Non-children's Hospitals Research Articles

Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation.

Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.

Association of Children’s Hospital Status With Value for Common Surgical Conditions

Although children's hospitals (CH) provide a substantial proportion of highly specialized pediatric care in the United States, the value of CH compared with non-children's hospitals (NCH) for routine surgical procedures is unknown. To examine the value of CH for routine surgical procedures by assessing clinical outcomes and payment data. This retrospective cohort study examined pediatric patients undergoing 1 of 13 commonly performed surgical procedures between 2010 and 2015 with 90-day follow-up using administrative data from the Health Care Cost Institute. Data analysis was conducted from July 2019 to December 2021. The primary exposure was tier of CH status, defined using self-reported pediatric services, affiliation with pediatric focused programs, and validated based on proportion of pediatric admissions. Payments for common surgical procedures from private insurers and overall complication and readmission rates at 30, 60, and 90 days. There were 368 220 pediatric patients who underwent one of the surgical procedures of interest; 220 899 (60.0%) of the patients were male; 118 977 (32.3%) had their procedure at freestanding CH (CH-A), 75 256 (20.4%) at CH attached to an adult hospital (CH-B), and 173 987 (47.3%) at NCH. The mean (SD) payment for all procedures at CH-A was $6533.56 ($6399.97), $5847.50 ($4947.47) at CH-B, and $5034.25 ($4787.07) at NCH. The mean (SD) overall complication rate was 0.004 (0.06) at CH-A, 0.01 (0.07) at CH-B, and 0.003 (0.06) at NCH. Readmission rates at 30, 60, and 90 days were similar across all hospital types. After adjusting for zip code, year, surgery, surgery setting, and observable patient, hospital, and county characteristics, the estimated payments for inpatient common procedures were 39% higher at CH-A than at NCH. Payments for outpatient common procedures were 34% higher at CH-A than at NCH. In this cohort study, children who underwent common surgical procedures had equivalent clinical outcomes at CH and NCH but the procedures were associated with higher payments and, thus, overall lower value care. To ensure delivery of optimal value to patients and payers, more research is needed to evaluate mechanisms to ensure access, decrease costs, and improve value at both CH and NCH.

Cost of Chiari I Malformation Surgery: Comparison of Treatment at Children's Hospitals Versus Non-children's Hospitals.

Chiari I malformation is a common entity in pediatric neurosurgery. Prior studies have shown that surgical treatment at children’s hospitals (CH) is associated with higher costs compared to non-children’s hospitals (NCH) for other diagnoses. Therefore, we hypothesized that costs would be increased for the treatment of Chiari I malformation at a CH. Data were extracted from the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). Patients who underwent surgery for Chiari I malformation were identified using International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. Univariate statistical tests, multivariable linear regression models, and propensity score matching were utilized to determine differences in hospital length of stay (LOS) and costs between patients treated at CH versus NCH.Treatment at a CH was associated with significantly higher costs compared to treatment at an NCH while hospital LOS and mortality were similar. In the multivariable linear regression model, the adjusted average cost for surgical treatment of Chiari I malformation was $13,716, and treatment at a CH was associated with an additional $6,343 (p<0.0001). Similar results were seen after propensity score matching: costs for treatment at a CH were $6,047 higher than they were for treatment at an NCH (p<0.0001). In our analysis, a significant increase in cost was seen with treatment at a CH while controlling for patient demographics and hospital characteristics, as well as imbalanced covariates between the cohorts. Further investigation is warranted to determine the drivers of increased cost outside of the patient and hospital characteristics we analyzed in our study.

Distinguishing Children's Hospitals From Non-Children's Hospitals in Large Claims Data.

The first methodologic step needed to compare pediatric health outcomes at children's hospitals (CHs) and non-children's hospitals (NCHs) is to classify hospitals into CH and NCH categories. However, there are currently no standardized or validated methods for classifying hospitals. The purpose of this study was to describe a novel and reproducible hospital classification methodology. By using data from the 2015 American Hospital Association survey, 4464 hospitals were classified into 4 categories (tiers A-D) on the basis of self-reported presence of pediatric services. Tier A included hospitals that only provided care to children. Tier B included hospitals that had key pediatric services, including pediatric emergency departments, PICUs, and NICUs. Tier C included hospitals that provided limited pediatric services. Tier D hospitals provided no key pediatric services. Classifications were then validated by using publicly available data on hospital membership in various pediatric programs as well as Health Care Cost Institute claims data. Fifty-one hospitals were classified as tier A, 228 as tier B, 1721 as tier C, and 1728 as tier D. The majority of tier A hospitals were members of the Children's Hospital Association, Children's Oncology Group, and National Surgical Quality Improvement Program-Pediatric. By using claims data, the percentage of admissions that were pediatric was highest in tier A (88.9%), followed by tiers B (10.9%), C (3.9%), and D (3.9%). Using American Hospital Association survey data is a feasible and valid method for classifying hospitals into CH and NCH categories by using a reproducible multitiered system.

Impact of Children's Hospital Designation on Outcomes and Costs after Cholecystectomy in Adolescent Patients

Variations in the management of adolescents at children's hospitals (CHs) and nonchildren's hospitals (NCHs) have been well described in the trauma literature. However, the effects of CH designation on outcomes after common general surgical procedures have not been investigated. The purpose of this study was to compare the outcomes and costs of adolescent cholecystectomies performed at CHs and NCHs. Within the California State Inpatient Database (2005-2011), we identified 8117 cholecystectomy patients aged 13 to 18 years at CHs and NCHs. Outcomes (laparoscopy, intraoperative cholangiogram, length of stay (LOS), and complications) and costs were analyzed. CHs cared for younger patients, more uninsured patients, and more black patients. NCHs were associated with higher laparoscopy use (95.7% vs 88.3%, P < 0.01), higher intraoperative cholangiogram rates (28.8% vs 11.9%, P < 0.001), shorter LOS (3.2 vs 5.0 days, P < 0.01), and lower costs by $5797 per patient ($11,219 vs $17,016, P < 0.01). Although there was no significant difference in overall complication rates, CHs had higher rates of infectious complications (2.0% vs 1.0%, P = 0.004). Adolescent cholecystectomies are safely performed at NCHs while achieving increased laparoscopy use, shorter LOS, and lower costs compared with CHs.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals

BackgroundVariations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy. MethodsThe Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost. ResultsMost of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance. ConclusionsVariations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Comparison of Antibiotic Prescribing for Pediatric Community-Acquired Pneumonia Between Children's and Non-Children's Hospitals

Comparison of Antibiotic Prescribing for Pediatric Community-Acquired Pneumonia Between Children's and Non-Children's Hospitals

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

BackgroundVariation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. MethodsUsing the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. ResultsNCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7–18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5–3.8), PN OR 2.6 (95% CI 1.4–4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4–0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9–12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. ConclusionsVariation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.

The impact of children's hospital designation on outcomes in children with malrotation

BackgroundThe benefit of Ladd's procedure for malrotation at a Children's Hospital (CH) has not previously been established. Our aim was to characterize the potential variations in management and outcomes between CH and Non-Children's Hospitals (NCH) in the treatment of malrotation with Ladd's procedure. MethodsThere were 2827 children identified with malrotation and complete information from the Kids' Inpatient Database (2003, 2006, 2009). Outcomes were compared between CH and NCH and evaluated with logistic and linear regressions. Additional propensity score matching was used to balance covariates between CH and NCH. ResultsThere were 2261 (80.0%) children with malrotation undergoing Ladd's procedures treated at CH; 566 (20.0%) were treated at NCH. In multivariate analysis, CH was associated with a 39% lower odds of resection (p=0.004), with no differences observed for mortality, morbidity and LOS. Comparison of a propensity score matched cohort confirmed these findings, as well as demonstrated no significant differences in associated costs. ConclusionsThe majority of pediatric intestinal malrotation is managed at CH. While measured outcomes of mortality, morbidity, LOS, and costs were not different at NCH, CH was less likely to perform intestinal resection during Ladd's procedure.

Thrombolysis for Children With Acute Ischemic Stroke: A Perspective From the Kids' Inpatient Database

Thrombolysis for acute ischemic stroke (AIS) in children is yet to be proven efficacious, and there is limited information about its safety in large pediatric samples. Here we evaluate the safety outcomes associated with thrombolysis in children as well as the trend of hospital utilization over the past decade in the United States. A cohort of children with acute ischemic stroke was identified from the Kids' Inpatient Database for the years 1998-2009. Acute ischemic stroke was identified by the International Classification of Diseases-9 clinical classification software codes (109 and 110). Multivariate logistic regression analyses were used to assess covariates associated with outcomes of hospital mortality and intracerebral hemorrhage. The Cochran-Armitage test was employed for linear trend of discrete variables. In this analysis, 9257 children were admitted with the diagnosis of acute ischemic stroke; only 67 (0.7%) received thrombolysis. Thrombolysis-treated children were older than the rest of the cohort (13.1 ± 7.3 vs 8.18 ± 7.5; P < 0.0001) and they had a longer hospital stay (median 11 vs 6 days; P < 0.0001). Gender, race, and family income approximated by postal code were similar among the treated and untreated children. Unadjusted analysis showed higher hospital mortality (10.45% vs 6.14%; P = 0.06) and intracerebral hemorrhage (2.99% vs 0.77%; P = 0.08) in the thrombolysis group. Adjusted analysis showed that intracerebral hemorrhage is predictive of a higher hospital mortality (odds ratio 3.43; 95% confidence interval 1.89-6.22), whereas thrombolysis was not (odds ratio 1.78; 95% confidence interval 0.86-3.64). The overall rate of thrombolysis per 3 years intervals had increased from 5.2 to 9.7 per 1000 children with acute ischemic stroke (P = 0.02). This increase was mainly seen in non-children hospitals (P = 0.01). Thrombolysis for acute ischemic stroke is infrequently used in children. There is a trend toward higher risks of intracerebral hemorrhage and hospital mortality, although these risks are as low as those reported in adult population. The hospitals' utilization of thrombolysis in children has increased during the study period.

Disparity in Management and Long-term Outcomes of Pediatric Splenic Injury in California

To determine the impact of evidence-based guidelines on the disparities in management of pediatric splenic injuries (PSI). Several studies have highlighted a disparity in the utilization of nonoperative management (NOM) for PSI based on hospital and surgeon characteristics. Whether evidence-based guidelines had an impact on mitigating this disparity is uncertain. From 1999 to 2006, children < or = 18 years with PSI were extracted from California's Patient Discharge Database (n = 5089). Patient demographics, injury grade, immediate and delayed operations, readmissions, and complications were analyzed. The overall rates of immediate operative management (IOM) decreased significantly from 23% in 1999 to 15% in 2006 (P < 0.001). This decline was attributed entirely to reduction of IOM at non-children's hospitals (NCH) (29% to 20%, P < 0.001). In contrast, IOM rates were low and unchanged at children's hospital (CH) (9%, P = NS). Failed NOM (3.3%), readmissions for complications (0.6%), and operations (0.3%) were rare and unaffected by NOM increase. NCH had increased risk of IOM compared to CH in multivariate analysis (OR: 2.00, 99% CI: 1.09-3.57). The rate of delayed splenic rupture was 0.2%. There were no differences when comparing the rates of readmissions (1.0% vs. 0.4%, P = NS) and readmit operations (0.3% vs. 0.3%, P = NS) between IOM versus NOM. A steady increase in the utilization of NOM for PSI in California over time was attributed entirely to changing practices at NCH. Increasing NOM has occurred without a concurrent increase in complications. Delayed splenic ruptures were rare. Although IOM rates at NCH decreased over time, disparity in NOM utilization still exists between NCH and CH.

The impact of hospital type and experience on the operative utilization in pediatric intussusception: a nationwide study

Purpose To determine the impact in clinical outcomes of pediatric idiopathic intussusceptions from hospital experience and designation as children's hospitals (CH) and non–children's hospitals (NCH) in the US. Methods A retrospective study was performed on 1263 children with idiopathic intussusception, 2 months to 3 years of age in 2000 and 2003 by extracting data from the Healthcare Cost and Utilization Project Kid's Inpatient Database. Main outcome measures were utilizations of operation and radiologic reduction. Statistical significance was defined as P < .05. Results The median hospital volume of intussusceptions was higher at CH (2.5 vs 0.5 cases per year, P < .001) compared to NCH. Children treated at CH had lower risk of operation (55 vs 68%, P < .001) and higher likelihood of radiologic reduction (39 vs 26%, P < .001) compared to NCH. Multivariate regression analysis showed a 17% reduction of operative utilization at CH vs NCH. Outcomes were positively related to experience as high-volume hospitals reduced operative utilization by 19%. Rates of successful radiologic reduction were similar between hospital types, which was 85% nationally. Conclusion Children with intussusception have decreased likelihood of operation when treated at CH compared to NCH. This decreased operative utilization can be attributed to the increased experience and utilization of radiologic reduction at these specialty hospitals.