Pediatric Health Information System Hospitals Research Articles

Race, Ethnicity, and Intensive Care Utilization for Common Pediatric Diagnoses: U.S. Pediatric Health Information System 2019 Database Study.

Racial and ethnic disparities in healthcare delivery for acutely ill children are pervasive in the United States; it is unknown whether differential critical care utilization exists. Retrospective study of the Pediatric Health Information System (PHIS) database. Multicenter database of academic children's hospitals in the United States. Children discharged from a PHIS hospital in 2019 with one of the top ten medical conditions where PICU utilization was present in greater than or equal to 5% of hospitalizations. None. Race and ethnicity categories included Asian, Black, Hispanic, White, and other. Primary outcomes of interest were differences in rate of PICU admission, and for children requiring PICU care, total hospital length of stay (LOS). One-quarter (n = 44,200) of the 178,134 hospital discharges included a PICU admission. In adjusted models, Black children had greater adjusted odds ratio (aOR [95% CI]) of PICU admission in bronchiolitis (aOR, 1.08 [95% CI, 1.02-1.14]; p = 0.01), respiratory failure (aOR, 1.18 [95% CI, 1.10-1.28]; p < 0.001), seizure (aOR, 1.28 [95% CI, 1.08-1.51]; p = 0.004), and diabetic ketoacidosis (DKA) (aOR, 1.18 [95% CI, 1.05-1.32]; p = 0.006). Together, Hispanic, Asian, and other race children had greater aOR of PICU admission in five of the diagnostic categories, compared with White children. The geometric mean (± sd) hospital LOS ranged from 47.7 hours (± 2.1 hr) in croup to 206.6 hours (± 2.8 hr) in sepsis. After adjusting for demographics and illness severity, non-White children had longer LOS in respiratory failure, pneumonia, DKA, and sepsis. The need for critical care to treat acute illness in children may be inequitable. Additional studies are needed to understand and eradicate differences in PICU utilization based on race and ethnicity.

Emergency Care Utilization for Mental and Sexual Health Concerns Among Adolescents Following Sexual Assault: A Retrospective Cohort Study

PurposeThis study aimed to explore the health outcomes of adolescent survivors of sexual assault, as measured by subsequent emergency department (ED) utilization for mental and sexual health concerns. MethodsThis retrospective cohort study used the Pediatric Health Information System (PHIS) database. We included patients aged 11–18 years seen at a PHIS hospital with a primary diagnosis of sexual assault. The control group included age- and sex-matched patients seen for an injury. Participants were followed in PHIS for 3–10 years; subsequent ED visits for suicidality, sexually transmitted infection, pelvic inflammatory disease (PID), or pregnancy were identified, and likelihoods of each were compared using Cox proportional hazards models. ResultsThe study population included 19,706 patients. ED return visit rates in the sexual assault and control groups were 7.9% versus 4.1% for suicidality, 1.8% versus 1.4% for sexually transmitted infection, 2.2% versus 0.8% for PID, and 1.7% versus 1.0% for pregnancy, respectively. Compared to controls, sexual assault patients were significantly more likely to return to the ED for suicidality throughout the follow-up period, with the highest hazard ratio of 6.31 (95% confidence interval 4.46–8.94) during the first 4 months. Sexual assault patients also had higher likelihood of returning for PID (hazard ratio 3.80, 95% confidence interval 3.07–4.71) throughout the follow-up period. DiscussionAdolescents seen in the ED for sexual assault were significantly more likely to return to the ED for suicidality and sexual health concerns, highlighting the need for increased allocation of research and clinical resources to improve their care.

Antimicrobial Dosing Recommendations in Pediatric Continuous Renal Replacement Therapy: A Critical Appraisal of Current Evidence.

ObjectivesContinuous renal replacement therapy (CRRT) is commonly employed in critically ill children and is known to affect antimicrobial pharmacokinetics. There is a lack of readily available, evidence-based antimicrobial dosing recommendations in pediatric CRRT. This study aims to quantify commonly used antimicrobial drugs in pediatric CRRT and identify gaps between contemporary literature-based dosing recommendations and those presented in a frequently used dosing reference.MethodsThe Pediatric Health Information System (PHIS) database was queried from July 1, 2018 through June 30, 2021 to identify admissions in which antimicrobials were billed on the same day as CRRT. Drugs of interest were selected if at least 10% of admission involved administration on at least one CRRT day, with additional clinically important antimicrobials selected by the authors. A comprehensive literature search was performed to identify antimicrobial pharmacokinetic (PK) studies in children for each selected drug. For identified articles, dosing recommendations were extracted and compared to those in a popular tertiary dosing reference (Lexi-Comp Online database). The level of agreement of the dosing recommendations was assessed.Results77 unique antimicrobial agents were identified amongst 812 admissions from 20 different PHIS hospitals. Fifteen antimicrobials were billed on the same day as CRRT in ≥10% of admissions, with 4 additional drugs deemed clinically relevant by the authors. Twenty PK studies were identified for these 19 drugs, and dosing recommendations were included in 8 (42.1%) of them. Seventeen agents (89.5%) had some type of CRRT-specific dosing guidance in Lexi-Comp, with only 1 directly based on a pediatric CRRT study. For the 8 agents with PK data available, Lexi-Comp recommendations matched primary literature dosing guidance in 3 (37.5%). Two (25%) lacked agreement between the Lexi-Comp and primary literature, and the remaining 3 (37.5%) had partial agreement with multiple dosing regimens suggested in the primary literature and at least one of these regimens recommended by Lexi-Comp.ConclusionSignificant gaps exist in the data supporting antimicrobial dosing recommendations for children receiving CRRT. Future studies should focus on antimicrobial dosing in pediatric CRRT, emphasizing provision of robust data from which dosing recommendations can be promptly incorporated into tertiary dosing references.

MP08-19 FACTORS AFFECTING ORCHIOPEXY GUIDELINE ADHERENCE

You have accessJournal of UrologyCME1 May 2022MP08-19 FACTORS AFFECTING ORCHIOPEXY GUIDELINE ADHERENCE Andrea Balthazar, Ted Lee, Tanya Logvinenko, Caleb Nelson, Hsin-Hsiao Scott Wang, and Caleb Nelson Andrea BalthazarAndrea Balthazar More articles by this author , Ted LeeTed Lee More articles by this author , Tanya LogvinenkoTanya Logvinenko More articles by this author , Caleb NelsonCaleb Nelson More articles by this author , Hsin-Hsiao Scott WangHsin-Hsiao Scott Wang More articles by this author , and Caleb NelsonCaleb Nelson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002530.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cryptorchidism affects 3%-5% of term males. AUA guidelines for evaluating and treating cryptorchidism recommend surgical repair before 18 months of age (MoA) in boys with unilateral or bilateral cryptorchidism. Our objective was to understand the factors associated with cryptorchidism guideline adherence. METHODS: Pediatric Health Information System (PHIS) is a database of freestanding children’s hospitals. Using PHIS, we performed a multicenter retrospective study of boys ages 18 years and younger undergoing orchiopexy between 1/1/2009-12/31/2019. Categorized subjects by race/ethnicity(R/E) (Hispanic defined as any subject who identifies as Hispanic regardless of race), insurance type, income quintile, and presence of comorbid conditions. PHIS hospitals without outpatient surgery information were excluded. We fitted multivariate mixed-effects logistic regression models to evaluate the association of sociodemographic factors with the odds of undergoing surgery after 18 MoA (hospital-level as random effect). Multiple imputations were used for missing observations. Sensitivity analysis (SA) was performed for 18 and 24 MoA. RESULTS: 89114 cryptorchid males had orchiopexy between 2009-2019; 59093 (66.3%) surgeries occurred ≥18 MoA. 45303 (50.8%) were White, and 42213 (47.4%) had public insurance. Increased odds of orchiopexy after 18 MoA correlates with Black or Hispanic (P < 0.001), self-pay/charity (P=0.007), higher-income quintile (P <0.001), and lower comorbidity level (P <0.001). Black (OR=1.22; 95% CI, 1.16-1.28; P <0.001) and Hispanic (OR=1.19; 95% CI, 1.14-1.24; P <0.001) were at increased odds of delayed orchiopexy compared to Whites. We did not attribute the associations of R/E, insurance, or income with the outcome to single hospitals. The highest income compared to lowest was associated with increased odds of surgery after 18 MoA at 29/34 hospitals (85%). Compared to private insurance, public correlates with increased odds of surgical delay at 13/34 hospitals (38%). SA with 24 MoA with similar results. CONCLUSIONS: Consistent with prior studies, orchiopexy remains delayed despite guidelines. In addition, Black, Hispanic, self-pay/charity, and lower comorbidity were significantly associated with delay. This highlights a need to refine provider education & outreach efforts to reduce disparities in care. Source of Funding: 5T32DK060442 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e133 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea Balthazar More articles by this author Ted Lee More articles by this author Tanya Logvinenko More articles by this author Caleb Nelson More articles by this author Hsin-Hsiao Scott Wang More articles by this author Caleb Nelson More articles by this author Expand All Advertisement PDF DownloadLoading ...

Hospital Charges Associated With Critical Bronchiolitis From 2009 to 2019.

To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period. In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care. Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database. Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition. None. PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001). In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.

Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis.

High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC. In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes. The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups. Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.

Influenza-Associated Neurologic Complications in Children

Research Article| October 01 2021 Influenza-Associated Neurologic Complications in Children AAP Grand Rounds (2021) 46 (4): 39. https://doi.org/10.1542/gr.46-4-39 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Influenza-Associated Neurologic Complications in Children. AAP Grand Rounds October 2021; 46 (4): 39. https://doi.org/10.1542/gr.46-4-39 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: influenza, neurologic complications Source: Antoon JW, Hall M, Herndon A, et al Prevalence, risk factors, and outcomes of influenza-associated neurologic complications in children [published online ahead of print June 30, 2021]. J Pediatr. doi:10.1016/j.jpeds.2021.06.075 Investigators from multiple institutions conducted a retrospective study to estimate the prevalence of neurologic complications in children hospitalized with influenza, identify risk factors associated with these complications, and assess hospital-related outcomes. For the study, they abstracted data from the Pediatric Health Information System (PHIS) database, which includes information on admissions to 49 tertiary care children’s hospitals across the US. Participants for the current study were children 2 months through 17 years old hospitalized at a PHIS hospital during the influenza seasons from 2015 through 2020 with an ICD-10 diagnostic code for influenza. Information abstracted from the PHIS database on these patients included demographic data, geographic region, hospital length of stay (LOS), ICU admission, other ICD-10 diagnoses, presence of chronic neurologic conditions (defined using the pediatric complex chronic conditions classification system version 2), and hospital charges. The primary study outcome was an ICD-10 code for a neurologic complication, including febrile seizure, non-febrile seizure, encephalopathy, encephalitis, aseptic meningitis, brain abscess and bacterial meningitis, Reye syndrome, and cerebral infarction. Multivariate regression analyses to identify risk factors for a neurologic complication, with controlling for confounders, were conducted. Predominant influenza type was included in the regression model and estimated from CDC influenza surveillance data in each patient’s census division during the week that they were hospitalized. Bivariate analyses were used to compare hospital-related outcomes including LOS, ICU admission, costs (estimated from charge data), and in-hospital death rates among patients with and without neurologic complications. Data were analyzed on 29,676 children hospitalized with influenza. The median age of the included patients was 4 years, and 56% were male. A total of 2,246 (7.6%) had a neurologic complication. The most common neurologic complications were febrile seizure (N = 1,447, 5.0% of influenza admissions), encephalopathy (514, 1.7%), and non-febrile seizure (364, 1.2%). Risk factors identified in the multivariate analyses included male sex (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0, 1.2), Asian race (OR, 1.7; 95% CI, 1.4, 2.1), other race (includes Pacific Islander, American Indian, multiracial, and other; OR, 1.2; 95% CI, 1.03, 1.4), and presence of a chronic neurologic condition (OR, 3.7; 95% CI, 3.1, 4.2). There was no statistical association between predominant influenza type and neurologic complication. Patients with neurologic complications had longer ICU LOS than those without (mean values 2.7 and 2.2 days, respectively; P <0.05), a higher rate of ICU admissions (24.5% vs 15.3%; P <0.001), a higher rate of in-hospital death (0.7% vs 0.2%; P <0.001), and higher costs (mean costs $6,013 vs $5,282; P <0.001). The authors conclude that neurologic complications were common among children hospitalized with influenza, particularly in those with chronic neurologic conditions. Dr Brady has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. For... You do not currently have access to this content.

Transplantation for Congenital Heart Disease: Focus on the Impact of Functionally Univentricular Versus Biventricular Circulation.

Varying single center data exist regarding the posttransplant outcomes of patients with single ventricle circulation, particularly following the Fontan operation. We sought to better elucidate these results in patients with congenital heart disease (CHD) through combining two national databases. The United Network for Organ Sharing (UNOS) transplantation database was merged with the Pediatric Health Information System (PHIS), an administrative database with 71% of UNOS patients matched. Patients undergoing transplantation at a PHIS hospital from 2006 to 2017 were categorized as single ventricle or biventricular strategy based on their diagnoses and procedures in 90% of patients. When known, single ventricle patients were further analyzed by their palliative stage post-Glenn or post-Fontan (known in 31%). A total of 1,517 CHD transplantations were identified, 67% with single ventricle strategy (1,016). Single ventricle, biventricular, and indeterminate patients had similar survival (log-rank P > .1). Risk factors for mortality in patients with CHD were extracorporeal membrane oxygenation (ECMO) support at transplant (hazard: 2.27), ABO blood type incompatibility (hazard: 1.61), African American recipient (hazard 1.42), and liver dysfunction (hazard 1.29). A total of 130 confirmed Fontan and 185 confirmed bidirectional Glenn patients underwent transplantation, each with survival equivalent to biventricular patients (log-rank P > .500). For Fontan patients, renal dysfunction (hazard: 5.40) and transplant <1 year after Fontan (hazard 2.82) were found to be associated with mortality. Single ventricle patients, as a group, experience similar outcomes as biventricular patients with CHD undergoing transplantation, and this extends to Fontan patients. Risk factors for mortality correlate with end-organ dysfunction as well as race and ABO blood type incompatibility in the CHD population.

The Impact of Donor Type on Outcomes and Cost of Allogeneic Hematopoietic Cell Transplantation for Pediatric Leukemia: A Merged Center for International Blood and Marrow Transplant Research and Pediatric Health Information System Analysis.

Allogeneic hematopoietic stem cell transplantation (alloHCT) may be associated with significant morbidity and mortality, resulting in increased healthcare utilization (HCU). To date, no multicenter comparative cost analyses have specifically evaluated alloHCT in children with acute leukemia. In this retrospective cohort study, we examined the relationship between survival and HCU while investigating the hypothesis that matched sibling donor (MSD) alloHCT has significantly lower inpatient HCU with unrelated donor (URD) alloHCT, and that among URDs, umbilical cord blood (UCB) alloHCT will have higher initial utilization but lower long-term utilization. Clinical and transplantation outcomes data from the Center for International Blood and Marrow Transplant Research (CIBMTR) were merged with inpatient cost data from the Pediatric Health Information System (PHIS) database using a probabilistic merge methodology. The merged dataset comprised US patients age 1 to 21 years who underwent alloHCT for acute leukemia between 2004 and 2011 with comprehensive CIBMTR data at a PHIS hospital. AlloHCT was analyzed by donor type, with specific analysis of utilization and costs using PHIS claims data. The primary outcomes of overall survival (OS), leukemia-free survival (LFS), and inpatient costs were evaluated using Kaplan-Meier curves and Cox and Poisson models. A total of 632 patients were identified in both the CIBMTR and PHIS data. The 5-year LFS was 60% for MSD alloHCT, 47% for well-matched matched unrelated donor bone marrow (MUD) alloHCT, 48% for mismatched unrelated donor alloHCT, and 45% for UCB alloHCT (P=.09). Total adjusted costs were significantly lower for MSD alloHCT versus MUD alloHCT by day 100 (adjusted cost ratio [ACR], .73; 95% confidence interval [CI], .62 to .86; P < .001), and higher for UCB alloHCT versus MUD alloHCT (ACR, 1.27; 95% CI, 1.11 to 1.45; P < .001). By 2 years, total adjusted costs remained significantly lower for MSD alloHCT compared with MUD alloHCT (ACR, .67; 95% CI, .56 to .81; P < .001) and higher for UCB alloHCT compared with MUD alloHCT (ACR, 1.25; 95% CI, 1.02 to 1.52; P=.0280). Our data show that UCB and MUD alloHCT provide similar survival outcomes; however, MUD alloHCT has a significant advantage in cost by day 100 and 2 years. More research is needed to determine whether the cost difference among URD alloHCT approaches remains significant with a larger sample size and/or beyond 2 years post-alloHCT.

Geographic and Specialty Access Disparities in US Pediatric Leukodystrophy Diagnosis

To examine disparities in the diagnosis of leukodystrophies including geographic factors and access to specialty centers. Retrospective cohort study of pediatric patients admitted to Pediatric Health Information System hospitals. Patients with leukodystrophy were identified with International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic codes for any of 4 leukodystrophies (X-linked adrenoleukodystrophy, Hurler disease, Krabbe disease, and metachromatic leukodystrophy). We used 3-level hierarchical generalized logistic modeling to predict diagnosis of a leukodystrophy based on distance traveled for hospital, neighborhood composition, urban/rural context, and access to specialty center. We identified 501 patients with leukodystrophy. Patients seen at a leukodystrophy center of excellence hospital were 1.73 times more likely to be diagnosed than patients at non-center of excellence hospitals. Patients who traveled farther were more likely to be diagnosed than those who traveled shorter. Patients living in a Health Professionals Shortage Area zip code were 0.86 times less likely to be diagnosed than those living in a non-Health Professionals Shortage Area zip code. Geographic factors affect the diagnosis of leukodystrophies in pediatric patients, particularly in regard to access to a center with expertise in leukodystrophies. Our findings suggest a need for improving access to pediatric specialists and possibly deploying specialists or diagnostic testing more broadly.

Burden of Vaccine-Preventable Infections Among Pediatric Hematopoietic Cell Transplant Recipients

<h3>Background</h3> Hematopoietic cell transplantation (HCT) recipients are increased risk for vaccine-preventable infections (VPI). However, the true prevalence of VPI in children post-HCT is unknown. <h3>Methods</h3> We performed an epidemiological study using the Pediatric Health Information System (PHIS) database in children and young adults who underwent allogeneic (allo) and autologous (auto) HCT and had a first hospitalization with a VPI (as defined by ICD-9 and ICD-10 codes) within 5-yr post-HCT between Jan 1, 2010 and Dec 31, 2018 at the 45 participating US PHIS hospitals. Prevalence for overall VPI and by infection were calculated at the following timepoints: at initial HCT admission, HCT discharge to D100, D101-D180, 6-12 months, 1-2 yr, and 2-5 yr post-HCT. <h3>Results</h3> We identified 9,591 unique HCT recipients (alloHCT: 6,602, 69%; autoHCT: 2,989, 31%) with a median age of 6.7 years (range infant-18.9 yrs) during the 8-yr study period. Of these, 684 HCT recipients (510 alloHCT, 174 autoHCT) were hospitalized with VPI in the first 5 yrs after HCT, for an overall prevalence of 7.1%. VPI occurred more frequently among alloHCT (8%) than autoHCT recipients (6%) at all time-points (p=0.0008). VPI hospitalizations occurred a median of 221 days post-HCT [range 0-5 yrs] with the majority occurring in the first 6-12 mos post-HCT (Figure 1). Influenza was the most frequent VPI (4.05%) (Table I). <h3>Conclusion</h3> The overall prevalence of VPI hospitalizations after pediatric HCT was 7.1%, occurring most frequently in the first 6-12 months post HCT and among alloHCT recipients. Continued efforts to prevent VPI, including optimizing vaccination strategies in this population, are warranted.

Children with Psychogenic Nonepileptic Seizures.

A large multicenter retrospective cohort study was conducted by researchers from the Pediatric Health Information System hospital network to determine differences in demographics, clinical characteristics, testing, treatment, and healthcare use between children aged 8-20 years with epilepsy (n = 13,241) and those with psychogenic nonepileptic seizures (PNES) secondary to conversion disorder (n = 399).

Shortened Antibiotic Course in Late-Onset GBS Bacteremia

Research Article| February 01 2019 Shortened Antibiotic Course in Late-Onset GBS Bacteremia AAP Grand Rounds (2019) 41 (2): 21. https://doi.org/10.1542/gr.41-2-21 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Shortened Antibiotic Course in Late-Onset GBS Bacteremia. AAP Grand Rounds February 2019; 41 (2): 21. https://doi.org/10.1542/gr.41-2-21 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bacteremia, antibiotic therapy, intravenous Source: Coon ER, Srivastava R, Stoddard G, et al. Shortened IV antibiotic course for uncomplicated, late-onset group B streptococcal bacteremia. Pediatrics. 2018; 142(5): e20180345; doi: https://doi.org/10.1542/peds.2018-0345Google Scholar Investigators from the University of Utah and Cincinnati Children’s Hospital Medical Center conducted a retrospective cohort study to determine the effect of an IV antibiotic course for uncomplicated, late-onset group B Streptococcus (GBS) bacteremia that was shorter than the recommended 10 days. The cohort was identified using the Pediatric Health Information System (PHIS) database, which provides demographic, billing, and administrative data for patients cared for at 49 US children’s hospitals. PHIS patients were eligible for inclusion in study analyses if they were 7 days to 4 months of age and were discharged from a PHIS hospital between 2000 and 2015 with an ICD-9 discharge diagnosis code for GBS disease and bacteremia. Patient demographics and medical history (eg, history of prematurity, other infections) were abstracted from the PHIS database. The primary exposure of interest was receipt of a shortened course of IV antibiotics, defined as ≤8 days. Patients with a procedure code or hospital charge for a peripherally inserted central catheter were not classified as having received a shortened course regardless of the measured duration of antibiotics while hospitalized (as they were assumed to have completed a longer antibiotic course). The primary outcome was recurrence of GBS disease, defined as a hospital revisit for GBS disease and bacteremia, meningitis, or osteomyelitis in a patient’s first year of life (using ICD-9 codes). Investigators tested the association between exposure and outcome by using propensity-adjusted logistic regression. There were 775 infants included in analysis. Of these, 21% (n=163) received a shortened course of IV antibiotics. A higher proportion of infants who received (vs did not receive) a shortened course were older and had a concomitant UTI. Overall, recurrence of GBS disease occurred in 2.2% (n=17). There was no difference in recurrence of GBS among patients who did and did not receive a shortened course of IV antibiotics (1.8% vs 2.3%, respectively; adjusted absolute difference, −0.2%; 95% CI, −3.0%–2.5%). The investigators conclude that GBS recurrence rates are low with a shortened course of IV antibiotics for uncomplicated, late-onset GBS bacteremia. Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. There exists a paradox for pediatricians caring for very young patients with documented GBS bacteremia. The AAP Red Book recommendation is treatment with 10 days of IV antibiotics,1 but one cannot find primary evidence to support this expert consensus. With a lack of data to oppose it, this recommendation has become the national standard of care. Although the current study begins to develop an evidence base for shortening the course in this clinical setting, it is even more interesting that >20% of patients in this study were treated with ≤8 days of IV antibiotics. According... You do not currently have access to this content.

Does the incidence of thoracic aortic injury warrant the routine use of chest computed tomography in children?

Thoracic aortic injury is a potentially life-threatening injury associated with rapid deceleration mechanisms. Diagnosis is made by chest computed tomography (CT), which is associated with a risk of radiation-induced malignancy. We sought to determine the incidence of aortic injuries in the pediatric population to weigh against the risk of CT imaging. The Pediatric Health Information Systems was queried for children ≤18 years with discharge diagnosis code of thoracic aortic injury (901.0) between December 2004 and 2014. Data abstracted included patient age, gender, diagnosis and procedure codes, and discharge disposition, where available. We also queried for imaging codes to determine what type of chest imaging the child received. Between December 2004 and 2014, 311,850 children were admitted to Pediatric Health Information Systems hospitals with traumatic injury. Of these patients, 46 (0.015%) were coded with a thoracic aortic injury and an accompanying E-code. Twenty-seven patients (58.7%) were male, and the median age was 13 years. The most common mechanism of injury was motor vehicle collision (63%, n = 29). Eighteen hospitals (41.9%) had no patients with a thoracic aortic injury in the 10-year period. In children with a thoracic aortic injury, the mortality rate was 11% (n = 5) and 22 (47.8%) underwent a chest CT during their hospitalization. Forty percent (124,909) of all trauma patients underwent chest CT, with a positive rate for aortic injury of 1.8/10,000. The reported estimated cancer risk from a chest CT scan is 25/10,000 for girls and 7.5/10, 000 in boys, greater than the positive CT rate. Thoracic aortic injuries are rare in children in the United States. The risk of cancer associated with screening chest CT is greater than the likelihood of identifying an aortic injury. Therefore, screening chest CT scans are unwarranted in injured children. Therapeutic/Care Management, level IV.

Magnitude and Pace of Improvement in Performance of Hospitals Treating Mechanically Ventilated Children in the United States: Analysis From Two National Databases.

To use two national databases to quantify the pace and magnitude of improvement in hospital performance (as measured by mortality) across hospitals caring for critically ill children in the United States. We used empirical Bayes shrinkage estimators to obtain shrinkage estimators of observed/expected mortality ratios for each hospital assuming a Gamma Poisson posterior distribution. Revised mortality rates for each hospital were obtained from the shrunken incidence ratios. Pediatric Health Information System participating hospital and Kids' Inpatient Database participating hospital. Patients less than or equal to 18 years old who received invasive mechanical ventilation during their hospital stay at a Pediatric Health Information System participating hospital (2005-2015) or a Kids' Inpatient Database participating hospital (1997-2012) were included. None. A total of 486,838 patients from 48 Pediatric Health Information System hospitals and 798,840 patients from 947 Kids' Inpatient Database hospitals were included. For the Pediatric Health Information System hospitals, the median shrunken adjusted mortality decreased from 11.66% in 2005 to 7.11% in 2015; for the Kids' Inpatient Database hospitals, it decreased from 5.79% in 1997 to 3.86% in 2012. By 2015, more than 95% of the Pediatric Health Information System hospitals performed better than or as well as the best 25% of the hospitals in 2005. By 2012, 33.7% of Kids' Inpatient Database hospitals performed better than or as well as the best 25% of the hospitals in 1997. This study provides insight into the magnitude of improvement in patient mortality in hospitals caring for critically ill children in the United States. This study quantifies hospital performance in pediatric critical care over time, and it provides benchmarks against which individual hospitals can assess their own performance. In future pediatric epidemiologic studies, we should identify outcomes other than mortality to quantify improvement in hospital performance.

The use of echinocandins in hospitalized children in the United States.

Echinocandins are used for treatment of invasive candidiasis, but data on their use in children are limited. We sought to describe the epidemiology of echinocandin use in hospitalized children in the United States.We performed a retrospective cohort study of children <18 years of age hospitalized between January 2005 and December 2015 and exposed to ≥1 day of a systemic antifungal agent using the Pediatric Health Information System (PHIS) database. Univariate analyses compared recipients of two echinocandin agents, caspofungin and micafungin. Crude prescribing rates of each antifungal group were calculated across hospitals and per year. The rate of antifungal agent prescribing over time was assessed using two-level mixed-effects negative binomial regression, accounting for variability in prescribing by hospital over time. From 2005 to 2015, fluconazole was prescribed most often (n = 148,859, 74.3%), followed by mould-active triazoles (n = 36,131, 18.0%), amphotericin products (n = 29,008, 14.5%), and echinocandins (n = 28,371, 14.2%). The crude rate of systemic antifungal prescribing decreased across all PHIS hospitals from 36.3 to 33.8 per 1000 admissions during the study period, but echinocandin prescribing increased from 2.2 to 7.2 per 1000 admissions. A mixed effects regression model revealed that echinocandin prescribing increased by 15.1% per year (95% CI 11.2-19.2). Echinocandin administration increased from 6.1% to 21.0% of admissions during which a systemic antifungal agent was given. In conclusion, echinocandin use has increased significantly over time, accounting for an increasing proportion of systemic antifungal prescribing in children.

3:27 PM Abstract No. 114 Nationwide trends in pediatric percutaneous kidney and liver biopsies: is there a value proposition for interventional radiologists who can safely perform these procedures as outpatients?

To investigate trends, costs, relative safety, and potential savings of inpatient versus outpatient percutaneous kidney and liver biopsies in the pediatric population. Data on admission type and cost (using billed charges as a cost-surrogate) from all percutaneous kidney and liver biopsies performed from 2008-2015 was collected using the Pediatric Health Information System (PHIS), a comparative database of patient encounters from 44 US Children’s Hospitals. Regression analysis was performed to evaluate the annual trend in the biopsy patients admitted as inpatients vs outpatients. Costs were compared using the Tukey-Kramer Method (significance: p < 0.05). To assess safety of outpatient biopsies performed by interventional radiology (IR), data was collected on all percutaneous kidney and liver biopsies performed at a single, large tertiary care children’s hospital (“Hospital A”) from 2014-2017, using complications requiring escalation in care (SIR Classifications B-F) as a surrogate for safety. 7,835 kidney and 9,984 liver biopsies were performed by all specialties at all PHIS hospitals. Regression analysis showed a significant annual decline in percentage of kidney (-0.6%, p = 0.008) and liver (-3.0%, p = 0.01) biopsies. Notably, > 15% and >10% of kidney and liver biopsies were still performed as inpatients as of 2015, respectively. Costs were significantly (p < 0.0001) higher for inpatient biopsies (mean: $65,872 + $201,572 for kidney, mean: $173,331+ $505,177 for liver) vs outpatients (mean: $13,410 + $7,385 kidney, mean: $10,338+ $7,273 liver). 223 kidney biopsies and 441 liver biopsies were performed on outpatients from 2014-17 by IR at Hospital A. Percutaneous kidney biopsy complication rate = 1.3% (1 SIR class C, 2 SIR class D). Percutaneous liver biopsy complication rate = 0.2% (1 SIR Class C). A substantial percentage of pediatric patients are still admitted as inpatients for postprocedure monitoring following percutaneous kidney and liver biopsies. Our study shows that these procedures can be done safely by IRs as outpatients, offering substantial potential cost savings for healthcare systems.

Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children's Hospitals.

In 2013, the Society of Hospital Medicine (SHM) released 5 pediatric recommendations for the Choosing Wisely Campaign (CWC). Our goals were to develop a report card on the basis of those recommendations, calculate achievable benchmarks of care (ABCs), and analyze performance among hospitals participating in the Pediatric Health Information System. Children hospitalized between January 2013 and September 2015 from 32 Pediatric Health Information System hospitals were studied. The quality metrics in the report card included the use of chest radiograph (CXR) in asthma and bronchiolitis, bronchodilators in bronchiolitis, systemic corticosteroids in lower respiratory tract infections (LRTI), and acid suppression therapy in gastroesophageal reflux (GER). ABCs were calculated for each metric. Calculated ABCs were 22.3% of patients with asthma and 19.8% of patients with bronchiolitis having a CXR, 17.9% of patients with bronchiolitis receiving bronchodilators, 5.5% of patients with LRTIs treated with systemic corticosteroids, and 32.2% of patients with GER treated with acid suppressors. We found variation among hospitals in the use of CXR in asthma (median: 34.7%, interquartile range [IQR]: 28.5%-45.9%), CXR in bronchiolitis (median: 34.4%, IQR: 27.9%-49%), bronchodilators in bronchiolitis (median: 55.4%, IQR: 32.3%-64.9%), and acid suppressors in GER (median: 59.4%, IQR: 49.9%-71.2%). Less variation was noted in the use of systemic corticosteroids in LRTIs (median: 13.5%, IQR: 11.1%-17.9%). A novel report card was developed on the basis of the SHM-CWC pediatric recommendations, including ABCs. We found variance in practices among institutions and gaps between hospital performances and ABCs. These findings represent a roadmap for improvement.

Comparing the Utilization of Health Care Resources in Children with ALL and AML Based on Geographic Location: A Retrospective Analysis Utilizing the PHIS Database

Introduction: Geographic barriers play a major role in access to health care and can increase health care utilization, especially in the Pediatric cancer patients where leukemia and treatment related complications are life threatening if not promptly managed.Objective: To assess health care utilization and costs in the pediatric ALL and AML population based on geographic distance from their primary cancer center based on the hypothesis that those living further away would incur greater cost due to delays in seeking and/or receiving care.Methods: To study this, we analyzed data from the Pediatric Health Information System (PHIS) database, which collects information for inpatient resource utilization at 45 children's hospitals in the USA. Data from patient's ≤ 21 years of age with the diagnosis of ALL or AML by ICD-9 code between the first quarter 2010 and the third quarter 2013 were used. The total number of hospitalizations and resources utilized and billed were measured 1 year following the index visit for ALL and 6 months for AML. Data collected were total cost / day, length of stay (LOS), and prevalence of ICU, TPN, and ventilator use. Stratified data depending on chemotherapy vs. non-chemotherapy stays were compared between children living <60 vs. >60 miles from the PHIS hospital using chi-square and Wilcoxon rank-sum statistics (Tables A & B).Results: Hospital admissions for chemotherapy (12,884) and non-chemotherapy (13,842) were recorded in the ALL group. Among chemotherapy admissions, no statistical significance in ICU, TPN or ventilator days in those <60 or ≥60 miles from a PHIS hospital was seen. There was significantly greater ICU (4.5% vs. 6.1%, p=0.001) and TPN (5.1% vs. 6.6%, p=0.004) use in children living >60 miles from the hospital admitted for non-chemo purposes.In children with AML, 2,855 chemo- and 1,414 non-chemo-related admissions were recorded. Those admitted for chemo living >60 miles away, had longer LOS, and more ICU use (4.1% vs. 6.7%, p=0.09), yet had lower cost per day. Those admitted for non-chemo purposes living ≥60 miles away had more prevalent ICU (8.3% vs. 14.5%, p=0.03) and TPN use (9.7% vs. 15.7%, p=0.06), and greater hospitalization cost and cost per day.Conclusion: Geographic distance from cancer centers increases health care resource consumption and cost especially in the unplanned admissions for complications in children with ALL and AML. Prospective studies are needed to confirm the resource utilization and costs associated with geographic distance from cancer center resources and should be considered in pediatric cancer center outreach planning.Table AALLOverall %<60 miles %≥60 miles %p-valueChemo AdmitTotal Admits - N1288410663 (82.8%)2221 (17.2%)ICU Use0.4%0.4%0.4%0.969TPN Use4.9%5%4.9%0.860Ventilator.004%.0038%.0045%0.870LOS (d): Median [IQR]3 [2, 4]3 [2, 4]3 [2, 4]0.367Cost (US$): Median [IQR]7820.5 [4850.4, 12251.3]7861.9 [4862.6, 12395]7666.9 [4825.2, 11647.3]0.059Cost/Day: Median [IQR]2478.9 [1729.6, 3525.3]2532.3 [1753.9, 3564.7]2276.3 [1677, 3347]<.001Non-Chemo AdmitTotal Admits - N1384211542 (83.4%)2300 (16.6%)ICU Use4.8%4.5%6.1%0.001TPN Use5.4%5.1%6.6%0.004Ventilator1.4%1.4%1.4%0.938LOS (d): Median [IQR]3 [2, 7]3 [2, 7]3 [2, 7]0.408Cost (US$): Median [IQR]8448.4 [4515.3, 18007.6]8439.7 [4535.4, 18001.3]8469.2 [4433, 18021.8]0.706Cost/Day: Median [IQR]2559.1 [1866.4, 3580]2578.8 [1888.1, 3595.5]2438.6 [1786.2, 3476.8]<.001Table BAMLOverall<60 miles≥60 milesp-valueChemo AdmitTotal Admits - N28552306 (80.8%)549 (19.2%)ICU Use4.60%4.10%6.70%0.009TPN Use8.70%8.70%8.70%0.958Ventilator0.90%0.80%1.30%0.264LOS (d): Median [IQR]22 [5, 28]22 [4, 28]23 [6, 27]0.010Cost (US$): Median [IQR]35483.6 [11914.3, 63738.3]34782.5 [11339.9, 64075.8]38384.5 [12817.1, 62315.9]0.329Cost/Day: Median [IQR]2284.5 [1686.8, 3129.8]2318 [1726.2, 3175.4]2166.6 [1548.7, 2925.8]0.002Non-Chemo AdmitTotal Admits - N14141165 (82.4%)249 (17.6%)ICU Use9.40%8.30%14.50%0.003TPN Use10.70%9.70%15.70%0.006Ventilator3.10%2.80%4.40%0.191LOS (d): Median [IQR]7 [3, 17]7 [3, 17]8 [2, 17]0.294Cost (US$): Median [IQR]17518.8 [7172.6, 46880.9]16018.1 [7031.4, 42745.5]23406.8 [7959.3, 58444.2]0.014Cost/Day: Median [IQR]2967.8 [2085.7, 4053.9]2907.4 [2086.1, 3914.9]3317.8 [2063, 4590.2]0.022 DisclosuresNo relevant conflicts of interest to declare.

Testing for Abuse in Children With Sentinel Injuries

Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries. This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries. Among all visits for children <24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children <12 months old with burns to 56.1% for children <24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries. Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.