Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals

OBJECTIVES

Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups.

METHODS

We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals.

RESULTS

Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals.

CONCLUSIONS

Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

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

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

Serologic Screening for Genital Herpes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

This systematic review to support the 2023 US Preventive Services Task Force Recommendation Statement on serologic screening for genital herpes summarizes published evidence on the benefits and harms of screening and interventions for genital herpes in asymptomatic sexually active adolescents, adults, and pregnant persons with no clinical history of genital herpes.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes

OBJECTIVES

To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization.

METHODS

Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement.

RESULTS

We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year.

CONCLUSIONS

Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns.

METHODS

This observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail.

RESULTS

Of 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51).

CONCLUSIONS

Hospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals

IMPORTANCE

Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined.

OBJECTIVE

To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019.

EXPOSURE

Hospitalization for bronchiolitis.

MAIN OUTCOMES AND MEASURES

Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost.

RESULTS

A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity.

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply

OBJECTIVE

To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates.

STUDY DESIGN

This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics.

RESULTS

Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]).

CONCLUSIONS

There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse.

Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses

IMPORTANCE

Two previous meta-analyses of nebulized hypertonic saline (HS) on hospital length of stay (LOS) in acute viral bronchiolitis have suggested benefit. Neither study fully addressed the issue of excessive heterogeneity in the cohort of studies, indicating that it may be inappropriate to combine such dissimilar studies to estimate a common treatment effect.

OBJECTIVE

To reanalyze the existing data set for sources of heterogeneity to delineate the population most likely to benefit from HS.

DATA SOURCES

We used the previously analyzed cohort of randomized trials from 2 published meta-analyses comparing HS with normal saline (or, in 1 case, with standard of care) in infants hospitalized for bronchiolitis. We also repeated the search strategy used by the most recent Cochrane Review in the Medline database through September 2015.

STUDY SELECTION

Eighteen randomized clinical trials of HS in infants with bronchiolitis reporting LOS as an outcome measure were included.

DATA EXTRACTION AND SYNTHESIS

The guidelines used for abstracting data included LOS, study year, setting, sample size, type of control, admission/discharge criteria, adjunct medications, treatment frequency, mean day of illness at study enrollment, mean severity of illness scores, and mean age.

MAIN OUTCOMES AND MEASURES

Weighted mean difference in LOS and study heterogeneity as measured by the I2 statistic.

RESULTS

There were 18 studies included of 2063 infants (63% male), with a mean age of 4.2 months. The mean LOS was 3.6 days. Two main sources of heterogeneity were identified. First, the effect of HS on LOS was entirely sensitive to the removal of one study population, noted to have a widely divergent definition of the primary outcome. Second, there was a baseline imbalance in mean day of illness at presentation between treatment groups. Controlling for either of these factors resolved the heterogeneity (I2 = reduced from 78% to 45% and 0%, respectively) and produced summary estimates in support of the null hypothesis (that HS does not affect LOS). There was a weighted mean difference in LOS of -0.21 days (95% CI, -0.43 to +0.02) for the sensitivity analysis and +0.02 days (95% CI, -0.14 to +0.17) for studies without unbalanced treatment groups on presentation.

CONCLUSIONS AND RELEVANCE

Prior analyses were driven by an outlier population and unbalanced treatment groups in positive trials. Once heterogeneity was accounted for, the data did not support the use of HS to decrease LOS in infants hospitalized with bronchiolitis.

Estimating the proportion of young adults on antihypertensive treatment that have been correctly diagnosed

This paper aims to identify how many young adults on antihypertensive treatment have been misclassified as hypertensive. We identified subjects aged under 35 on antihypertensive treatment, from the Health Surveys for England, 1998-2004. Pretreatment systolic and diastolic blood pressures were calculated by adjusting on-treatment blood pressures for the effects of treatment. Treatment effects were derived from meta-analysis. Subjects were classified as hypertensive if pretreatment blood pressure was >or=160/100 mm Hg, or was >or=140/90 mm Hg in conjunction with high cardiovascular risk. We then identified the proportion of treated subjects on antihypertensive treatment who were truly eligible for treatment. From the survey data we identified 65 adults (25 men and 40 women) under 35 on diuretics, beta-blockers, angiotensin converting enzyme inhibitors, calcium blockers or other antihypertensives. Average pretreatment blood pressure was 164/100 mm Hg in those eligible for treatment, and 136/79 mm Hg in those not eligible. The analysis indicated that 29.2% of adults aged 16-34 (95% confidence interval (CI): 18.6-41.8%) were truly eligible for antihypertensive treatment: 32.0% (95% CI: 14.9-53.5%) of men and 25.0% (95% CI: 12.7-41.2%) of women. A total of 73.7% (14 of 19) of subjects eligible and 41.3% (19 of 46) of subjects not eligible for treatment either had a body mass index >30 kg m(-2) or kidney disease (chi(2)-test P=0.018). Because of biological variation in blood pressure, most young adults on treatment for hypertension have been misclassified as hypertensive. Most who have been correctly diagnosed are either clinically obese or have kidney disease.

Factors affecting the uptake of cardiac rehabilitation services in a rural locality

INTRODUCTION

A number of studies have investigated factors affecting uptake of cardiac rehabilitation services. However, little information on factors affecting uptake of services in rural localities is available.

STUDY DESIGN

A cross-sectional survey.

METHODS

A survey of patients eligible for cardiac rehabilitation was undertaken to investigate uptake of services. The effects of individual and geographic factors on service utilization were explored.

RESULTS

Utilization rates for cardiac rehabilitation services within the South Staffordshire locality are low, with 59.3% of eligible patients invited to attend cardiac rehabilitation services following discharge from hospital, 38.6% attending and 22.5% completing the programme. Two factors were independently associated with low service utilization. Patients under the age of 65 years are 1.90 [95% confidence intervals (CI) 1.01-3.65] times more likely to complete rehabilitation than patients aged over 65 years, and women are only 0.48 (95% CI 0.22-1.03) times as likely as men to complete rehabilitation. The major reported barrier to utilization of services was access. This included problems with public transport, parking and the time and location of classes. Access and medical problems were significantly higher in older people and may have contributed to their low overall completion rate. Electoral ward deprivation, geographical access score, living in an urban or rural electoral ward, electoral ward of residence and provider were not significantly associated with service utilization.

CONCLUSIONS

Overall, utilization rates were low. No geographical factors were associated with uptake of services, although the possible effect may have been mediated by the relative affluence of the locality. Two individual factors, age and sex, were most likely to influence uptake.

Chemical contamination of private drinking water supplies in the West Midlands, United Kingdom

INTRODUCTION

In the United Kingdom, private drinking water supplies are subject to much less stringent sampling and testing regimes than are public supplies. Information regarding the quality of private drinking water supplies is disparate and poorly defined. The aim of this study was to collate the data for chemical contamination of private drinking water supplies in the West Midlands, a region of Central England with a population of 5.3 million.

METHODS

The most recent year's data on the number of private supplies, the number of supplies sampled, and the number and type of failures for chemical parameters were obtained from District and Local Authorities in the West Midlands Region.

RESULTS

Data covered 12-month periods during 1995-1996. Of the 6013 private supplies identified, samples from 1297 had been tested for chemical parameters during the period of the study. A total of 420 individual failures for chemical parameters were reported in 386 water supplies. The majority of breaches of United Kingdom and European Union standards were due to increased concentrations of nitrates (270), magnesium (21), manganese (17), and iron (15). Increased turbidity was present in 27 cases. Only 6 samples breached the standard for lead and 6 for pesticides.

CONCLUSIONS

Over a quarter of the supplies tested during the period of the study were in breach of United Kingdom and European Union legislation. Of the reported failures, the high concentrations of nitrate and nitrite, lead, copper, and sulfate are of concern to health and remedial action is warranted. Regular sampling of private drinking water supplies remains necessary to prevent risk to health from a wide variety of toxic contaminants.