machine learning. Int J Med Inform 2021; 151:104468. [PMID: 33940479 DOI: 10.1016/j.ijmedinf.2021.104468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
MOTIVATION The timely identification of patients for hospitalization in emergency departments (EDs) can facilitate efficient use of hospital resources. Machine learning can help the early prediction of ED disposition; however, application of machine learning models requires both computer science skills and domain knowledge. This presents a barrier for those who want to apply machine learning to real-world settings. OBJECTIVES The objective of this study was to construct a competitive predictive model with a minimal amount of human effort to facilitate decisions regarding hospitalization of patients. METHODS This study used the electronic health record data from five EDs in a single healthcare system, including an academic urban children's hospital ED, from January 2009 to December 2013. We constructed two machine learning models by using automated machine learning algorithm (autoML) which allows non-experts to use machine learning model: one with data only available at ED triage, the other adding information available one hour into the ED visit. Random forest and logistic regression were employed as bench-marking models. The ratio of the training dataset to the test dataset was 8:2, and the area under the receiver operating characteristic curve (AUC), accuracy, and F1 were calculated to assess the quality of the models. RESULTS Of the 9,069 ED visits analyzed, the study population was made up of males (62.7 %), median (IQR) age was 6 (4, 10) years, and public insurance coverage (66.0 %). The majority had an Emergency Severity Index score of 3 (52.9 %). The prevalence of hospitalization was 22.5 %. The AUCs were 0.914 and 0.942. AUCs were 0.831 and 0.886 for random forests, and 0.795 and 0.823 for logistic regression. Among the predictors, an outcome at a prior visit, ESI level, time to first medication, and time to triage were the most important features for the prediction of the need for hospitalization. CONCLUSIONS In comparison with the conventional approaches, the use of autoML improved the predictive ability for the need for hospitalization. The findings can optimize ED management, hospital-level resource utilization and improve quality. Furthermore, this approach can support the design of a more effective patient ED flow for pediatric asthma care.
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Affiliation(s)
- Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hoon Jang
- College of Global Business, Korea University, 2511 Sejong-ro, Sejong, Republic of Korea.
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12
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DeLaroche AM, Rodean J, Aronson PL, Fleegler EW, Florin TA, Goyal M, Hirsch AW, Jain S, Kornblith AE, Sills MR, Wells JM, Neuman MI. Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic. Pediatrics 2021; 147:peds.2020-039628. [PMID: 33361360 DOI: 10.1542/peds.2020-039628] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic. METHODS We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children's hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017-2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low-resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed. RESULTS ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017-2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low-resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period. CONCLUSIONS The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.
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Affiliation(s)
- Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan;
| | | | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric W Fleegler
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Monika Goyal
- Department of Pediatrics, Children's National Hospital and The George Washington University, Washington, District of Columbia
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Shobhit Jain
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Aaron E Kornblith
- Division of Emergency Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Marion R Sills
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado; and
| | - Jordee M Wells
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, College of Medicine, The Ohio State University Columbus, Ohio
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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13
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Kaiser SV, Kornblith AE, Richardson T, Pantell MS, Fleegler EW, Fritz CQ, Parikh K, Zagel A, Sills MR, Souza HGD, Goyal MK, Hogan AH, Heller KR, DeLaroche AM, Cooper JN, Puls HT. Emergency Visits and Hospitalizations for Child Abuse During the COVID-19 Pandemic. Pediatrics 2021; 147:peds.2020-038489. [PMID: 33380432 DOI: 10.1542/peds.2020-038489] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California San Francisco, San Francisco, California; .,Contributed equally as co-first authors
| | - Aaron E Kornblith
- Department of Pediatrics, University of California San Francisco, San Francisco, California.,Contributed equally as co-first authors
| | | | - Matthew S Pantell
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | | | | | | | | | - Marion R Sills
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | | | | | - Jennifer N Cooper
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Henry T Puls
- Children's Mercy Hospital, Kansas City, Missouri
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14
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Rao S, Kwan BM, Curtis DJ, Swanson A, Bakel LA, Bajaj L, Boguniewicz J, Lockwood JM, Ogawa K, Pemberton K, Fuhlbrigge RC, Brumbaugh D, Givens P, Nozik ES, Sills MR. Implementation of a Rapid Evidence Assessment Infrastructure during the Coronavirus Disease 2019 (COVID-19) Pandemic to Develop Policies, Clinical Pathways, Stimulate Academic Research, and Create Educational Opportunities. J Pediatr 2021; 230:4-8.e2. [PMID: 33091418 PMCID: PMC7572277 DOI: 10.1016/j.jpeds.2020.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Suchitra Rao
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Epidemiology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Bethany M Kwan
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO
| | - Donna J Curtis
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Angela Swanson
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Leigh Anne Bakel
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lalit Bajaj
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Juri Boguniewicz
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Justin M Lockwood
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kaleigh Ogawa
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | | | - Robert C Fuhlbrigge
- Department of Pediatrics (Rheumatology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - David Brumbaugh
- Department of Pediatrics (Gastroenterology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patricia Givens
- Department of Nursing, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Eva S Nozik
- Department of Pediatrics (Critical Care), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Marion R Sills
- Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
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15
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Jang H, Ozkaynak M, Amura CR, Ayer T, Sills MR. Analysis of medication patterns for pediatric asthma patients in emergency department: Does the sequence placement of glucocorticoids administration matter? J Asthma 2021; 58:180-189. [PMID: 31607182 DOI: 10.1080/02770903.2019.1666866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/27/2019] [Accepted: 09/08/2019] [Indexed: 01/31/2023]
Abstract
Objectives: Timely glucocorticoid administration is associated with decreased admission rate and is thus a common quality metric for ED asthma care; less is known about the impact of the timing of glucocorticoids in the context of the sequence of asthma medications administered. Therefore, we investigated the distribution of asthma medication sequences in one ED and analyzed the effect of the sequence placement of glucocorticoids administration on treatment outcomes.Methods: A retrospective study using five-year electronic health record data obtained from an academic urban children's hospital ED was conducted. We clustered the sequences of medication administration using an exact string-matching algorithm to identify the most frequently used asthma medication sequences. Then, we used the identified patterns to perform statistical tests to examine the effect of the sequence placement of glucocorticoids administration on the outcomes length-of-stay and ED disposition.Results: A total of 4,844 encounters were included in our study. The ten most common treatment sequences accounted for 43% of all encounters. Stratified analyses confirmed that treatment sequences pattern was correlated with patient severity, but ED crowding does not impact treatment sequences. In multivariable models, glucocorticoids administration earlier in the treatment sequence was associated with shorter length of stay and lower hospital admission rates.Conclusions: By analyzing medication sequence patterns for the ED encounter of pediatric asthma, we found that the earlier sequence placement of glucocorticoids administration is associated with improved outcomes. Our findings can help inform quality improvement and clinical guideline development related to ED asthma care for children.
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Affiliation(s)
- Hoon Jang
- College of Global Business, Korea University, Sejong, Republic of Korea
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Claudia R Amura
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
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16
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Abstract
OBJECTIVES Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.
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Affiliation(s)
- Hoon Jang
- From the Science and Technology Policy Institute, Sejong, South Korea
| | - Mustafa Ozkaynak
- School of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
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17
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Russell H, Hall M, Morse RB, Cutler GJ, Macy M, Bettenhausen JL, Lopez MA, Shah SS, Sills MR. Longitudinal Trends in Costs for Hospitalizations at Children's Hospitals. Hosp Pediatr 2020; 10:797-801. [PMID: 32747333 DOI: 10.1542/hpeds.2020-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Children's hospitals are increasingly focused on value-based improvement efforts to improve outcomes and lower costs. Such efforts are generally focused on improving outcomes in specific conditions. Examination of cost drivers across all admissions may facilitate strategic prioritization of efforts. METHODS Pediatric Health Information System data set discharges from 2010 to 2017 were aggregated into services lines and billing categories. The mean annual growth per discharge as a percentage of 2010 total costs was calculated for aggregated medical and surgical service lines and 6 individual service lines with highest rates of growth. The mean annual growth per discharge for each billing category and changes in length of stay was further assessed. RESULTS The mean annual growth in total costs was similar for aggregated medical (2.6%) and surgical (2.7%) service lines. Individual medical service lines with highest mean annual growth were oncology (3.5%), reproductive services (2.9%), and nonsurgical orthopedics (2.8%); surgical service lines with highest rate of growth were solid organ transplant (3.7%), ophthalmology (3.3%), and otolaryngology (2.9%). CONCLUSIONS Room costs contributed most consistently to cost increases without concomitant increases in length of stay. Value-based health care initiatives must focus on room cost increases and their impacts on patient outcomes.
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Affiliation(s)
- Heidi Russell
- Department of Pediatrics and .,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Rustin B Morse
- Children's Health, Children's Medical Center, Dallas, Texas.,Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Gretchen J Cutler
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | - Michelle Macy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | | | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Marion R Sills
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
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18
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Lopez MA, Hall M, Auger KA, Bettenhausen JL, Colvin JD, Cutler GJ, Fieldston E, Macy ML, Morse R, Raphael JL, Russell H, Shah SS, Sills MR. Care of Pediatric High-Cost Hospitalizations Across Hospital Types. Hosp Pediatr 2020; 10:206-213. [PMID: 32024665 DOI: 10.1542/hpeds.2019-0258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND High-cost hospitalizations (HCHs) account for a substantial proportion of pediatric health care expenditures. We aimed to (1) describe the distribution of pediatric HCHs across hospital types caring for children and (2) compare characteristics of pediatric HCHs by hospital type. METHODS Cross-sectional analysis of all pediatric hospitalizations in the 2012 Kids' Inpatient Database. HCHs were defined as costs >$40 000 (94th percentile). Hospitals were categorized as children's, small general, and large general. RESULTS Approximately 166 000 HCHs were responsible for 50.8% of aggregate hospital costs ($18.1 of $35.7 billion) and were mostly at children's hospitals (65%). Children with an HCH were largely neonates (45%), had public insurance (50%), and had ≥1 chronic condition (74%). A total of 131 children's hospitals cared for a median of 559 HCHs per hospital (interquartile range [IQR]: 355-1153) compared to 76 HCHs per hospital (IQR: 32-151) at 397 large general hospitals and 5 HCHs per hospital (IQR: 2-22) at 3581 small general hospitals. The median annual aggregate cost for HCHs was $60 million (IQR: $36-$135) per children's hospital compared to $6.6 million (IQR: $2-$15) per large general hospital and $300 000 (IQR: $116 000-$1.5 million) per small general hospital. HCHs from children's hospitals encompassed nearly 5 times as many unique clinical conditions as large general hospitals and >30 times as many as small general hospitals. CONCLUSIONS Children's hospitals cared for a disproportionate volume, cost, and diversity of HCHs compared to general hospitals. Future studies should characterize the factors driving cost, resources, and reimbursement practices for HCH to ensure the long-term financial viability of the pediatric health care system.
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Affiliation(s)
- Michelle A Lopez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas;
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Katherine A Auger
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Evan Fieldston
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle L Macy
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Rustin Morse
- Children's Health System of Texas, Dallas, Texas; and
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Heidi Russell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Center for Medical Ethics and Health Policy and
| | - Samir S Shah
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marion R Sills
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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19
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Colborn KL, Helmkamp L, Bender BG, Kwan BM, Schilling LM, Sills MR. Colorado Asthma Toolkit Implementation Improves Some Process Measures of Asthma Care. J Am Board Fam Med 2019; 32:37-49. [PMID: 30610140 PMCID: PMC6943943 DOI: 10.3122/jabfm.2019.01.180155] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/30/2018] [Accepted: 10/02/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Colorado Asthma Toolkit Program (CATP) has been shown to improve processes of care with less evidence demonstrating improved outcomes. OBJECTIVE To model the association between pre-and-post-CATP status and asthma-related process and outcome measures among patients ages 5 to 64 years receiving care in safety-net primary care practices. METHODS This is an implementation study involving secondary prepost analysis of existing structured clinical, administrative, and claims data. Nine primary care practices in a federally qualified health center network implemented the CATP. Processes of care and health and utilization outcomes were evaluated prepost implementation in a cohort of patients with asthma using generalized linear mixed models. RESULTS The study cohort included 2678 patients age 5 to 64 years with at least one visit to one of the 9 participating practices during the study period (March 12, 2010 to December 1, 2012). A comparison of 12 months pre- and post-CATP implementation showed improvement in some process measures of asthma care associated with the intervention, including the rate of asthma-severity measurement, although no change in 2 Health care Effectiveness Data and Information Set measures: asthma medication ratio and medication management for people with asthma. We also found no change in asthma outcomes measured across multiple domains: exacerbations, utilization, symptom scores, and pulmonary physiology measures. CONCLUSIONS Implementation of the CATP in a primary care setting led to some improved processes of asthma care, but no changes in measured outcomes. Recommendations for future work include supplemental follow-up training including case review.
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Affiliation(s)
- Kathryn L Colborn
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS).
| | - Laura Helmkamp
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Bruce G Bender
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Bethany M Kwan
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Lisa M Schilling
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
| | - Marion R Sills
- From the Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, Colorado (KLC); Adult & Child Consortium for Health Outcomes Research & Delivery Science, Aurora, CO (LH); Department of Pediatrics, National Jewish Health, Denver (BGB); Department of Medicine, University of Colorado School of Medicine, Aurora (BMK, LMS); Pediatrics, University of Colorado School of Medicine, Aurora (MRS)
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Sills MR, Macy ML, Kocher KE, Sabbatini AK. Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children. Acad Emerg Med 2018; 25:283-292. [PMID: 28960666 DOI: 10.1111/acem.13324] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/26/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit. METHODS This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission). RESULTS Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission. CONCLUSIONS Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.
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Affiliation(s)
- Marion R. Sills
- Departments of Pediatrics and Emergency Medicine and the Adult and Child Consortium for Outcomes Research and Delivery Science University of Colorado School of Medicine and Children's Hospital Colorado (MRS) AuroraCO
| | - Michelle L. Macy
- Department of Pediatrics University of Michigan Ann Arbor MI
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Child Health Evaluation and Research University of Michigan Ann Arbor MI
| | - Keith E. Kocher
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Amber K. Sabbatini
- Division of Emergency Medicine University of Washington Harborview Medical Center Seattle WA
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Patel SJ, Arnold DH, Topoz I, Sills MR. Literature Review: Prediction Modeling of Emergency Department Disposition Decisions for Children with Acute Asthma Exacerbations. Clinical Pediatric Emergency Medicine 2018. [DOI: 10.1016/j.cpem.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Jonas JA, Shah SS, Zaniletti I, Hall M, Colvin JD, Gottlieb LM, Sills MR, Bettenhausen J, Morse RB, Macy ML, Fieldston ES. Regional Variation in Standardized Costs of Care at Children's Hospitals. J Hosp Med 2017; 12:818-825. [PMID: 28991947 DOI: 10.12788/jhm.2829] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE (1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation. DESIGN/SETTING Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children<s hospitals from October 2014 to September 2015. MEASUREMENTS Variation in trimmed standardized costs were assessed within and across regions. Linear mixed effects models were adjusted for patient- and encounter-level variables to assess drivers of variation. RESULTS After adjusting for patient-level factors, variation remained. Using census division clusters, mean trimmed and adjusted total standardized costs were 120% higher for asthma ($1920 vs $4227), 46% higher for DKA ($7429 vs $10,881), and 150% higher for AGE ($3316 vs $8292) in the highest-cost compared with the lowest-cost region. Comparing hospitals in the same region, standardized costs were significantly different (P < 0.001) for each condition in each region. Drivers of variation were encounter-level variables including length of stay and intensive care unit utilization. For this cohort, annual savings from reducing variation would equal $69.1 million at the interregional level and $25.2 million at the intraregional level. CONCLUSIONS Pediatric hospital costs vary between and within regions. Future studies should examine how much of this variation is avoidable. To the extent that less spending does not compromise outcomes, care models may be adjusted to eliminate unwarranted variation and reduce costs.
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Affiliation(s)
- Jennifer A Jonas
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | | | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas, USA
| | - Jeffrey D Colvin
- Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Laura M Gottlieb
- University of California San Francisco, San Francisco, California, USA
| | - Marion R Sills
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Jessica Bettenhausen
- Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Rustin B Morse
- Children's Medical Center Dallas and University of Texas Southwestern, Dallas, Texas, USA
| | - Michelle L Macy
- C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Evan S Fieldston
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Adelgais KM, Brent A, Wathen J, Tong S, Massanari D, Deakyne S, Sills MR. Intranasal Fentanyl and Quality of Pediatric Acute Care. J Emerg Med 2017; 53:607-615.e2. [PMID: 28967529 DOI: 10.1016/j.jemermed.2017.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 05/18/2017] [Accepted: 05/30/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting. OBJECTIVE The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia. METHODS This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes. RESULTS During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes. CONCLUSIONS INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.
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Affiliation(s)
- Kathleen M Adelgais
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Alison Brent
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Joseph Wathen
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Suhong Tong
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Derrek Massanari
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Sara Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Marion R Sills
- Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
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Walsh CG, Sills MR, Arnold DH. Time-dependent severity change during treatment of pediatric patients hospitalized for acute asthma exacerbations. Ann Allergy Asthma Immunol 2016; 118:226-227. [PMID: 27865715 DOI: 10.1016/j.anai.2016.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Colin G Walsh
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marion R Sills
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Donald H Arnold
- Division of Emergency Medicine, Department of Pediatrics, Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee.
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Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss the challenges around clinical decision-making for hospitalization of children with acute asthma exacerbations and the development, internal validation, and future potential of the asthma prediction rule (APR) to provide meaningful clinical decision-support that might decrease unnecessary hospitalizations. RECENT FINDINGS The APR was developed and internally validated using predictor variables available before treatment in the emergency department, and performed well to predict 'need-for-hospitalization.' Oxygen saturation on room air and expiratory phase prolongation were most strongly associated with need-for-hospitalization. SUMMARY Research on prediction rules in pediatric asthma is rare. We developed and internally validated the APR using clinically intuitive predictor variables that are available at the bedside. Before incorporation into electronic decision-support the APR must undergo external validation and an impact analysis to determine if use of this tool will change clinician behavior and improve patient outcomes.
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Affiliation(s)
- Donald H Arnold
- aDivision of Emergency Medicine, Department of Pediatrics and Center for Asthma Research, Vanderbilt University School of Medicine, Nashville, Tennessee bSection of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado cDepartment of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Sills MR, Hall M, Colvin JD, Macy ML, Cutler GJ, Bettenhausen JL, Morse RB, Auger KA, Raphael JL, Gottlieb LM, Fieldston ES, Shah SS. Association of Social Determinants With Children's Hospitals' Preventable Readmissions Performance. JAMA Pediatr 2016; 170:350-8. [PMID: 26881387 DOI: 10.1001/jamapediatrics.2015.4440] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood. OBJECTIVE To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015. EXPOSURES Two risk-adjustment models: a baseline model adjusted for severity of illness and an SDH-enhanced model that adjusted for severity of illness and the following 4 SDH variables: race, ethnicity, payer, and median household income for the patient's home zip code. MAIN OUTCOMES AND MEASURES Change in a hospital's potentially preventable readmissions penalty status (ie, change in whether a hospital exceeded the penalty threshold) using an observed-to-expected potentially preventable readmissions ratio of 1.0 as a penalty threshold. RESULTS For the 179,400 hospital discharges from the 43 hospitals meeting inclusion criteria, median (interquartile range [IQR]) hospital-level percentages for the SDH variables were 39.2% nonwhite (n = 71,300; IQR, 28.6%-54.6%), 17.9% Hispanic (n = 32,060; IQR, 6.7%-37.0%), and 58.7% publicly insured (n = 106,116; IQR, 50.4%-67.8%). The hospital median household income for the patient's home zip code was $ 40,674 (IQR, $ 35,912-$ 46,190). When compared with the baseline model, adjustment for SDH resulted in a change in penalty status for 3 hospitals within the 15-day window (2 were no longer above the penalty threshold and 1 was newly penalized) and 5 hospitals within the 30-day window (3 were no longer above the penalty threshold and 2 were newly penalized). CONCLUSIONS AND RELEVANCE Risk adjustment for SDH changed hospitals' penalty status on a readmissions-based P4P measure. Without adjusting P4P measures for SDH, hospitals may receive penalties partially related to patient SDH factors beyond the quality of hospital care.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jeffrey D Colvin
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor5Department of Pediatrics, University of Michigan, Ann Arbor
| | - Gretchen J Cutler
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - Jessica L Bettenhausen
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City
| | - Rustin B Morse
- Children's Health System of Texas, University of Texas Southwestern, Dallas
| | - Katherine A Auger
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Laura M Gottlieb
- Department of Family and Community Medicine, University of California at San Francisco
| | - Evan S Fieldston
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Samir S Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Zonfrillo MR, Zaniletti I, Hall M, Fieldston ES, Colvin JD, Bettenhausen JL, Macy ML, Alpern ER, Cutler GJ, Raphael JL, Morse RB, Sills MR, Shah SS. Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury. J Pediatr 2016; 169:250-5. [PMID: 26563534 PMCID: PMC6180292 DOI: 10.1016/j.jpeds.2015.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/17/2015] [Accepted: 10/09/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.
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Affiliation(s)
- Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Hasbro Children's Hospital, Providence, RI; Alpert Medical School of Brown University, Providence, RI.
| | | | - Matthew Hall
- Children's Hospital Association, Overland Park, KS
| | - Evan S Fieldston
- Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey D Colvin
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Michelle L Macy
- Department of Emergency Medicine, Child Health Evaluation and Research Unit, Division of General Pediatrics, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Elizabeth R Alpern
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gretchen J Cutler
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Jean L Raphael
- Department of Pediatrics, Section on Academic General Pediatrics, Baylor College of Medicine, Houston, TX
| | | | | | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Piña IL, Cohen PD, Larson DB, Marion LN, Sills MR, Solberg LI, Zerzan J. A framework for describing health care delivery organizations and systems. Am J Public Health 2015; 105:670-9. [PMID: 24922130 PMCID: PMC4358211 DOI: 10.2105/ajph.2014.301926] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 11/04/2022]
Abstract
Describing, evaluating, and conducting research on the questions raised by comparative effectiveness research and characterizing care delivery organizations of all kinds, from independent individual provider units to large integrated health systems, has become imperative. Recognizing this challenge, the Delivery Systems Committee, a subgroup of the Agency for Healthcare Research and Quality's Effective Health Care Stakeholders Group, which represents a wide diversity of perspectives on health care, created a draft framework with domains and elements that may be useful in characterizing various sizes and types of care delivery organizations and may contribute to key outcomes of interest. The framework may serve as the door to further studies in areas in which clear definitions and descriptions are lacking.
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Affiliation(s)
- Ileana L Piña
- Ileana L. Piña is with Albert Einstein College of Medicine and Montefiore-Einstein Medical Center, Bronx, NY. Perry D. Cohen is with the Parkinson Pipeline Project, Washington, DC. David B. Larson is with the Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Lucy N. Marion is with the Medical College of Georgia School of Nursing, Macon. Marion R. Sills is with the University of Colorado School of Medicine, Denver. Leif I. Solberg is with HealthPartners Medical Group and Clinics, Minneapolis, MN. Judy Zerzan is with the Colorado Department of Health Care Policy and Financing, Denver
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Brittan MS, Sills MR, Fox D, Campagna EJ, Shmueli D, Feinstein JA, Kempe A. Outpatient follow-up visits and readmission in medically complex children enrolled in Medicaid. J Pediatr 2015; 166:998-1005.e1. [PMID: 25641248 DOI: 10.1016/j.jpeds.2014.12.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 11/12/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the association between postdischarge outpatient follow-up and 30-day readmissions in Medicaid enrolled children with complex, chronic conditions. STUDY DESIGN This was a retrospective cohort analysis of Colorado Medicaid recipients with complex, chronic conditions who were discharged from the hospital between 2006 and 2008. The primary outcome was readmission between 4 and 30 days after index hospital discharge. Using multivariable logistic regression, we examined the association between early postdischarge outpatient visits (≤ 3 days postdischarge) and readmission. We secondarily analyzed the relationship between any outpatient visit from 4 to 29 days of index discharge and readmission. RESULTS For the 2415 patients with complex, chronic conditions included in the analysis, the 4- to 30-day readmission rate was 6.3%. The odds of readmission was significantly greater for patients with ≥ 1 outpatient visit ≤ 3 days after discharge compared with patients without a visit ≤ 3 days after discharge (aOR 1.7 [1.1-2.4]). The odds of readmission were significantly lower for patients with ≥ 1 outpatient visit from 4 to 29 days after discharge compared with patients without such visits (aOR 0.5 [0.3-0.7]). Other factors associated with readmission included index hospital length of stay and number of complex, chronic conditions. CONCLUSIONS In medically complex children, there is a positive association between early postdischarge outpatient follow-up and readmission. There is an inverse association between later postdischarge outpatient follow-up and readmission. Outpatient follow-up occurring within 4-29 days after discharge may help to prevent 30-day readmissions. Additional research is needed to inform guidelines regarding longer term postdischarge outpatient follow-up in these children.
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Affiliation(s)
- Mark S Brittan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO.
| | - Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
| | - David Fox
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth J Campagna
- Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Doron Shmueli
- Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
| | - James A Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Allison Kempe
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Children's Outcome Research Program, University of Colorado School of Medicine, Aurora, CO
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Brogan TV, Hall M, Sills MR, Fieldston ES, Simon HK, Mundorff MB, Fagbuyi DB, Shah SS. Hospital Readmissions Among Children With H1N1 Influenza Infection. Hosp Pediatr 2014; 4:348-58. [PMID: 25362076 DOI: 10.1542/hpeds.2014-0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe readmissions among children hospitalized with H1N1 (influenza subtype, hemagglutinin1, neuraminidase 1) pandemic influenza and secondarily to determine the association of oseltamivir during index hospitalization with readmission. METHODS We reviewed data from 42 freestanding children's hospitals contributing to the Pediatric Health Information System from May through December 2009 when H1N1 was the predominant influenza strain. Children were divided into 2 groups by whether they experienced complications of influenza during index hospitalization. Primary outcome was readmission at 3, 7, and 30 days among both patient groups. Secondary outcome was the association of oseltamivir treatment with readmission. RESULTS The study included 8899 children; 6162 patients had uncomplicated index hospitalization, of whom 3808 (61.8%) received oseltamivir during hospitalization, and 2737 children had complicated influenza, of whom 1055 (38.5%) received oseltamivir. Median 3-, 7-, and 30-day readmission rates were 1.6%, 2.5%, and 4.7% for patients with uncomplicated index hospitalizations and 4.3%, 5.8%, and 10.3% among patients with complicated influenza. The 30-day readmission rates did not differ by treatment group among patients with uncomplicated influenza; however, patients with complicated index hospitalizations who received oseltamivir had lower all-cause 30-day readmissions than untreated patients. The most common causes of readmission were pneumonia and asthma exacerbations. CONCLUSIONS Oseltamivir use for hospitalized children did not decrease 30-day readmission rates in children after uncomplicated index hospitalization but was associated with a lower 30-day readmission rate among children with complicated infections during the 2009 H1N1 pandemic. Readmission rates for children who had complicated influenza infection during index hospitalizations are high.
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Affiliation(s)
- Thomas V Brogan
- Seattle Children's Hospital, and Department of Pediatrics, Division of Critical Care Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Marion R Sills
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Evan S Fieldston
- Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Harold K Simon
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael B Mundorff
- Department of Systems Improvement, Children's Primary Hospital, Salt Lake City, Utah
| | - Daniel B Fagbuyi
- The George Washington University School of Medicine, and Children's National Medical Center, Washington, District of Columbia
| | - Samir S Shah
- Divisions of Infectious Diseases and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio Department of Pediatrics and Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Sills MR, Kwan BM, Yawn BP, Sauer BC, Fairclough DL, Federico MJ, Juarez-Colunga E, Schilling LM. Medical home characteristics and asthma control: a prospective, observational cohort study protocol. EGEMS (Wash DC) 2013; 1:1032. [PMID: 25848577 PMCID: PMC4371502 DOI: 10.13063/2327-9214.1032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background: This paper describes the methods for an observational comparative effectiveness research study designed to test the association between practice-level medical home characteristics and asthma control in children and adults receiving care in safety-net primary care practices. Methods: This is a prospective, longitudinal cohort study, utilizing survey methodologies and secondary analysis of existing structured clinical, administrative, and claims data. The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) is a safety net-oriented, primary care practice-based research network, with federated databases containing electronic health record (EHR) and Medicaid claims data. Data from approximately 20,000 patients from 50 practices in four healthcare organizations will be included. Practice-level medical home characteristics will be correlated with patient-level asthma outcomes, controlling for potential confounding variables, using a clustered design. Linear and non-linear mixed models will be used for analysis. Study inception was July 1, 2012. A causal graph theory approach was used to guide covariate selection to control for bias and confounding. Discussion: Strengths of this design include a priori specification of hypotheses and methods, a large sample of patients with asthma cared for in safety-net practices, the study of real-world variations in the implementation of the medical home concept, and the innovative use of a combination of claims data, patient-reported data, clinical data from EHRs, and practice-level surveys. We address limitations in causal inference using theory, design and analysis.
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Fieldston ES, Zaniletti I, Hall M, Colvin JD, Gottlieb L, Macy ML, Alpern ER, Morse RB, Hain PD, Sills MR, Frank G, Shah SS. Community household income and resource utilization for common inpatient pediatric conditions. Pediatrics 2013; 132:e1592-601. [PMID: 24276839 DOI: 10.1542/peds.2013-0619] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI). METHODS Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups. RESULTS From 116,636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had $8.4 million more in hospitalization-level costs and $13.6 million more in patient-level costs. CONCLUSIONS Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.
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Affiliation(s)
- Evan S Fieldston
- MBA, MSHP, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, CHOP North, Room 1516, Philadelphia, PA 19104.
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Morse RB, Hall M, Fieldston ES, Goodman DM, Berry JG, Gay JC, Sills MR, Srivastava R, Frank G, Hain PD, Shah SS. Children's hospitals with shorter lengths of stay do not have higher readmission rates. J Pediatr 2013; 163:1034-8.e1. [PMID: 23683748 DOI: 10.1016/j.jpeds.2013.03.083] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 02/22/2013] [Accepted: 03/27/2013] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates. STUDY DESIGN Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression. RESULTS Mean LOS was <3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all <5%. Condition-specific readmission rates for complex patients ranged from <1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10). CONCLUSION In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.
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Affiliation(s)
- Rustin B Morse
- Department of Pediatrics, Children's Medical Center, Dallas, TX.
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Rappaport LD, Deakyne S, Carcillo JA, McFann K, Sills MR. Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older. Am J Emerg Med 2013; 31:838-42. [PMID: 23478110 DOI: 10.1016/j.ajem.2013.01.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/07/2013] [Accepted: 01/15/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups. BASIC PROCEDURES Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older. MAIN FINDINGS The primary analysis included 33906 subjects (101837 weighted) 10 years and older. The secondary analysis included 13393 subjects (37983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years. CONCLUSIONS This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.
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Bagdure D, Rewers A, Campagna E, Sills MR. Epidemiology of hyperglycemic hyperosmolar syndrome in children hospitalized in USA. Pediatr Diabetes 2013; 14:18-24. [PMID: 22925225 DOI: 10.1111/j.1399-5448.2012.00897.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 05/17/2012] [Accepted: 06/01/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Previous studies of hyperglycemic hyperosmolar syndrome (HHS) in children are limited to case series or single-institution reviews, which describe HHS primarily in children with type 2 diabetes mellitus. OBJECTIVE To estimate the incidence and describe the epidemiologic characteristics of HHS among children in USA. SUBJECTS All discharges in the Kids' Inpatient Database - a triennial, nationwide, stratified probability sample of hospital discharges for years 1997-2009 - with age 0-18 yr and a diagnosis of HHS. METHODS Using sample weights, we calculated the incidence and population rate of hospitalization with a diagnosis of HHS. RESULTS Our sample included 1074 HHS hospitalizations; of these, 42.9% were 16-18 yr, 70.6% had type 1 diabetes (T1D), and 53.0% had major or extreme severity of illness. The median length of stay was 2.6 d, 2.7% of hospitalizations ended in death, and median hospital charge was $10 882. When comparing HHS hospitalizations by diabetes type, the proportion with T1D fell steadily with age, from 89.1% among children 0-9 yr, to 65.1% in 16-18 yr olds. Patients with T1D had a shorter length of stay by 0.9 d, and had a lower median charge by $5311. There was no difference in mortality by diabetes type. Population rates for HHS hospitalization rose 52.4% from 2.1 to 3.2 per 1 000 000 children from 1997 to 2009. CONCLUSION Hospitalizations for a diagnosis of HHS have high morbidity and are increasing in incidence since 1997. In contrast to prior reports, we found a substantial percentage of HHS hospitalizations occurred among children with T1D.
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Affiliation(s)
- Dayanand Bagdure
- Department of Pediatrics, University of Maryland School of Medicine, Division of Pediatric Critical Care Medicine, Baltimore, MD 21201, USA.
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Sills MR, Hall M, Fieldston ES, Hain PD, Simon HK, Brogan TV, Fagbuyi DB, Mundorff MB, Shah SS. Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States. Emerg Infect Dis 2012; 17:1685-91. [PMID: 21888795 PMCID: PMC3320222 DOI: 10.3201/eid1709.101950] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Marion R Sills
- University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Abstract
OBJECTIVE To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department. METHODS Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission. RESULTS In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely β-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely β-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association. CONCLUSIONS We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to children in a multicenter study. Although the quality of emergency department care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes.
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Affiliation(s)
| | - Adit A. Ginde
- Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sunday Clark
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Sills MR, Fairclough DL, Ranade D, Mitchell MS, Kahn MG. Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures. Acad Emerg Med 2011; 18:1330-8. [PMID: 22168199 DOI: 10.1111/j.1553-2712.2011.01136.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures. METHODS This cross-sectional, retrospective study included patients 0-21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children's hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested. RESULTS The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding-an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p < 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles. CONCLUSIONS Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, Children's Outcomes Research Program, University of Colorado School of Medicine, Aurora, USA.
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Morse RB, Hall M, Fieldston ES, McGwire G, Anspacher M, Sills MR, Williams K, Oyemwense N, Mann KJ, Simon HK, Shah SS. Hospital-level compliance with asthma care quality measures at children's hospitals and subsequent asthma-related outcomes. JAMA 2011; 306:1454-60. [PMID: 21972307 DOI: 10.1001/jama.2011.1385] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The Children's Asthma Care (CAC) measure set evaluates whether children admitted to hospitals with asthma receive relievers (CAC-1) and systemic corticosteroids (CAC-2) and whether they are discharged with a home management plan of care (CAC-3). It is the only Joint Commission core measure applicable to evaluate the quality of care for hospitalized children. OBJECTIVES To evaluate longitudinal trends in CAC measure compliance and to determine if an association exists between compliance and outcomes. DESIGN, SETTING, AND PATIENTS Cross-sectional study using administrative data and CAC compliance data for 30 US children's hospitals. A total of 37,267 children admitted with asthma between January 1, 2008, and September 30, 2010, with follow-up through December 31, 2010, accounted for 45,499 hospital admissions. Hospital-level CAC measure compliance data were obtained from the National Association of Children's Hospitals and Related Institutions. Readmission and postdischarge emergency department (ED) utilization data were obtained from the Pediatric Health Information System. MAIN OUTCOME MEASURES Children's Asthma Care measure compliance trends; postdischarge ED utilization and asthma-related readmission rates at 7, 30, and 90 days. RESULTS The minimum quarterly CAC-1 and CAC-2 measure compliance rates reported by any hospital were 97.1% and 89.5%, respectively. Individual hospital CAC-2 compliance exceeded 95% for 97.9% of the quarters. Lack of variability in CAC-1 and CAC-2 compliance precluded examination of their association with the specified outcomes. Mean CAC-3 compliance was 40.6% (95% CI, 34.1%-47.1%) and 72.9% (95% CI, 68.8%-76.9%) for the initial and final 3 quarters of the study, respectively. The mean 7-, 30-, and 90-day postdischarge ED utilization rates were 1.5% (95% CI, 1.3%-1.6%), 4.3% (95% CI, 4.0%-4.5%), and 11.1% (95% CI, 10.5%-11.7%) and the mean quarterly 7-, 30-, and 90-day readmission rates were 1.4% (95% CI, 1.2%-1.6%), 3.1% (95% CI, 2.8%-3.3%), and 7.6% (95% CI, 7.2%-8.1%). There was no significant association between overall CAC-3 compliance (odds ratio [OR] for 5% improvement in compliance) and postdischarge ED utilization rates at 7 days (OR, 1.00; 95% CI, 0.98-1.02), 30 days (OR, 0.97; 95% CI, 0.90-1.04), and 90 days (OR, 0.96; 95% CI, 0.77-1.18). In addition, there was no significant association between overall CAC-3 compliance (OR for 5% improvement in compliance) and readmission rates at 7 days (OR, 1.00; 95% CI, 0.99-1.02), 30 days (OR, 0.99; 95% CI, 0.96-1.02), and 90 days (OR, 1.01; 95% CI, 0.90-1.12). CONCLUSION Among children admitted to pediatric hospitals for asthma, there was high hospital-level compliance with CAC-1 and CAC-2 quality measures and moderate compliance with the CAC-3 measure but no association between CAC-3 compliance and subsequent ED visits and asthma-related readmissions.
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Affiliation(s)
- Rustin B Morse
- Phoenix Children's Hospital, University of Arizona College of Medicine, 1919 E Thomas Rd, Phoenix, AZ 85016, USA.
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Fieldston ES, Hall M, Shah SS, Hain PD, Sills MR, Slonim AD, Myers AL, Cannon C, Pati S. Addressing inpatient crowding by smoothing occupancy at children's hospitals. J Hosp Med 2011; 6:462-8. [PMID: 21612012 PMCID: PMC3163108 DOI: 10.1002/jhm.904] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 12/25/2010] [Accepted: 01/10/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To quantify the difference in weekday versus weekend occupancy, and the opportunity to smooth inpatient occupancy to reduce crowding at children's hospitals. METHODS Daily inpatient census data for 39 freestanding, tertiary-care children's hospitals were used to calculate occupancy and to model the impact of reducing variation in occupancy and the change in the number of patients, patient-days, and hospitals exposed to high occupancy pre- and post-smoothing. We also calculated the proportion of weekly admissions that would require different scheduling to achieve within-week smoothing. RESULTS Overall, hospitals' mean occupancy ranged from 70.9% to 108.1% on weekdays, and 65.7% to 94.9% on weekends. Weekday occupancy exceeded weekend occupancy with a median difference of 8.2% points. The mean post-smoothing reduction in weekly maximum occupancy across all hospitals was 6.6% points. Through smoothing, 39,607 patients from the 39 hospitals were removed from exposure to occupancy levels >95%. To achieve within-week smoothing, a median 2.6% of admissions would have to be scheduled on a different day of the week; this equates to a median of 7.4 patients per week (range: 2.3-14.4). CONCLUSION Hospitals do have substantial unused capacity, and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.
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Affiliation(s)
- Evan S Fieldston
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, USA.
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Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Ann Emerg Med 2011; 57:191-200.e1-7. [PMID: 21035903 DOI: 10.1016/j.annemergmed.2010.08.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 07/28/2010] [Accepted: 08/18/2010] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations. METHODS This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models. RESULTS The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05). CONCLUSION ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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Sills MR, Hall M, Simon HK, Fieldston ES, Walter N, Levin JE, Brogan TV, Hain PD, Goodman DM, Fritch-Levens DD, Fagbuyi DB, Mundorff MB, Libby AM, Anderson HO, Padula WV, Shah SS. Resource burden at children's hospitals experiencing surge volumes during the spring 2009 H1N1 influenza pandemic. Acad Emerg Med 2011; 18:158-66. [PMID: 21314775 DOI: 10.1111/j.1553-2712.2010.00992.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. METHODS The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). RESULTS Overall, 390,983 visits, and 88,885 visits for IRI, were included for Calendar Weeks 16 through 29, when 2009 H1N1 influenza was circulating. The subset of 106,330 visits and 31,703 IRI visits made to the 14 hospitals experiencing the authors' definition of ED surge during Weeks 16 to 29 was also studied. During surge weeks, the 14 EDs experienced 29% more total visits and 51% more IRI visits than expected (p < 0.01 for both comparisons). Of ED IRI visits during surge weeks, only 4.8% were admitted to non-intensive care beds (70% of expected, p < 0.01), 0.19% were admitted to intensive care units (44% of expected, p < 0.01), and 0.01% received mechanical ventilation (5.0% of expected, p < 0.01). Factors associated with more-than-expected visits included ages 2-17 years, payer type, and asthma. No factors were associated with more-than-expected hospitalizations from the ED. CONCLUSIONS During the spring 2009 H1N1 influenza pandemic, pediatric EDs nationwide experienced a marked increase in visits, with far fewer than expected requiring nonintensive or intensive care hospitalization. The data in this study can be used for future pandemic planning.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Section of Emergency Medicine, Children's Hospital, Aurora, USA.
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Sills MR, Ginde AA, Clark S, Camargo CA. Multicenter study of chronic asthma severity among emergency department patients with acute asthma. J Asthma 2010; 47:920-8. [PMID: 20831467 DOI: 10.3109/02770903.2010.504878] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The initiation of controller therapy for asthma depends on chronic asthma severity. To facilitate initiation of inhaled corticosteroids (ICSs), the preferred controller therapy, in the emergency department (ED), the objective of the study was to describe chronic asthma severity, as defined by the national asthma guidelines, among children presenting to the ED with acute asthma. METHODS Investigators at 14 U.S. sites prospectively enrolled consecutive children 2–17 years presenting to the ED with acute asthma. Three factors (daytime symptoms, nighttime symptoms, and medication usage) were used to categorize children into four chronic asthma severity groups: intermittent, mild persistent, moderate persistent or severe persistent. RESULTS This multistate cohort of 311 children had a mean age of 7.7 years, was 51% Black, and 89% had a primary care provider (PCP). Regarding chronic severity, 18% were intermittent and 82% persistent: 37% mild persistent, 24% moderate persistent, and 20% severe persistent. Chronic severity groups did not differ by demographics or PCP status. Patients with persistent asthma were more likely to report moderate-severe asthma symptoms (58% versus 19%; p < .001), poor asthma control (2% versus 18%; p = .002), and more ED visits (median, 2 versus 1; p < .001) in the past year. The groups did not differ in acute asthma severity, ED treatment, or admission rate. Rate of discharge prescription for ICSs was low, albeit higher among children with persistent asthma (24% versus 4%; p = .003). CONCLUSIONS The high prevalence of persistent asthma among ED patients exceeds the prevalence reported previously, and supports ED initiation of ICS, as recommended by national guidelines.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Sills MR, Ginde AA, Clark S, Camargo CA. Multicenter Study of Chronic Asthma Severity Among Emergency Department Patients With Acute Asthma. J Asthma 2010. [DOI: 10.1080/02770903.2010.504878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
OBJECTIVE High hospital occupancy may lead to overcrowding in emergency departments and inpatient units, having an adverse impact on patient care. It is not known how children's hospitals acutely respond to high occupancy. The objective of this study was to describe the frequency, direction, and magnitude of children's hospitals' acute responses to high occupancy. METHODS Patients who were discharged from 39 children's hospitals that participated in the Pediatric Health Information System database during 2006 were eligible. Midnight census data were used to construct occupancy levels. Acute response to high occupancy was measured by 8 variables, including changes in hospital admissions (4 measures), transfers (2 measures), and length of stay (2 measures). RESULTS Hospitals were frequently at high occupancy, with 28% of midnights at 85% to 94% occupancy and 42% of midnights at > or =95% occupancy. Whereas half of children's hospitals used occupancy-mitigating responses, there was variability in responses and magnitudes were small. When occupancy was >95%, no more than 8% of hospitals took steps to reduce admissions, 13% increased transfers out, and up to 58% reduced standardized length of stay. Two-day lag response was more common but remained of too small a magnitude to make a difference in hospital crowding. Additional modeling techniques also revealed little response. CONCLUSIONS We found a low rate of acute response to high occupancy. When there was a response, the magnitude was small.
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Affiliation(s)
- Evan S Fieldston
- University of Pennsylvania School of Medicine, Robert Wood Johnson Clinical Scholars Program, Philadelphia, PA 19104, USA.
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Schilling LM, Crane LA, Kempe A, Main DS, Sills MR, Davidson AJ. Perceived frequency and impact of missing information at pediatric emergency and general ambulatory encounters. Appl Clin Inform 2010; 1:318-30. [PMID: 23616844 DOI: 10.4338/aci-2010-04-ra-0022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 08/05/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To document the perceived frequency, type, and impact of unavailable ("missing") clinical information during pediatric emergency and general ambulatory encounters. METHODS This prospective cohort set in the Emergency Department and General Ambulatory Pediatric Clinic at The Children's Hospital, Aurora, CO, assessed pediatric attending physician perceptions regarding missing information at emergency and general ambulatory encounters. The main outcome measures were the frequency of perceived missing information; its presumed location; time spent seeking; and the perceived effects on resource utilization and overall quality of care. RESULTS Pediatric physicians reported missing information for 2% of emergency and 22% of general ambulatory encounters. Types of missing information at general ambulatory visits included immunization (34% of types), general past medical (29%), and disease or visit specific histories (13%). Missing information at ambulatory visits was sought 20% of the time, obtained 4% of the time, and rated "somewhat or very important for today's care" (73% of the time) and "somewhat or very important for future care" (84% of the time). For encounters with unattained missing information, physicians reported adverse affects on the efficiency of the visit (64%), physician's confidence in care (33%), patient/family satisfaction (17%), disposition decisions (8%), and recommended additional treatment (38%), laboratory studies (16%), and imaging (12%). For 57% of encounters with missing information, physicians perceived an adverse effect on overall quality of care. Missing information was associated with not having a primary care visit at TCH within 12 months of the encounter, (OR 2.8; 95% CI, 1.7, 4.5). CONCLUSION Pediatric physicians more commonly experience missing information at general ambulatory visits than emergency visits and report that missing information adversely impacts quality, efficiency, their confidence in care, patient and family satisfaction, and leads to potentially redundant resource utilization.
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Affiliation(s)
- Lisa M Schilling
- University of Colorado Denver School of Medicine, Department of Medicine
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Abstract
OBJECTIVE Emergency department (ED) overcrowding has been quantified with a scale that reflects the degree of overcrowding (National ED Overcrowding Scale, or NEDOCS) in general academic EDs. However, validity of the 5-question NEDOCS scale has not been established for a pediatric ED. Our primary objectives were to validate the NEDOCS model in our institution's pediatric ED and explore the possibility of another pediatric ED overcrowding model that would be better than the NEDOCS model. METHODS Objective data were determined by prospectively collecting 20 variables at 42 random site-sampling times in one pediatric ED. Data were obtained by counting patients, determining patient's times, and obtaining information from registration, triage, and ancillary services. The 5 questions needed for the NEDOCS scale were among the data collected. Expert consensus (EC) was obtained using a Likert scale completed by the charge nurse and ED physicians who rated the degree of overcrowding. National ED Overcrowding Scale scores were compared with EC score to determine predictive validity of a model for a pediatric ED. Spearman correlation and multivariable linear regression were used to evaluate individual variables. RESULTS Overcrowding based on EC score was found in 18 (44%) of 41 times in the pediatric ED. In pediatric EDs, high correlations were found between EC score and NEDOCS (0.68), number of patients in the waiting room (0.74), full rooms (0.64), and total registered patients (0.65). In a multivariable analysis, a combination of patients in the waiting room and total registered patients had a high correlation (0.80) with EC score in the pediatric ED. CONCLUSIONS Overcrowding is quantifiable in a pediatric ED. Although the NEDOCS performed well in the pediatric ED, it was outperformed by other variables and other variable combinations. In this pediatric ED, a combination of 2 variables, total registered patients and patients in the waiting room, was a better model than the NEDOCS score for quantifying pediatric ED overcrowding.
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Affiliation(s)
- Steven J Weiss
- University of New Mexico Medical Center, Albuquerque, NM 87131-0001, USA.
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Abstract
OBJECTIVE The objective of this study was to determine the association between parental depression and pediatric health care use patterns. METHODS We selected all children who were 0 to 17 years of age, enrolled in Kaiser Permanente of Colorado during the study period July 1997 to December 2002, and linked to at least 1 parent/subscriber who was enrolled for at least 6 months during that period. Unexposed children were selected from a pool of children whose parents did not have a depression diagnosis. Outcome measures were derived from the child's payment files and electronic medical charts and included 5 categories of use: well-child-care visits, sick visits to primary care departments, specialty clinic visits, emergency department visits, and inpatient visits. We compared the rate of use per enrollment month for these 5 categories between exposed and unexposed children within each of the 5 age strata. RESULTS Our study population had 24,391 exposed and 45,274 age-matched, unexposed children. For the outcome of well-child-care visits, teenagers showed decreased rates of visits among exposed children. The rate of specialty department visits was higher in exposed children in the 4 oldest age groups. The rates of both emergency department visits and sick visits to primary care departments were higher for exposed children across all 5 age categories. The rate of inpatient visits was higher among exposed children in 2 of the 5 age groups. CONCLUSIONS Overall, having at least 1 depressed parent is associated with greater rate of emergency department and sick visits across all age groups, greater use of inpatient and specialty services in some age groups, and a lower rate of well-child-care visits among 13- to 17-year-olds. This pattern of increased use of expensive resources and decreased use of preventive services represents one of the hidden costs of adult depression.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80218, USA.
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Abstract
OBJECTIVES To describe the incidence and case-fatality rates of traumatic brain injury (TBI) in young children in Colorado, to compare these injuries based on intentionality and outcome (prehospital death, in-hospital death, or survival), and to model the association of intentionality with TBI-related mortality. METHODS Cases were drawn from the 1994-2002 Colorado Traumatic Brain Injury Surveillance System. Incidence and case-fatality rates for intentional and unintentional TBI were calculated. We performed univariate comparisons based on the intentionality and outcome of the TBI. Multivariate logistic regression was used to estimate the association of intentionality and mortality, controlling for injury severity. RESULTS Of the 1333 children aged 0 to 36 months with TBI, 340 had intentional and 993 had unintentional TBI. Incidence for intentional and unintentional TBI was 16.1 and 47.0 per 100,000, respectively. Children with intentional TBI had a higher case-fatality rate, in-hospital death rate, and injury severity. Intentional TBI deaths were twice as likely to occur in hospital than prehospital, whereas unintentional TBI deaths were twice as likely to occur prehospital. Intentionality was significantly associated with mortality, with the effect increasing with increasing age. CONCLUSION Intentionality--independent of severity--raises the mortality of TBI in young children.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, Denver 80218, USA.
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Valuck RJ, Libby AM, Sills MR, Giese AA, Allen RR. Antidepressant treatment and risk of suicide attempt by adolescents with major depressive disorder: a propensity-adjusted retrospective cohort study. CNS Drugs 2005; 18:1119-32. [PMID: 15581382 DOI: 10.2165/00023210-200418150-00006] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
CONTEXT The US FDA has issued an advisory warning of a possible link between antidepressant treatment for paediatric patients with major depressive disorder (MDD) and an increased risk of suicidal behaviour. A large database of paid health insurance claims for adolescents with MDD provided the opportunity to examine this possible relationship. OBJECTIVE To examine the potential empirical link between antidepressant treatment and suicide attempts among adolescents aged 12-18 years using a community sample of managed care enrollees across the US. DESIGN A retrospective longitudinal cohort using paid insurance claims for all healthcare and prescription fills for adolescents who were newly diagnosed with MDD and had at least 6 months of follow-up data. A multivariate Cox proportional hazards regression analysis was used to test the hypothesis that antidepressant use increased the risk of suicide attempt, adjusting for propensity for allocation to each treatment group and for demographic and clinical characteristics. SETTING Managed care plans including both commercial and Medicaid plans in the east, midwest, south and western regions of the US from January 1997 to March 2003. PARTICIPANTS All adolescent insurance members aged 12-18 years at first diagnosis of MDD. MAIN OUTCOME MEASURES Suicide attempts as indicated by medical utilisation with International Classification of Diseases (9th edition) [ICD-9] or 10th edition (ICD-10) codes in any healthcare setting or by any covered provider. RESULTS 24 119 adolescents met inclusion criteria (63% female). Crude suicide attempt rates ranged from 0.0-2.3% by index treatment group. Treatment with SSRIs (hazard ratio) [HR] = 1.59; CI 0.89, 2.82), other antidepressants (HR = 1.03; CI 0.43, 2.44), or multiple antidepressants (HR = 1.43; CI 0.70, 2.89) after index MDD diagnosis resulted in no statistically increased risk of suicide attempt. Treatment with antidepressant medication for at least 180 days (6 months) reduced the likelihood of suicide attempt compared with antidepressant treatment for <55 days (8 weeks) [HR = 0.34; CI 0.21, 0.55]. Other variables that were independently associated with greater risk of suicide attempts included female gender, severity of illness indicators, younger age at time of MDD diagnosis, and living in the midwest or west. CONCLUSIONS Antidepressant medication use had no statistically significant effect on the likelihood of suicide attempt in a large cohort of adolescents across the US after propensity adjustment for treatment allocation and controlling for other factors. The relationship between suicidal behaviour and antidepressant medication use is complex and requires further investigation.
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Affiliation(s)
- Robert J Valuck
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado, Denver, Colorado 80262, USA.
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