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Shayo F, Sawe HR, Hyuha GM, Moshi B, Gulamhussein MA, Mussa R, Mdundo W, Rwegoshora S, Mfinanga JA, Kilindimo S, Weber EJ. Clinical profile and outcomes of paediatric patients with acute seizures: a prospective cohort study at an urban emergency department of a tertiary hospital in Tanzania. BMJ Open 2024; 14:e069922. [PMID: 38184308 PMCID: PMC11148702 DOI: 10.1136/bmjopen-2022-069922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2024] Open
Abstract
OBJECTIVE Children with seizures require immediate and appropriate intervention in the emergency department (ED). This study describes the clinical profile and outcome of paediatric patients with seizures at the ED in a country with limited resources. DESIGN A prospective, observational cohort study of paediatric patients with seizure presenting to an ED conducted over a six-month period from 1 August 2019 to 31 January2020. SETTING The study was conducted at the ED of Muhimbili National Hospital, a level 1 trauma centre located in Dar es Salaam, Tanzania. PARTICIPANTS Paediatric patients aged 1 month to 14 years presenting at the ED with acute seizure, defined as any seizure occurring from 24 hours to 7 days prior to the visit, were included in this study. Patients were consecutively enrolled during times a research assistant was present in the department. Newborns, children with repeat visits or no signs of life on arrival were excluded. OUTCOME The primary outcome was the proportion of paediatric patients presenting with seizures and their mortality rate; secondary outcome was risk factors for mortality. RESULT During the study period, 1011 children were seen in the department, of whom 114 (11.3%) (95% CI 9.3% to 13.3%) presented with seizures. Median age was 24 months (IQR 9-60), 78.1% were under 5 years and 55.3% were males. The majority 76 (66.7%) of the patients presented with generalised seizures. Half 58 (50.9%) of patients presented with fever. Meningitis was the most common aetiology, diagnosed in 30 (26.3%). Overall mortality was 16.7% (95% CI 10.3% to 24.8%). Using negative log binominal analysis, fever (relative risk, RR 2.7), altered mental status (RR 21.1), hypoxia (RR 3.3), abnormal potassium (RR 2.4) and clinical diagnosis of meningitis (RR 3.4) were statistically significantly associated with mortality. CONCLUSIONS Findings from this study revealed higher incidence of paediatric patients with seizures than that reported in high-income countries and other low-income and middle-income countries. The acuity of illness was high, with 16.7% mortality rate. The presence of fever, altered mental status, hypoxia, abnormal potassium levels and meningitis diagnosis were associated with higher risk of mortality. Further research is needed to develop interventions to improve outcomes in paediatric patients with seizures in our setting.
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Affiliation(s)
- Frida Shayo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Hendry R Sawe
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Gimbo M Hyuha
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Baraka Moshi
- Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Masuma A Gulamhussein
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Raya Mussa
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Winnie Mdundo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Shamila Rwegoshora
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Said Kilindimo
- Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Ellen J Weber
- Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Philpott NG, Dante SA, Philpott D, Perin J, Bhatia P, Henderson E, Costabile P, Stratton M, Dabrowski A, Kossoff EH, Klein BL, Noje C. Treatment Guideline Nonadherence Pretransport Associated With Need for Higher Level of Care in Children Transferred to a Pediatric Tertiary Care Center for Status Epilepticus. Pediatr Emerg Care 2023; 39:780-785. [PMID: 37163683 DOI: 10.1097/pec.0000000000002952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We sought to investigate the association between adherence to the American Epilepsy Society (AES) 2016 guidelines for management of convulsive status epilepticus (SE) and clinical outcomes among children requiring interhospital transport for SE. We hypothesized that pretransport guideline nonadherence would be associated with needing higher level of care posttransfer. METHODS This was a retrospective cohort study of children aged 30 days to 18 years transferred to our pediatric tertiary center from 2017 to 2019 for management of SE. Their care episodes were classified as 2016 American Epilepsy Society guideline adherent or nonadherent. There were 40 referring hospitals represented in this cohort. RESULTS Of 260 care episodes, 55 (21%) were guideline adherent, 184 (71%) were guideline nonadherent, and 21 (8%) had insufficient data to determine guideline adherence. Compared with the adherent group, patients in the nonadherent care group had longer hospitalizations (32 hours [17-68] vs 21 hours [7-48], P = 0.006), were more likely to require intensive care unit admission (47% vs 31%), and less likely to be discharged home from the emergency department (16% vs 35%; χ 2 test, P = 0.01). Intubation rates did not differ significantly between groups (25% vs 18%, P = 0.37). When we fit a multivariable model to adjust for confounding variables, guideline nonadherence was associated with need for higher level of care (odds ratio, 2.04; 95% confidence interval, 1.04-3.99). Treatment guideline adherence did not improve over the 3-year study period (2017: 22%, 2018: 19%, 2019: 29% [χ 2 test for differences between any 2 years, P = 0.295]). CONCLUSIONS Guideline nonadherence pretransport was associated with longer hospitalizations and need for higher level of care among children transferred for SE at our institution. These findings suggest a need to improve SE guideline adherence through multifaceted quality improvement efforts targeting both the prehospital and community hospital settings.
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Affiliation(s)
- Natalia Garza Philpott
- From the Department of Pediatrics. Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siddhartha A Dante
- Department of Pediatrics, University of Maryland School of Medicine. Baltimore, MD
| | - David Philpott
- From the Department of Pediatrics. Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Pooja Bhatia
- Pediatric Transport, Johns Hopkins Children's Center, Baltimore, MD
| | - Eric Henderson
- Pediatric Transport, Johns Hopkins Children's Center, Baltimore, MD
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Mahant S, Guttmann A. Shifts in the Hospital Care of Children in the US-A Health Equity Challenge. JAMA Netw Open 2023; 6:e2331763. [PMID: 37656462 DOI: 10.1001/jamanetworkopen.2023.31763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Sanjay Mahant
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- SickKids Research Institute, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario Canada, Toronto, Ontario, Canada
- Edwin S. H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
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Brown L, França UL, McManus ML. Neighborhood Poverty and Distance to Pediatric Hospital Care. Acad Pediatr 2023; 23:1276-1281. [PMID: 36754164 DOI: 10.1016/j.acap.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care. METHODS This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity. RESULTS Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001). CONCLUSIONS Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.
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Affiliation(s)
- Lauren Brown
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass; Department of Anesthesiology, Mass General Brigham, Brigham and Women's Hospital (L Brown), Boston, Mass.
| | - Urbano L França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass
| | - Michael L McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (L Brown, UL França, and ML McManus), Boston, Mass; Harvard Medical School (L Brown, UL França, and ML McManus), Boston, Mass
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Suen CG, Wood AJ, Burke JF, Betjemann JP, Guterman EL. Hospital EEG Capability and Associations With Interhospital Transfer in Status Epilepticus. Neurol Clin Pract 2023; 13:e200143. [PMID: 37064585 PMCID: PMC10101704 DOI: 10.1212/cpj.0000000000200143] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/06/2023] [Indexed: 03/18/2023]
Abstract
Background and Objectives EEG is widely recommended for status epilepticus (SE) management. However, EEG access and use across the United States is poorly characterized. We aimed to evaluate changes in inpatient EEG access over time and whether availability of EEG is associated with interhospital transfers for patients hospitalized with SE. Methods We performed a cross-sectional study using data available in the National Inpatient Sample data set from 2012 to 2018. We identified hospitals that used continuous or routine EEG during at least 1 seizure-related hospitalization in a given year using ICD-9 and ICD-10 procedure codes and defined these hospitals as EEG capable. We examined annual change in the proportion of hospitals that were EEG capable during the study period, compared characteristics of hospitals that were EEG capable with those that were not, and fit multivariable logistic regression models to determine whether hospital EEG capability was associated with likelihood of interhospital transfer. Results Among 4,550 hospitals in 2018, 1,241 (27.3%) were EEG capable. Of these, 1,188 hospitals (95.7%) were in urban settings. From 2012 to 2018, the proportion of hospitals that were EEG capable increased in urban settings (30.5%-41.1%, Mann-Kendall [M-K] test p < 0.001) and decreased in rural settings (4.0%-3.2%, M-K p = 0.026). Among 130,580 patients hospitalized with SE, 80,725 (61.8%) presented directly to an EEG-capable hospital. However, EEG use during hospitalization varied from 8% to 98%. Initial admission to a hospital without EEG capability was associated with 22% increased likelihood of interhospital transfer (adjusted RR 1.22, [95% CI, 1.09-1.37]; p < 0.01). Among those hospitalized at an EEG-capable hospital, patients admitted to hospitals in the lowest quintile of EEG volume were more than 2 times more likely to undergo interhospital transfer (adjusted RR 2.22, [95% CI 1.65-2.93]; p < 0.001). Discussion A minority of hospitals are EEG capable yet care for most patients with SE. Inpatient EEG use, however, varies widely among EEG-capable hospitals, and lack of inpatient EEG access is associated with interhospital transfer. Given the high incidence and cost of SE, there is a need to better understand the importance and use of EEG in this patient population to further organize inpatient epilepsy systems of care to optimize outcomes.
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Affiliation(s)
- Catherine G Suen
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Andrew J Wood
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - James F Burke
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - John P Betjemann
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
| | - Elan L Guterman
- Department of Neurology (C.G.S., A.J.W., E.L.G.), University of California San Francisco; Department of Neurology (J.F.B.), Ohio State Wexner Medical Center, Columbus; Department of Neurology (J.P.B.), Kaiser Permanente Northern California, San Francisco; Philip R. Lee Institute for Health Policy Studies (E.L.G.), University of California, San Francisco
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Taraschenko O. National Patterns of Interfacility Transfers for Seizure-Related Emergencies: Could the Utilization of Transfer Networks for Seizures Be Optimized? Neurology 2022; 99:1081-1082. [PMID: 36220599 DOI: 10.1212/wnl.0000000000201530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Olga Taraschenko
- From the Comprehensive Epilepsy Program, Department of Neurological Sciences, University of Nebraska Medical Center, 988435 Nebraska Medical Center, Omaha, NE.
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Acton EK, Blank LJ, Willis AW, Hamedani AG. Interfacility Transfers for Seizure-Related Emergencies in the United States. Neurology 2022; 99:e2718-e2727. [PMID: 36220601 PMCID: PMC9757868 DOI: 10.1212/wnl.0000000000201319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/12/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Interfacility transfer protocols are important for seizure-related emergencies, the cause of approximately 1% of all emergency department (ED) visits in the United States, but data on current practices are lacking. We assessed the prevalence, temporal trends, and patterns of interfacility transfers following seizure-related ED visits. METHODS We performed a retrospective longitudinal cross-sectional analysis of ED dispositions for seizure-related emergencies among adult and pediatric populations using the Nationwide Emergency Department Sample (NEDS). We used joinpoint regression to analyze annual trends in ED visits and transfer rates from 2007 to 2018. Logistic regression models using data from 2016 to 2018 explored the patient- and hospital-level factors associated with transfer vs admission. Sampling weights were applied to account for the complex survey design of the NEDS. RESULTS Using nationally representative data from 2007 to 2018, there were 7,372,065 weighted ED visits for seizure-related emergencies, including 419,368 (5.6%) visits for a primary diagnosis of status epilepticus. We found that 2.3%-5.6% of all these seizure-related ED visits resulted in an interfacility transfer and that the rate of transfer increased significantly over time. Among ED visits specifically for status epilepticus, interfacility transfers resulted from 19.8% to 23.24% of visits, which also increased over time. Multivariable logistic regression of adult and pediatric visits for status epilepticus revealed that transferring hospitals were more likely to be nonmetropolitan (adjusted odds ratio [aOR] 2.2, 95% CI 1.6-2.9) and less likely to have continuous electroencephalography (cEEG) capabilities (aOR 0.3, 98% CI 0.3-0.4). Transferred patients were more likely to be children (aOR 1.5, 95% CI 1.3-1.6 for those 1-4 years old; aOR 1.5 (95% CI 1.3-1.7) for ages 5-14 years), have acute cerebrovascular disease (aOR 1.4, 95% CI 1.1-1.8), and have received mechanical ventilation (aOR 1.5, 95% CI 1.4-1.7). DISCUSSION By 2018, approximately 1 in 19 seizure-related and 1 in 5 status epilepticus ED visits resulted in interfacility transfers. In order of strength of association, illness severity, ED seizure volume, comorbid meningitis and traumatic brain injury, nonrural location, cEEG capabilities, and pediatric age favored admission. Rural location, lack of cEEG capabilities, and comorbid stroke favored transfer. Thoughtful deployment of novel EEG technologies and teleneurology tools may help optimize triage and prevent unnecessary ED transfers.
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Affiliation(s)
- Emily K Acton
- From the Center for Pharmacoepidemiology Research and Training (E.K.A.,M.S.C.E., A.W.W.), Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (E.K.A.,M.S.C.E., A.W.W., A.G.H.), Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Biostatistics, Epidemiology, and Informatics (E.K.A., A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Division of Health Outcomes and Knowledge Translation Research (L.J.B.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia; and Leonard Davis Institute of Health Economics (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Leah J Blank
- From the Center for Pharmacoepidemiology Research and Training (E.K.A.,M.S.C.E., A.W.W.), Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (E.K.A.,M.S.C.E., A.W.W., A.G.H.), Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Biostatistics, Epidemiology, and Informatics (E.K.A., A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Division of Health Outcomes and Knowledge Translation Research (L.J.B.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia; and Leonard Davis Institute of Health Economics (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison W Willis
- From the Center for Pharmacoepidemiology Research and Training (E.K.A.,M.S.C.E., A.W.W.), Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (E.K.A.,M.S.C.E., A.W.W., A.G.H.), Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Biostatistics, Epidemiology, and Informatics (E.K.A., A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Division of Health Outcomes and Knowledge Translation Research (L.J.B.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia; and Leonard Davis Institute of Health Economics (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Ali G Hamedani
- From the Center for Pharmacoepidemiology Research and Training (E.K.A.,M.S.C.E., A.W.W.), Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (E.K.A.,M.S.C.E., A.W.W., A.G.H.), Translational Center of Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Biostatistics, Epidemiology, and Informatics (E.K.A., A.W.W.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Division of Health Outcomes and Knowledge Translation Research (L.J.B.), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy (L.J.B.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia; and Leonard Davis Institute of Health Economics (A.W.W., A.G.H.), University of Pennsylvania Perelman School of Medicine, Philadelphia.
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Brown L, França UL, McManus ML. Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma. Acad Pediatr 2022; 22:29-36. [PMID: 34051373 DOI: 10.1016/j.acap.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe the current system of pediatric asthma care and identify potential options for unloading tertiary centers. METHODS Retrospective, cross-sectional study using 2014 inpatient and emergency department all-encounter administrative datasets from Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. Study participants included children <18 with primary diagnosis of asthma. RESULTS There were 174,239 encounters for pediatric asthma, with 26,316 admissions and 3101 transfers. About 94.4% of transfers were admitted, with median stay length 2 days (interquartile range [IQR] 1.0-3.0). About 637 hospitals saw pediatric asthma, but 58.7% never admitted these patients. Fifty-four hospitals (8.5%) regularly received transfers; these hospitals were broadly capable pediatric centers (mean pediatric hospital capability indices = 0.82, IQR: 0.64-0.89). Two hundred nine facilities (32.8%) did not regularly receive transfers but were highly capable of caring for pediatric asthma (mean condition-specific capability = 0.92, IQR: 0.85-1.00). Median distance from transferring hospitals to the nearest pediatric center was 25.7 miles (IQR: 6.45-50.15) vs 18.0 miles (IQR: 8.35-29.25) to the nearest potential receiving hospital. Mean cost of a 2-day asthma admission in receiving hospitals was $3927 (IQR: $3083-$4894) versus $3427 (IQR: $2485-$4102) in potential receivers. CONCLUSIONS While nearly all acute care hospitals encounter children with asthma, more than half never admit them. Children are primarily transferred to a small subset of specialized centers, despite the existence, in many regions, of closer community hospitals with high pediatric asthma capability. In settings with long transfer distances and tertiary center crowding, a tiered system of hospital care for pediatric asthma may be feasible.
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Affiliation(s)
- Lauren Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass.
| | - Urbano L França
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass
| | - Michael L McManus
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass
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Abstract
OBJECTIVES To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States. DESIGN Retrospective, cross-sectional study. SETTING Contiguous United States. PATIENTS Children less than 18 years as represented in the 2016 American Community Survey. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas. CONCLUSIONS In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.
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Affiliation(s)
- Lauren E Brown
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Urbano L França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Michael L McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Abstract
BACKGROUND In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery. METHODS A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth. RESULTS Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation. CONCLUSIONS Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers. EDITOR’S PERSPECTIVE
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Sánchez Fernández I, Amengual-Gual M, Barcia Aguilar C, Gaínza-Lein M. Descriptive epidemiology and health resource utilization for status epilepticus in the emergency department in the United States of America. Seizure 2021; 87:7-16. [PMID: 33639504 DOI: 10.1016/j.seizure.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/11/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To describe the epidemiology and health resource utilization for convulsive status epilepticus (SE) in the emergency department (ED). METHODS Retrospective descriptive study in the Nationwide Emergency Department Sample (NEDS). Primary SE and secondary SE (SE in a case who visited the ED for other primary reason) were compared with non-SE seizures. Secondary SE is expected to have worse outcomes and higher costs because of another primary cause for ED visit. RESULTS In the period 2010-2014, there were 149,750 ED visits with primary SE; 83,459 ED with secondary SE; and 5,359,103 ED visits with non-SE seizures. On multivariable analysis adjusting for potential confounders, the odds of hospital admission were 7 times higher for primary SE than for non-SE seizures, and 5 times higher for secondary SE than for non-SE seizures; the odds of transfer to another hospital were 9 times higher for primary SE than for non-SE seizures, and 3 times higher for secondary SE than for non-SE seizures; the odds of death were 2.5 times higher for primary SE than for non-SE seizures, and 12 times higher for secondary SE than for non-SE seizures; and the charges (in January 2020 USA dollars) were $9000 higher in primary SE than in non-SE seizures, and $35,000 higher in secondary SE than in non-SE seizures. CONCLUSION Among all reasons for ED visits, SE, and in particular, secondary SE, are among the most resource-consuming conditions, being much more expensive than non-SE seizures in the ED.
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Affiliation(s)
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile; Servicio de Neuropsiquiatría Infantil. Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
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