Pediatric Hospital Information System Database Research Articles

Epidemiology of anticoagulation for children supported by extracorporeal membrane oxygenation in the United States: A Pediatric Hospital Information System database study.

Due to the risk of thrombosis, nearly all children supported by extracorporeal membrane oxygenation (ECMO) receive systemic anticoagulation. While heparin has traditionally been used, there are reports of increased use of direct thrombin inhibitors. We sought to describe the use of anticoagulation in children supported by ECMO in the United States using a large administrative database. We performed a retrospective cohort study of children supported by ECMO within the Pediatric Health Information System (PHIS) database. Pediatric encounters involving ECMO from 2012 to 2020 were identified. Data regarding demographics, diagnoses, anticoagulation, complications, and outcomes were extracted for eligible encounters. Eleven thousand five hundred ninety-five encounters that involved ECMO were identified. Fifty-four percent were male with an age range of 0-17years and a median (IQR) age of 0 (0-2) years. Unfractionated heparin (UFH) only was used in 94% (95% CI: 93.6-94.5%) of encounters and UFH followed by bivalirudin in 5% (95% CI: 4.3-5.1%) of cases. There was a significant difference in the use of bivalirudin from 2012 to 2020 (p < 0.001). Differences in anticoagulation regimens were observed between infants and children (p = 0.004) and between those with and without cardiac indications for ECMO (p < 0.001). Four percent (95% CI: 4.1-4.8%) of encounters were associated with diagnostic coding for thrombosis and differences in occurrence of thrombosis were observed between different anticoagulant regimens (p < 0.001). Though the majority of children on ECMO in the United States receive heparin anticoagulation, there is an increase in use of direct thrombin inhibitors. Prospective studies must evaluate the efficacy of different anticoagulants in this patient population.

Hospital-level variation in genetic testing in children’s hospitals’ neonatal intensive care units from 2016 to 2021

PurposeThis study aimed to examine variation in genetic testing between neonatal intensive care units (NICUs) across hospitals over time. MethodsWe performed a multicenter large-scale retrospective cohort study using NICU discharge data from the Pediatric Hospital Information System database between 2016 and 2021. We analyzed the variation in the percentage of NICU patients who had any genetic testing across hospitals and over time. We used a multivariable multilevel logistic regression model to investigate the potential association between patient characteristics and genetic testing. ResultsThe final analysis included 207,228 neonates from 38 hospitals. Overall, 13% of patients had at least 1 genetic test sent, although this varied from 4% to 50% across hospitals. Over the study period, the proportion of patients tested increased, with the increase disproportionately borne by hospitals already testing high proportions of patients. On average, patients who received genetic testing had higher illness severity. Controlling for severity, however, only minimally reduced the degree of hospital-level variation in genetic testing. ConclusionThe percentage of NICU patients who undergo genetic testing varies among hospitals and increasingly so over time. Variation is largely unexplained by differences in severity between hospitals. The degree of variation suggests that clearer guidelines for NICU genetic testing are warranted.

Nephrotoxic medications and associated acute kidney injury in hospitalized neonates.

Hospitalized neonates are oftentreated with nephrotoxic medications, a known risk factor for acute kidney injury (AKI). Nephrotoxic medications and AKI, especially in periviable neonates, could be detrimental to nephrogenesis. Our objectives were to evaluate the prevalence of neonatal treatment with nephrotoxic medications and itsrelationship with AKI in in the first 28daysof life, and to delineate the associated demographics and diagnoses. Multicenter retrospective analysis using the national Pediatric Hospital Information System database, including 49 pediatric hospitals. Neonates admitted within the first two postnatal days were included. Treatment with 37 nephrotoxic medications across demographics and clinical variables, and relationship with AKI were evaluated. AKI was determined by using the International Classification of Diseases codes. Of 192,229 neonates, 74% were treated with at least one nephrotoxic medication. Incidence ofAKI was significantly higher in the treated group (aRR 3.68 [95% CI: 2.85, 4.75]). The aRRs of treatment were increased in infants born< 32-week, and < 2000g. Nephrotoxic medications were prescribed to 90-95% of neonates born≤ 28-week gestational age. Most treatments (95-98%) occurred in the first 3days. Intravascular aminoglycosides were the most frequent type; 28% of neonates were treated for ≥ 4 calendar days. Most common diagnoses were infections (25%) and patent ductus arteriosus (20%). Neonatal treatment with nephrotoxic medications is common, especially among the smallest, most immature preterm neonates and demonstrates a need for initiatives to reduce neonatal exposure to these agents, when feasible. Across all gestational age categories, the prevalence of AKI is higher in the neonatestreated with nephrotoxic drugs. The long-term effects of treatment with nephrotoxic medications and subsequent AKI on nephrogenesis and nephron endowment will need to be evaluated.

Diuretic therapy and acute kidney injury in preterm neonates and infants.

Acute kidney injury (AKI) in preterm infants is associated with prolonged hospitalization and high mortality. Diuretic therapy has been used to enhance urine output in preterm infants with AKI. Treatment with diuretics, prescription patterns, and relationship with length of stay (LOS), mechanical ventilation (MV), and mortality in preterm infants who also had AKI have not been fully evaluated. This multicenter retrospective study used the Pediatric Hospital Information System database. We included 2121 preterm infants with AKI diagnosis from 46 hospital Neonatal Intensive Care Units (NICUs) born <37 weeks gestational age (GA). Treatment with diuretics, practice patterns across 46 NICUs in the USA, and associated outcomes including LOS, MV, and mortality were evaluated. Seventy-six percent of infants received at least one dose of diuretics (median treatment 18 days). Diuretic prescription varied significantly across hospitals and ranged from 42 to 96%. Diuretics were used more frequently in infants with younger GA and smaller birth weight. Infants with older GA who received diuretics at or before 28 days postnatally had worse survival even after adjusting for known confounders. Preterm infants with AKI diagnosis were frequently treated with diuretics. Moreover, infants with younger GA and smaller birth weight were more likely to receive diuretics. Worse survival in infants with older GA who received diuretics could be the result of more underlying severe illness in these infants and not the cause of more severe illness. Prospective studies are needed to best determine patient safety and outcomes with diuretic treatment in preterm infants with AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

The Clinical Characteristics of Fractures in Pediatric Patients Exposed to Proton Pump Inhibitors.

There are increasing concerns regarding proton pump inhibitor (PPI) use and the risk of fractures in adults. Few studies have evaluated this risk among pediatric patients. This study examined fractures and fracture location among pediatric patients exposed to PPI compared with those without documented exposure. Encounters for patients 6 months to 15.5 years were identified between July 1, 2011 to December 31, 2015 in the Pediatric Hospital Information System database. Exclusion criteria was applied for chronic illnesses, conditions or medications predisposing to fracture. Encounters were classified as PPI encounters if a charge for PPI was documented. PPI encounters were propensity matched to non-PPI encounters. Following initial encounter, patients were evaluated over a 2-year period for hospitalizations resulting from fracture. There was a statistically significant higher rate of fractures among the PPI-exposed group (1.4% vs 1.2%, P = 0.019). Adjusting for remaining differences in sex, race, encounter type, payer, and resource intensity after matching, the difference remained statistically significant (P = 0.017) with an adjusted odds ratio (95% CI) of 1.2 (1.0--1.4). Upper extremity was the most common location for fracture; however, the PPI cohort was more likely to suffer from lower extremity, rib, and spinal fractures (P = 0.01). This study suggests an increased risk of fracture among pediatric patients taking PPI. Among patients hospitalized with a fracture, those with PPI exposure had a higher rate of lower extremity, rib, and spine fractures compared with controls. This appeared to be a class effect not related to individual PPI agent.

Diagnostic and Treatment Trends in Children With Kawasaki Disease in the United States, 2006-2015.

To evaluate variations in treatment practice and compliance with national guidelines for the diagnostic evaluation of children with Kawasaki disease (KD). We used the Pediatric Hospital Information System database to analyze demographic, laboratory and treatment data from patients admitted with KD between January 1, 2006, and December 31, 2015. During the study period, 12,089 children with KD were diagnosed. Nearly all patients had a complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein ordered. Fewer patients had alanine aminotransferase (48.6%) or a urinalysis (75.3%). A small percentage of children had abdominal imaging (11.5%), neck imaging (5.9%), and lumbar punctures (4.5%), and 36.0% of patients received antibiotic therapy. Obtaining echocardiograms pretreatment and the use of steroids and infliximab significantly increased over the study period (P < 0.001). For patients who failed initial intravenous immunoglobulin (IVIG) monotherapy, 82.0% received a second dose of IVIG, 7.7% received steroids, 6.5% received infliximab, and 3.9% received combination therapy. Patients receiving infliximab or steroids as second therapy had a higher response rate than those who received only a second IVIG dose (87.9% versus 83.0% versus 73.3%, P < 0.001). KD remains a challenging diagnosis. Opportunities exist for earlier use of echocardiograms in the evaluation of children with potential KD. Significant variations in practice exist surrounding second-line therapy. Our data suggest superiority of second-line therapy use of infliximab or steroids over IVIG in terms of reducing need for additional therapies. Prospective, controlled studies are needed to confirm this finding.

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness.

This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI). This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL. Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]). Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.

Practice Patterns in Medicaid and Non-Medicaid Asthma Admissions

JH Silber, PR Rosenbaum, W Wang. Pediatrics. 2016;138(2):e20160371 To evaluate any differences in practice patterns between Medicaid and non-Medicaid patients admitted for asthma at 40 Children’s Hospital Association hospitals that contribute to the Pediatric Hospital Information System database. This cohort consisted of 17 739 matched pairs of children (Medicaid and non-Medicaid) admitted for asthma at the same institution …

Mortality associated with gastrointestinal bleeding in children: A retrospective cohort study.

AIMTo determine the clinical characteristics of children with gastrointestinal bleeding (GIB) who died during the course of their admission.METHODSWe interrogated the Pediatric Hospital Information System database, including International Classification of Diseases, Current Procedural Terminology and Clinical Transaction Classification coding from 47 pediatric tertiary centers extracting the population of patients (1-21 years of age) admitted (inpatient or observation) with acute, upper or indeterminate GIB (1/2007-9/2015). Descriptive statistics, unadjusted univariate and adjusted multivariate analysis of the associations between patient characteristics and treatment course with mortality was performed with mortality as primary and endoscopy a secondary outcome of interest. All analyses were performed using the R statistical package, v.3.2.3.RESULTSThe population with GIB was 19528; 54.6% were male, overall mortality was 2.07%; (0.37% in patients with the principal diagnosis of GIB). When considering only the mortalities in which GIB was the principal diagnosis, 48% (12 of 25 principal diagnosis GIB mortalities) died within the first 3 d of admission, whereas 19.8% of secondary diagnosis GIB patients died with 3 d of admission. Patients who died were more likely to have received octreotide (19.8% c.f. 4.04%) but tended to have not received proton pump inhibitor therapy in the first 48 h, and far less likely to have undergone endoscopy during their admission (OR = 0.489, P < 0.0001). Chronic liver disease associated with a greater likelihood of endoscopy. Mortalities were significantly more likely to have multiple complex chronic conditions.CONCLUSIONGIB associated mortality in children is highest within 7 d of admission. Multiple comorbidities are a risk factor whereas early endoscopy during the admission is protective.

Trends and variation in management and outcomes of very low-birth-weight infants with patent ductus arteriosus.

We examined recent trends and interhospital variation in use of indomethacin, ibuprofen, and surgical ligation for patent ductus arteriosus (PDA) in very-low-birth-weight (VLBW) infants. Included in this retrospective study of the Pediatric Hospital Information System database were 13,853 VLBW infants from 19 US children's hospitals, admitted at age < 3 d between 1 January 2005 and 31 December 2014. PDA management and in-hospital outcomes were examined for trends and variation. PDA was diagnosed in 5,719 (42%) VLBW infants. Cyclooxygenase inhibitors and/or ligation were used in 74% of infants with PDA overall, however studied hospitals varied greatly in PDA management. Odds of any cyclooxygenase inhibitor or surgical treatment for PDA decreased 11% per year during the study period. This was temporally associated with improved survival but also with increasing bronchopulmonary dysplasia, periventricular leukomalacia, retinopathy of prematurity, and acute renal failure in unadjusted analyses. There was no detectable correlation between hospital-specific changes in PDA management and hospital-specific changes in outcomes of preterm birth during the study period. Use of cyclooxygenase inhibitors and ligation for PDA in VLBW infants decreased over a 10-y period at the studied hospitals. Further evidence is needed to assess the impact of this change in PDA management.

Demographic disparities of children presenting with symptomatic Meckel's diverticulum in children's hospitals.

Most of the literature about Meckel's diverticulum (MD) consists of single institutional longitudinal case series. We queried the pediatric hospital information system (PHIS) database to obtain information about the epidemiology of MD from a large number of children at geographically diverse locations. After IRB approval, the PHIS database was queried over a 9-year period for de-identified patients with both ICD-9 diagnoses of MD and a procedure code for Meckel's diverticulectomy. Data from five hospitals were excluded due to incomplete information. 4,338,396 were children admitted during the study interval; 945 had a symptomatic MD. The incidence decreased with age: 56.4% were under 5 years old, 26.8% were between the ages of 6-12 years, and 16.8% were older than 12 years. 74% were male, which was significantly higher than the PHIS population (53.8% male, P < 0.0001). Caucasians are over-represented in the symptomatic MD group (63.4%) compared to the rest of the PHIS population (48.1%, P < 0.0001). According to the PHIS data, there appears to be significant gender and race influence on symptomatic MD. Males present more commonly, as do non-Hispanic White patients, while it is less common among non-Hispanic Black patients.

Variation in Occult Injury Screening for Children With Suspected Abuse in Selected US Children’s Hospitals

To describe variation across selected US children's hospitals in screening for occult fractures in children <2 years old diagnosed with physical abuse and in infants <1 year old who have injuries associated with a high likelihood of physical abuse. We performed a retrospective study of children <2 years old with a diagnosis of physical abuse and infants <1 year old with non-motor vehicle crash-associated traumatic brain injuries or femur fractures admitted to 40 hospitals within the Pediatric Hospital Information System database from January 1, 1999, to December 31, 2009. We examined variation among the hospitals in the performance of screening for occult fractures as defined by receipt of skeletal survey or radionuclide bone scan. Marginal standardization implemented with logistic regression analysis was used to examine hospital variation after adjusting for patient demographic characteristics, injury severity, and year of admission. Screening for occult fractures was performed in 83% of the 10,170 children <2 years old with a diagnosis of physical abuse, 68% of the 9942 infants who had a traumatic brain injury, and 77% of the 2975 infants who had femur fractures. After adjustment for patient characteristics, injury severity, and year of admission, hospitals varied significantly in use of screening for occult fractures in all 3 groups of children. The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.

Local Macroeconomic Trends and Hospital Admissions for Child Abuse, 2000–2009

To examine the relationship between local macroeconomic indicators and physical abuse admission rates to pediatric hospitals over time. Retrospective study of children admitted to 38 hospitals in the Pediatric Hospital Information System database. Hospital data were linked to unemployment, mortgage delinquency, and foreclosure data for the associated metropolitan statistical areas. Primary outcomes were admission rates for (1) physical abuse in children <6 years old, (2) non-birth, non-motor vehicle crash-related traumatic brain injury (TBI) in infants <1 year old (which carry high risk for abuse), and (3) all-cause injuries. Poisson fixed-effects regression estimated trends in admission rates and associations between those rates and trends in unemployment, mortgage delinquency, and foreclosure. Between 2000 and 2009, rates of physical abuse and high-risk TBI admissions increased by 0.79% and 3.1% per year, respectively (P ≤ .02), whereas all-cause injury rates declined by 0.80% per year (P < .001). Abuse and high-risk TBI admission rates were associated with the current mortgage delinquency rate and with the change in delinquency and foreclosure rates from the previous year (P ≤ .03). Neither abuse nor high-risk TBI rates were associated with the current unemployment rate. The all-cause injury rate was negatively associated with unemployment, delinquency, and foreclosure rates (P ≤ .007). Multicenter hospital data show an increase in pediatric admissions for physical abuse and high-risk TBI during a time of declining all-cause injury rate. Abuse and high-risk TBI admission rates increased in relationship to local mortgage delinquency and foreclosure trends.

831 CHILDREN WITH SPINAL ABNORMALITIES HAVE AN INCREASED PREVALENCE OF UROLITHIASIS

You have accessJournal of UrologyPediatrics: Stones/Tumors1 Apr 2012831 CHILDREN WITH SPINAL ABNORMALITIES HAVE AN INCREASED PREVALENCE OF UROLITHIASIS George Chiang, Nicholas Holmes, and Puneeta Ramachandra George ChiangGeorge Chiang San Diego, CA More articles by this author , Nicholas HolmesNicholas Holmes San Diego, CA More articles by this author , and Puneeta RamachandraPuneeta Ramachandra San Diego, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.922AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Immobility in children has been thought to increase the likelihood of urolithiasis. Immobile children are often affected by spina bifida or various forms of spinal curvature. However, it has been difficult to establish any significantly increased risk in this select population as a result of small data sets. We examined the possible correlation between these conditions and urolithiasis in a large patient cohort. METHODS Data was extracted from the Pediatric Hospital Information System database over a 5-year period from October 2005 to September 2010. Both inpatient and same day surgery encounters were analyzed. Emergency department data was excluded. Only 24 of the total 40 hospitals were analyzed as a result of incomplete data. The number of unique patients with stone disease and spinal abnormalities based on ICD -9 diagnosis encounters was compared to the number of unique patients with stone disease and no history of spinal abnormality. The total number of unique patients with diagnoses corresponding to spinal abnormalities and the total number of patients without spinal abnormalities seen over the 5 year period were used to establish prevalence. RESULTS The inpatient and surgical encounters of 1,755,853 unique patients were reviewed. Within this cohort were 27,632 patients with a history of spinal abnormalities by diagnosis. Urolithiasis was seen in 594 of these patients corresponding to a prevalence of approximately 1 in 50. There were 5,153 patients with stone disease among the remaining 1,728,221 patients without spinal abnormalities corresponding to a prevalence of 3 in 1000. CONCLUSIONS Children with spinal abnormalities such as spina bifida or spinal curvature have a much higher prevalence of stone disease compared to the general population seen at children's hospitals. Aggressive screening may be required for this high risk group. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e339 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information George Chiang San Diego, CA More articles by this author Nicholas Holmes San Diego, CA More articles by this author Puneeta Ramachandra San Diego, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Unnecessary Care for Bronchiolitis Decreases With Increasing Inpatient Prevalence of Bronchiolitis

To measure the association between inpatient bronchiolitis prevalence (IBP) and the delivery of unnecessary tests and treatments to patients hospitalized with bronchiolitis. A multicenter, retrospective, cohort study was performed using the Pediatric Hospital Information System database. All patients 2 months to 2 years of age hospitalized with bronchiolitis during 2004-2008 at participating pediatric hospitals were included. Main outcome measures were the probability of receiving potentially unnecessary care for bronchiolitis, including steroids, intravenously administered antibiotics, chest or neck radiographs, and any laboratory tests during hospitalization. During winter months, with each 1% absolute increase in IBP, patients were less likely to receive steroids (incidence rate ratio: 0.968 [95% confidence interval: 0.960-0.976]; P < .001), radiographs (incidence rate ratio: 0.988 [95% confidence interval: 0.984-0.992]; P < .001), and laboratory tests (incidence rate ratio: 0.992 [95% confidence interval: 0.988-0.995]; P < .001). During summer months, similar associations were observed for steroids and radiographs. No association between IBP and antibiotic use was observed during either time period. The frequency with which several types of unnecessary care were delivered to patients with bronchiolitis seemed to decrease with increasing IBP. This finding suggests that an association exists between contextual information and care delivery during the management of acute illness, and it highlights the importance of such information for delivery of high-quality health care.