Pediatric Health Information System Research Articles

Patterns of Use of β-2 Agonists, Steroids, and Mucoactive Medications to Treat Bronchiolitis in the PICU: U.S. Pediatric Health Information System 2009-2022 Database Study.

Describe β2-agonists, steroids, hypertonic saline (HTS), n-acetylcysteine (NAC), and dornase alfa (DA) use to treat bronchiolitis, factors associated with use, and associations between use and PICU length of stay (LOS). Retrospective, multicenter cohort study. PICUs in the Pediatric Health Information System database. PICU admitted children 24 months young or younger with bronchiolitis. None. We analyzed 47,520 hospitalizations between July 1, 2018, and June 30, 2022. We calculated the rate of medication use overall and the median (range) rate for each hospital: β2-agonist (24,984/47,520 [52.6%]; median hospital, 51.7% [21.4-81.7%]), steroid (15,878/47,520 [33.4%]; median hospital, 33.4% [6.0-54.8%]), HTS (7,041/47,520 [14.8%]; median hospital, 10.5% [0-66.1%]), NAC (1,571/47,520 [3.3%]; median hospital, 0.8% [0-22.0%], and DA (840/47,520 [1.8%]; median hospital, 1.4% [0-13.6%]). Logistic regression using generalized estimating equations (GEEs) identified associations between concurrent asthma and β2-agonist (adjusted odds ratio [aOR], 8.68; 95% CI, 7.08-10.65; p < 0.001) and steroid (aOR, 10.10; 95% CI, 8.84-11.53; p < 0.001) use. Mechanical ventilation was associated with all medications: β2-agonists (aOR, 1.79; 95% CI, 1.57-2.04; p < 0.001), steroids (aOR, 2.33; 95% CI, 1.69-3.21; p < 0.001), HTS (aOR, 1.82; 95% CI, 1.47-2.25; p < 0.001), NAC (aOR, 3.29; 95% CI, 2.15-5.03; p < 0.001), and DA (aOR, 7.65; 95% CI, 4.30-13.61; p < 0.001). No medication was associated with decreased PICU LOS. To assess changes in medication use over time and associations with the 2014 American Academy of Pediatrics bronchiolitis guidelines, we expanded our analysis to 83,820 hospitalizations between July 1, 2009, and June 30, 2022. Logistic regression with GEEs found no change in β2-agonist use; steroid use increased after guideline publication (aOR, 1.05; 95% CI, 1.01-1.10; p = 0.02), HTS use changed from increasing prior to the guidelines (aOR, 1.32; 95% CI, 1.11-1.56; p = 0.001) to stable since guideline publication (aOR, 0.93; 95% CI, 0.81-1.07; p = 0.33). β2-agonists, steroids, and HTS are commonly, but variably used for PICU bronchiolitis treatment. Medication use appears relatively stable over the last decade.

Unplanned Readmission Rate Before Interval Appendectomy After Nonoperative Management of Complicated Appendicitis.

There remains clinical equipoise regarding the preference for upfront appendectomy or nonoperative management for patients with complicated appendicitis. However, the natural history of the appendix following nonoperative management and pending interval appendectomy in children is not well characterized, and the risk of recurrent appendicitis as a function of time from index admission not known. The Pediatric Health Information System (PHIS) was queried for all patients younger than 18 with an ICD-10 diagnosis code for complicated appendicitis admitted between 2018-2021. Patients were included for analysis if they received antibiotics on three or more consecutive days and did not undergo appendectomy during index admission. Kaplan-Meier analysis was performed to determine rates of unplanned readmission, defined as patients readmitted for appendicitis and receiving antibiotics on three or more consecutive days following index admission. 2,826 patients were included in the study for complicated appendicitis. 2,016 (71.4%) patients underwent appendectomy, while the remaining 810 did not undergo appendectomy. Kaplan-Meier survival analysis demonstrated a 7% decrease unplanned readmission rates for each additional day patients were removed from index admission (HR 0.93, 95% CI 0.89-0.96). Additionally, unplanned readmission rates in the first 50 days following index admission were twice as high as days 50-100 (HR 2.31, 95% CI 1.76-3.05). The highest likelihood of recurrent appendicitis or complications following nonoperative management of complicated appendicitis occurs in the first 50 days following index admission. This information will help surgeons during shared decision-making conversations regarding timing of interval appendectomy.

Acute kidney injury associated with increased costs in the neonatal intensive care unit: analysis of Pediatric Health Information System database.

Compare neonatal intensive care unit hospitalization costs between neonates with and without AKI; identify predictors of AKI-associated costs. We hypothesized neonates with AKI would amass more costs than those without AKI. Retrospective, multicenter cohort study of surviving neonates cared for 2015-2021 in Pediatric Health Information System database. The primary outcome was estimated hospitalization costs. Data from 304,725 neonates were evaluated, 8774 (3%) with AKI and 295,951 (97%) without AKI. Neonates with AKI had $58,807 greater adjusted costs than those without AKI. AKI-associated costs were most strongly driven by Feudtner Pediatric Complex Chronic Conditions Classifications (cardiovascaular, congenital/genetic, gastrointestinal, medical technology) and gestational age. Adjusted costs decreased with increasing gestational age, regardless of AKI status. AKI is independently associated with increased hospital costs. Knowledge of these drivers can help in identifying high-value practices for cost mitigation strategies.

Variability in Palliative Care and Discharge Disposition in a National Sample of Pediatric Patients: A Retrospective Study

AbstractThis study investigates factors associated with palliative care consultation (PCC) and discharge disposition among pediatric patients who were declared death by neurological criteria (DNC). It hypothesizes PCC is associated with longer stays and chronic conditions. It aims to identify disparities in PCC rates and factors associated with the continuation of technological (somatic) support after brain death, which is costly and indicates difficulties families face in accepting brain death diagnoses. This retrospective observational study used the Pediatric Health Information System database and included patients ≤21 years old who were declared DNC between 2015 and 2022; demographics, diagnoses, discharge disposition, and PCC status were extracted. Generalized linear mixed-effects models were developed. Of 3,169 patients from 44 hospitals, 14.2% (n = 449) received PCC, and 3.1% (n = 97) were discharged as “not expired,” indicating continued technological support after brain death, with transfer to a location other than the pediatric intensive care unit. PCC rates varied from 0 to 80.0% (median 11.0%); the percentage “not expired” ranged from 0 to 33% (median 0.4%). PCC was associated with longer stay in days (adjusted odds ratio [aOR] = 1.01, p &lt; 0.001) and malignant condition (aOR = 2.69, p &lt; 0.001), and negatively associated with trauma (aOR = 0.59, p &lt; 0.001). Discharge as “not expired” was twice as likely in trauma than nontrauma patients (aOR = 2.00, p = 0.006), and less likely in Black than White patients (aOR = 0.34, p = 0.002). PCC rates were lower in trauma patients and higher in malignant conditions and longer stays. White patients had higher rates of discharge as “not expired,” indicating continued ventilatory support at family request. Further research is needed to integrate palliative care and mitigate disparities.

Use of Sedative and Analgesic Agents in Pediatric Intensive Care Unit Patients: Pediatric Health Information System Database

Use of Sedative and Analgesic Agents in Pediatric Intensive Care Unit Patients: Pediatric Health Information System Database

Identifying opportunities to reduce imaging overuse in hospitalized children.

Radiologic imaging is routinely performed to aid in diagnosis for hospitalized children. Identifying and reducing variability in imaging practices can improve care while reducing harms and costs. To identify common inpatient pediatric conditions with high prevalence of imaging and variation in imaging practices and imaging-related costs across hospitals. We conducted a cross-sectional study of children 0-18 years old admitted to 50 children's hospitals in the Pediatric Health Information Systems database between 2017 and 2019. We excluded patients with complex chronic conditions, pregnancy, newborn, or neonatal intensive care charges, and those who died or who were discharged to hospice or rehabilitation facilities. Conditions with at least 2500 discharges and in which ≥30% of patients received imaging were included. Outcomes included imaging frequency, standardized imaging-related costs (including all modalities across all encounters), and hospital-level variation in imaging costs using the intraclass correlation coefficient (ICC). Of the 56 included conditions, imaging was most frequently conducted in patients with pectus excavatum (97.8%), scoliosis (96.2%), and intestinal obstruction (96%). Fracture ($21.4 million), trauma ($15.7 million), and appendicitis ($8.6 million) had the highest total imaging-related costs. Conditions with the highest geometric mean standardized imaging costs were nervous system disorders ($507), osteomyelitis ($494), vesicoureteral reflux/hydronephrosis ($468). Scoliosis (ICC = 0.49) and preseptal cellulitis (ICC = 0.48) had the highest variation in imaging-related costs. To reduce imaging overuse in hospitalized children, conditions with frequent imaging, high imaging-related costs, and high hospital-level variation in imaging practices should serve as priorities for future evidence generation, guideline development, and/or improvement initiatives.

Patterns of inpatient antibiotic utilization by race and ethnicity at US children's hospitals.

Racial and ethnic variations in antibiotic utilization are well-reported in outpatient settings but little is known about inpatient settings. Our objective was to describe national inpatient antibiotic utilization among children by race and ethnicity. This study included hospital visit data from the Pediatric Health Information System between 01/01/2022 and 12/31/2022 for patients <20 years. Primary outcomes were the percentage of hospitalization encounters that received an antibiotic and antibiotic days of therapy (DOT) per 1000 patient days. Mixed-effect regression models were used to determine the association of race-ethnicity with outcomes, adjusting for covariates. There were 846,530 hospitalizations. 45.2% of children were Non-Hispanic (NH) White, 27.1% were Hispanic, 19.2% were NH Black, 4.5% were NH Other, 3.5% were NH Asian, 0.3% were NH Native Hawaiian/Other Pacific Islander (NHPI) and 0.2% were NH American Indian. Adjusting for covariates, NH Black children had lower odds of receiving antibiotics compared to NH White children (aOR 0.96, 95%CI 0.94-0.97), while NH NHPI had higher odds of receiving antibiotics (aOR 1.16, 95%CI 1.05-1.29). Children who were Hispanic, NH Asian, NH American Indian, and children who were NH Other received antibiotic DOT compared to NH White children, while NH NHPI children received more antibiotic DOT. Antibiotic utilization in children's hospitals differs by race and ethnicity. Hospitals should assess policies and practices that may contribute to disparities in treatment; antibiotic stewardship programs may play an important role in promoting inpatient pharmacoequity. Additional research is needed to examine individual diagnoses, clinical outcomes, and drivers of variation.

Postoperative Pneumonia Risk in Children With Neurologic and Neuromuscular Disorders.

Children with neurologic and neuromuscular complex chronic conditions (NNCCCs) undergo various procedures to optimize their health. We assessed the prevalence, characteristics, and risk of postoperative pneumonia (PoP) across surgery types, hospitals, and comorbidities in children with NNCCC. This study is a retrospective analysis of 63 732 inpatient surgical encounters (2016-2020) in 45 freestanding children's hospitals for patients of any age with NNCCCs in the Pediatric Health Information System database. NNCCCs were distinguished with International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes using Feudtner's system. PoP within 7 days of surgery was identified with International Classification of Diseases, 10th Revision, Clinical Modification codes with antibiotic exposure (coded documentation of antibiotics being given). PoP likelihood was assessed by type of procedure across hospitals and by clinical characteristics using Rao-Scott χ2 tests and estimating equations. The prevalence of 7-day PoP was 1.1% (n = 688), with significant variation (P < .001) across hospitals (range: 0.4% to 3.0%). The highest PoP rates were found for bone marrow transplant (12.5%), solid organ transplantation (8.1%), and cardiothoracic surgery (4.5%); the lowest PoP rates included craniofacial/plastic (0.8%) and neurology (0.3%). Patients with ≥4 coexisting chronic conditions had the highest likelihood of acquiring PoP (odds ratio 10.69 [95% confidence interval 6.62-17.25]). PoP in children with NNCCCs varied significantly across hospitals and types of surgery. Further investigation is needed to assess how to ameliorate the risk of PoP in children with NNCCCs, especially those with multimorbidity.

Cost-Effectiveness of Nonoperative Management vs Upfront Laparoscopic Appendectomy for Pediatric Uncomplicated Appendicitis Over 1 Year.

Non-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis. A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs). Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities. NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.

From Acute Pancreatitis to Diabetes: Risk Factors and Timeline Analysis in a Pediatric Population Study

Abstract Objectives Identify the risk profile for post-pancreatitis diabetes mellitus (PPDM) in children after a single acute pancreatitis (AP) episode, investigate episode severity's association with complications, length of stay (LOS), and intensive care unit (ICU) needs. Methods This cross-sectional study used the Pediatric Health Information System database for patients ≤19 years old with index AP admissions (2011-2020). A query (2012-2021) was performed for diabetes mellitus (DM). Patients were excluded if they had prior DM or pancreatic surgery on or before AP or DM diagnoses. Results Out of 12,822 patients with index AP admissions (median age: 13.4 years, 54% female), 686 (5.4%) developed PPDM, 320 (2.5%) during and 366 (2.9%) at a later admission. The median collective time to PPDM during and after index AP admission was 1.9 months (IQR: 0-20.8). Patients with PPDM experienced extended LOS, heightened ICU needs, and increased complications such as sepsis, pancreatic necrosis, cyst formation, along with higher rates of organ dysfunction and comorbidities. Conclusions Children face DM risks during or following AP episodes. Enhanced DM screening is crucial for patients with existing comorbidities, local or systemic complications or organ dysfunction. Close outpatient follow-up within 3-6 months of discharge from an index AP episode is recommended.

Abstract 4136509: Children in Foster Care with Heart Disease Have Greater Resource Utilization and Mortality

Background: While children and youth in foster care (CYFC) have greater healthcare needs generally, data are lacking in heart disease. We characterize CYFC with heart disease, assess the impacts of being in foster care on outcomes, and examine validity of ICD-10 code Z62.21 for identification of CYFC in administrative data. Methods: In this single-center, retrospective cohort study of all cardiac surgical patients (&lt;18yo) admitted 2017-2022, CYFC were identified using institutional Electronic Medical Records via natural language processing or ICD codes, with confirmation by chart review. Demographics, medical characteristics and outcomes of CYFC were compared to children not in foster care. Generalized linear models assessed associations with primary outcomes of mortality at current follow-up (logit link) and total hospital days (log link), controlling for clinical factors and length of follow-up. We separately added Child Opportunity Index (COI) and payer to models. This cohort was then studied in the administrative pediatric health information system (PHIS) dataset to calculate ICD code sensitivity and specificity. Results: Of 4,431 cardiac surgical patients, 67 (1.5%) were in foster care. CYFC did not have significantly higher mortality (9% vs 5.8%), 30-day readmission or cardiac reoperation, number of complex chronic conditions (CCC), RACHS-2, or distance from center compared to non-CYFC. CYFC had lower COI (median 61 vs 72, p=0.016) and more Medicaid coverage (87% vs 40%, p&lt;0.001). Length of stay after index surgery was similar; however, cumulative hospital days during the study were significantly higher for CYFC (median 22 [IQR 10,45] vs 12 [6,27], p&lt;0.001). Adjusting for RACHS-2, CCC, age, readmission, reoperation, and follow-up duration, CYFC had higher odds of mortality (2.7 [95%CI 1.0,6.9] p=0.046) and more total hospital days (p=0.008). With COI or payer in the model, CYFC was not associated with mortality but remained an independent risk factor for more total hospital days. Only 16/67 (23.9%) of CYFC were coded with the Z62.21 in PHIS, yielding sensitivity of 21.9% (95%CI 13.1,33.1), and specificity of 100% (99.9,100). Conclusion: CYFC with heart disease have a relative social disadvantage, greater hospital resource utilization, and long-term mortality despite similar illness severity. Improved capture of foster care status in administrative data is needed to guide future studies and reduce health disparities for the vulnerable population of CYFC.

Clinical and demographic factors linked to low-value emergency department visits in pediatric patients with spina bifida.

Identifying factors associated with emergency visits that could be delivered at lower-cost sites may help guide population health strategies for pediatric patients with spina bifida. Emergency department encounters (2016-2023) by patients with spina bifida (< 18-years-old) in Pediatric Health Information System were identified. Absence of clinical and imaging charges was defined as low-value emergency visit. We utilized a control population of patients (<18-years-old) with obstructive/reflux uropathy who presented for emergency department encounters (2016-2023). Mixed effects (with repeated individual measurements as random effect) logistic regression was fitted to model odds of low-value emergency visit. In total, we included 22,672 emergency visits by patients with spina bifida. 20.7% of these emergency visits were low-value versus 17.7% in controls (p<0.001). Costs related to low-value emergency visits account for 3.8% of all costs for emergency visit-related encounters in patients with spina bifida. Low-value emergency visits were associated with younger age [OR 1.05 (1.04 - 1.06) per year younger], Hispanic/Latino [OR 1.21 (1.06 - 1.39) compared to non-Hispanics], black [OR 1.35 (1.16 - 1.58) compared to white], public insurance [OR 1.14 (1.01 - 1.29) compared to private insurance], and genitourinary encounter diagnosis [OR 1.16 (1.04 - 1.30)]. Using a standard patient, we found that the odds of low-value emergency visit across hospitals ranged from 0.31 to 5.36. Younger age, Hispanic/Latino ethnicity, black and other race, public insurance, and genitourinary encounter diagnosis were associated with higher odds for low-value emergency visits in pediatric patients with spina bifida. There was wide variation across hospitals that warrants further investigation to elucidate best practices.

Abstract 4133324: Socioeconomic status, race, and ethnicity in management of pediatric SVT

Introduction: Electrophysiology study and ablation (EPS) is often the preferred approach to management of supraventricular tachycardia (SVT) and/or ventricular pre-excitation (WPW) in older children/adolescents. There are inequities in arrhythmia management in adults, and in other areas of pediatric cardiology, but little is known about disparities in management of SVT in children. Research question: Do racial/ethnic and socioeconomic inequities affect referral for EPS in patients with SVT and/or WPW? Methods: This retrospective observational study utilized the Pediatric Health Information System of 49 children’s hospitals’ administrative data from 2016-2022. We included patients with SVT or WPW seen in the emergency department, admitted for observation, or inpatient. We excluded patients with congenital heart disease. The outcome was having a procedure code for EPS. The childhood opportunity index (COI, scale 1-100) based on zip code was used to measure socioeconomic status (SES). Results: Among 37,818 patients with primary diagnosis of SVT (27620, 73%) or WPW (10198, 27%), 9840 (26%) underwent EPS (Table 1). COI was higher in patients who underwent EPS than those who did not (median 59 [IQR 34,82] vs 57 [IQR 30,81]). In addition, time from initial visit with diagnosis of SVT/WPW to EPS was longer in patients with lower COI (beta= -0.026, p=0.007). Black (21.2%), Hispanic (23.8%), and American Indian (19.8%) patients were less likely to undergo EPS than White (26.5%) and Asian (28.31%) patients and those with other (28.4%) or unknown/missing (35.7%) race (p&lt;0.001, Figure 1). In both subgroups of patients with SVT and WPW, EPS differed by race and COI, and higher COI predicted shorter time to EPS. Conclusions: In this hospital database of pediatric patients, we found disparities in use of EPS for the management of SVT and/or WPW. Patients of minoritized race/ethnicity and lower SES were less likely to undergo EPS.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: National Trends, Outcomes, and Predictors of Utilization

PurposeIntercostal nerve cryoablation during minimally invasive repair of pectus excavatum (MIRPE) is an effective pain control technique. Some insurers may not reimburse for cryoablation in this context, contending that it’s an experimental procedure. This study aimed to describe national trends in cryoablation use and evaluate outcomes and predictors of its use. MethodsThe Pediatric Health Information System database was queried for pectus excavatum patients aged 9–21 who underwent MIRPE between 2016 and 2023. Concurrent cryoablation use was identified using billing/supply codes. Temporal trends in cryoablation utilization were described and quantified using linear regression. Demographics, resource utilization, and outcomes were compared for patients based on cryoablation utilization using chi-square and Kruskal–Wallis tests. Predictors of cryoablation use were evaluated with logistic regression. ResultsThis analysis included 2068 patients (mean age 15 ± 1.8 years; 86 % male). Cryoablation utilization increased from 33 % to 61 % from 2016 to 2023, with a strong positive trend (R2 = 0.73). Cryoablation patients had fewer surgical complications (8 % vs 12 %, p = 0.004), shorter LOS (2.0 ± 1.3 vs. 2.8 ± 1.6 days, p < 0.001), fewer total mean opiate days billed (1.4 ± 1.1 vs. 1.6 ± 1.4 days, p < 0.0001) and higher total costs ($24,045 ± $9696 vs. $20,751 ± $9,237, p < 0.001). High-volume centers (odds ratio (OR) 1.9, 95 % confidence interval (CI) 1.2–3.0) and commercial HMO insurance (OR 2.7, 95 % CI 1.9–3.8) were predictors of cryoablation use. ConclusionCryoablation during MIRPE has increased nationally since 2016; now being performed in nearly two-thirds of all cases. Cryoablation should be considered a standard adjunct to MIRPE rather than an experimental technique. Level of evidence2.

Economic burden of inpatient hospitalizations for pediatric chronic kidney disease in the US.

Children with chronic kidney disease (CKD) face extensive healthcare needs, leading to substantial financial strain on both families and healthcare systems due to costly kidney replacement therapies and associated comorbidities. Limited research on inpatient healthcare utilization is available for the individual stages of pediatric CKD. This retrospective cohort study included inpatient encounters for pediatric patients (≤ 18years) using the Pediatric Health Information System Database (PHIS) between January 2016 and December 2022, with an ICD-10 code for any CKD stage (1-5). Hospitalization cost, length of stay (LOS), morbidity, and mortality data were collected. We identified 23,980 pediatric CKD cases [stage 1: 5,059, stage 2: 6,763, stage 3: 7,012, stage 4: 3,102, and stage 5: 2,044] across 49 different children's hospitals in the United States. Mortality rates were observed to increase with increasing CKD severity, but no clear trend was observed for surgical, medical, and infection rates by CKD stage.The LOS for patients with CKDstage4 and CKDstage5was56% and71% longer relative to the LOS of a typical hospitalization for a patient without CKD, and thebilled chargesfor these hospitalizations were92% and147% higher than those of a typical hospitalization. LOS and hospitalization costs were significantly higher for patients with CKD than for patients without CKD. Furthermore, pediatric patients with stage 5 CKD had significantly higher in-patient costs and all-cause hospitalization LOS compared to those with CKD stages 1-4.

Epidemiology of Emergency Department Visits for Children With Clinically Significant Cardiovascular Disease.

The aim of the study is to determine the epidemiology, cost, and factors associated with hospital admission, deterioration if hospitalized, and mortality for children with a history of clinically significant cardiovascular disease (CVD) presenting to pediatric emergency departments (EDs). Using the Pediatric Health Information System, we performed a retrospective analysis of ED encounters of children ≤17 years old with clinically significant CVD between 2016 and 2021. Patients were included if they had a cardiovascular complex chronic condition, defined by ICD diagnosis, and procedure codes. We assessed the primary diagnosis, admission rate, ICU transfer rate (as a marker of disease progression), mortality, resource utilization, and costs. We conducted multivariable analyses to identify risk factors for admission, ICU transfer, and mortality. There were 201,551 ED visits (mean 33,592 ± 3354 per year) among 129,938 children with clinically significant CVD. Most ED encounters had a primary diagnosis of a circulatory (21.1%) or respiratory (19.7%) illness. Seventy-six percent of visits had at least one blood test or imaging study conducted. The overall admission rate was 59.7%, with 28.7% admitted to the ICU, and 6.2% transferred to the ICU after the first 24 hours. The median costs for encounters resulting in admission were $13,605 in US 2023 dollars. In multivariable analyses, younger age, a greater number of noncardiac complex chronic conditions, and CVD type were associated with increased odds of admission, ICU transfer after 24 hours, and mortality (all P < 0.05). ED visits for children with clinically significant CVD lead to substantial resource utilization, including frequent hospitalization, ICU level of care, and costs. This baseline data aids in the development of prospective studies to inform the appropriate ED management for children with clinically significant CVD.

Sociodemographic predictors of imaging utilization in children with right lower quadrant pain.

Inequities in health care access lead to inequities in outcome. In recent years, health outcome disparities have been documented in children with acute appendicitis and sociodemographic predictors of imaging utilization have not been adequately assessed. The purpose of our study is to assess sociodemographic predictors for the diagnostic imaging of children with right lower quadrant (RLQ) pain. Our hypothesis is that disparities exist in imaging utilization. Our nationwide retrospective cohort study of the Pediatric Health Information System (PHIS) database queried emergency department encounters for children aged 0-18years presenting with RLQ pain (ICD code CM R10.31) between January 2018 and September 2023. Primary exposures included neighborhood-level sociodemographic metrics as measured by Child Opportunity Index, race/ethnicity, and insurance status. Outcomes included no diagnostic imaging, diagnostic imaging with radiography alone, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Multivariable logistic regression analyses assessed modality usage with respect to the primary exposures after controlling for demographic (age, gender) and additional (hospital geographic region, time of imaging) covariates. To avoid the perpetuation of bias, reference categories were determined by the lowest numerical value for each covariate. In total, 100,161 patient encounters met inclusion criteria (mean patient age 11.2years ± 3.9; 59.3%, n = 59,416 females). Imaging utilized was US (78.0%; n = 78,115), CT (16.4%, n = 16,405), no imaging (13.9%, n = 13,894), radiography alone (4.4%, n = 4,429), and MRI (3.1%, n = 3,148). The most predictive factors for no imaging were moderate, low, and very low Child Opportunity Index (aOR 1.25, 1.17, and 1.18 [95% CI 1.10-1.33] compared to very high Child Opportunity Index); Black race/ethnicity (aOR 1.26 [95% CI 1.11-1.44] compared to White or Asian race/ethnicity); and public or other insurance (aOR 1.23 and 1.32 [95% CI 1.18-1.41] compared to commercial insurance). The most predictive factors for radiography alone were Black race/ethnicity (aOR 1.30 [95% CI 1.17-1.45] compared to Hispanic race/ethnicity) and public or other insurance (aOR 1.26 [95% CI 1.11-1.44] compared to commercial). The most predictive factors for US were very-high Child Opportunity Index (aOR 1.16 [95% CI 1.09-1.22] compared to very low Child Opportunity Index); Asian, NH-White, or Hispanic race/ethnicity (aOR 1.33, 1.31, 1.30 [95% CI 1.18-1.40] compared to Black race/ethnicity); and commercial insurance (aOR 1.20 [95% CI 1.16-1.25] compared to public insurance). The most predictive factor for CT was White race/ethnicity (aOR 1.26 [95% CI 1.11-1.43] compared with Asian race/ethnicity) and the most predictive factor for MRI was Hispanic race/ethnicity (aOR 1.49 [95% CI 1.17-1.61] compared with Black race/ethnicity). The greatest predictor of cross-sectional imaging was a hospital's region, with CT most likely in southern hospitals (aOR 4.09 [95% CI 2.17-7.70] compared with northeast hospitals). Patient Child Opportunity Index did not predict the likelihood of cross-sectional imaging with CT or MRI in tertiary pediatric centers. Sociodemographic disparities exist in the imaging of children presenting to tertiary pediatric hospitals with RLQ pain. Future studies are needed to analyze the causes of such disparities both on hospital and departmental levels.

Pediatric Hospital Utilization During Medical Stabilization for Patients With Eating Disorders.

Few studies have examined pediatric hospital utilization across the spectrum of eating disorder (ED) diagnoses among hospitalized patients. We describe sociodemographic and clinical characteristics, hospital utilization, and enteral tube feeding and examine factors associated with hospital utilization among patients with EDs. Using data from the Pediatric Health Information System, we included patients aged 4 to 20 years with primary ED diagnoses hospitalized from 2018 to 2022. We examined sociodemographic factors, length of stay, costs, and enteral tube feeding by ED diagnosis. Adjusted regression models compared hospital utilization by diagnosis, adjusting for sociodemographic and clinical factors. Among N = 10 279 hospitalizations from 49 hospitals, anorexia nervosa (AN) was most common (70.9%), followed by avoidant restrictive food intake disorder (ARFID) (15.6%). Mean age was 15.1 years (SD = 2.5), and most were female (86.6%), of white non-Hispanic race (70.9%), with private insurance (70.1%), with 63.9% occurring after the coronavirus disease 2019 pandemic onset. Median (interquartile range) length of stay was 8.0 days (7.0), and hospital costs were $18 099 ($15 592). A total of 18.8% received enteral tube feeding, with significant hospital variation. In adjusted models, compared with AN, ARFID, binge disorders, and unspecified feeding and ED had shorter stays, whereas hospital costs were lower for binge disorders, and enteral feeding was more likely for ARFID. Our findings indicate long and costly hospitalizations, especially for AN, with implications for hospital and treatment capacity, highlighting the need for earlier diagnosis and treatment to prevent the need for hospitalization.

Antibiotic Management After Neonatal Enteric Operations in US Children's Hospitals

BackgroundThere are few evidence-based guidelines for perioperative antibiotic management in neonates who undergo enteric operations. We sought to assess antibiotic administration practices in a large population of patients who underwent operations involving enteric anastomoses and evaluate the incidence of postoperative infection and other outcomes based on antibiotic approach. MethodsThe Pediatric Health Information Systems database was queried for patients who underwent repair of esophageal, duodenal or jejuno-ileal atresia in 2021. The type and number of consecutive days of perioperative antibiotics was determined and ICD-10 codes corresponding to infection were noted. The incidences of post operative infections (bacterial and fungal), antibiotic-resistant infections and anti-fungal medication administration were determined. Results516 infants were identified. A wide variety of antibiotics were administered and 39 % of patients received more than one day of treatment. There were no differences in the incidence of postoperative infection between those who received more or less than one day of perioperative antibiotics for any of the operations assessed. The incidence of bacterial infection in patients treated with cefazolin or cefoxitin monotherapy was no different than that for all other regimens. There were no significant differences in the incidence of post-operative fungal infection based on antibiotic type or duration. ConclusionThere was substantial variation in the duration and type of antibiotics administered after neonatal enteric operations. We identified a low incidence of infection with only one day of perioperative antibiotics and there was no evidence that longer treatment reduced infection risk. Cefazolin monotherapy was likewise associated with a low risk for perioperative infections. Study typeNon-interventional observational database study. Level of evidence3.

Contemporary use of fibrinolytics in the management of pediatric empyema.

This study seeks to investigate the contemporary use and effectiveness of fibrinolysis as a first-line option in pediatric empyema. The Pediatric Health Information System (PHIS) was queried to identify patients with empyema without fistula (2018-2023). First-line treatments were chest drainage (CD), chest drainage with fibrinolysis (CDF), and video-assisted thoracoscopic surgery/open decortication (VATS/OD). Outcomes between groups were compared using Kruskal-Wallis and Chi-Square tests. Multivariate generalized linear model was used to account for covariates. 581 individuals/cases met inclusion criteria. CD accounted for 11.9% of cases, CDF for 67.6%, and VATS/OD for 20.7%. After adjusting for covariates differences in LOS were not significant (p = 0.393). Subsequent VATS/ODs were required in 6.9% of CDF cases, 8.9% of CD, and 3.3% of primary VATS/OD. Additionally, 32.5% of primary VATS/OD received adjuvant fibrinolysis. Complications were more often observed in the VATS/OD group compared to CD and CDF (11.7% vs 5.8% and 4.1% respectively; p = .008). There were no differences in 30-day readmission rate (VATS/OD:1.2%, CTD:1.5%, and CTDF:1%; p = 0.83). Fibrinolysis is now utilized as first-line treatment for most patients and as adjunct in other approaches. The findings justify further implementation as it is the less invasive first-line primary therapy in patients with empyema.