Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0

Neurodevelopmental and Mental Health Conditions in Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) may be at a high risk of neurodevelopmental and mental health conditions given disease comorbidities and lived experiences. Little is known about the prevalence of these conditions at a population level. In this study, we estimated the prevalence of neurodevelopmental and mental health diagnoses in CMC relative to children without medical complexity and measured associations between these diagnoses in CMC and subsequent health care utilization and in-hospital mortality.

METHODS

We applied the Child and Adolescent Mental Health Disorders Classification System to identify neurodevelopmental and mental health diagnoses using all-payer claims data from three states (2012-2017). Poisson regression was used to compare outcomes in CMC with neurodevelopmental and mental health diagnoses to CMC without these diagnoses, adjusting for sociodemographic and clinical characteristics.

RESULTS

Among 85 581 CMC, 39 065 (45.6%) had ≥1 neurodevelopmental diagnoses, and 31 703 (37.0%) had ≥1 mental health diagnoses, reflecting adjusted relative risks of 3.46 (3.42-3.50) for neurodevelopmental diagnoses and 2.22 (2.19-2.24) for mental health diagnoses compared with children without medical complexity. CMC with both neurodevelopmental and mental health diagnoses had 3.00 (95% confidence interval [CI]: 2.98-3.01) times the number of ambulatory visits, 69% more emergency department visits (rate ratio = 1.69, 95% CI: 1.66-1.72), 58% greater risk of hospitalization (rate ratio = 1.58, 95% CI: 1.50-1.67), and 2.32 times (95% CI: 2.28-2.36) the number of hospital days than CMC without these diagnoses.

CONCLUSIONS

Neurodevelopmental and mental health diagnoses are prevalent among CMC and associated with increased health care utilization across the continuum of care. These findings illustrate the importance of recognizing and treating neurodevelopmental and mental health conditions in this population.

Pediatric Nirmatrelvir/Ritonavir Prescribing Patterns During the COVID-19 Pandemic

OBJECTIVES

This study seeks to identify demographic and clinical factors prompting clinician prescribing of nirmatrelvir/ritonavir to pediatric patients for management of coronavirus disease 2019 (COVID-19) infection.

METHODS

Patients aged 12 to 17 years with a COVID-19 infection and nirmatrelvir/ritonavir prescription during an outpatient clinical encounter within a PEDSnet-affiliated institution between January 2022 and August 2023 were identified using electronic health record data. A multivariate logistic regression analysis was used to estimate odds of nirmatrelvir/ritonavir prescription after adjusting for various factors.

RESULTS

A total of 20 959 patients aged 12 to 17 years were diagnosed with a COVID-19 infection on the basis of an electronic health record-documented positive polymerase chain reaction or antigen test or diagnosis during an outpatient clinical visit. Of these patients, 408 received a nirmatrelvir/ritonavir prescription within 5 days of diagnosis. Higher odds of nirmatrelvir/ritonavir treatment were associated with having chronic or complex chronic disease (chronic: odds ratio [OR] 2.50 [95% confidence interval (CI) 1.83-3.38]; complex chronic: OR 2.21 [95% CI 1.58-3.08]). Among patients with chronic disease, each additional body system conferred 1.18 times higher odds of treatment (95% CI 1.10-1.26). Compared with non-Hispanic white patients, Hispanic patients (OR 0.61 [95% CI 0.44-0.83]) had lower odds of treatment.

CONCLUSIONS

Children with chronic conditions are more likely than those without to receive nirmatrelvir/ritonavir prescriptions. However, nirmatrelvir/ritonavir prescribing to children with chronic conditions remains infrequent. Pediatric data concerning nirmatrelvir/ritonavir safety and effectiveness in preventing severe disease and hospitalization are critical optimizing clinical decision-making and use among children.

Long-Term Cardiovascular Outcomes in Children and Adolescents With Hypertension

Importance

Hypertension affects 6% of all children, and its prevalence is increasing. Childhood hypertension tracks into adulthood and is associated with subclinical cardiovascular disease; however, there is a lack of evidence linking childhood hypertension to cardiovascular outcomes, which may contribute to underdiagnosis and undertreatment.

Objective

To determine the long-term associated risk of major adverse cardiac events (MACE) among children diagnosed with hypertension.

Design, Setting, and Participants

This was a population-based, retrospective, matched cohort study conducted from 1996 to 2022. The study included all children (aged 3-18 years) alive in Ontario, Canada, from 1996 to 2021, who were identified using provincial administrative health databases. Children with prior kidney replacement therapy were excluded.

Exposure

Incident hypertension diagnosis, identified by validated case definitions using diagnostic and physician billing claims. Each case was matched with 5 controls without hypertension by age, sex, birth weight, maternal gestational hypertension, prior comorbidities (chronic kidney disease, diabetes, cardiovascular surgery), and a propensity score for hypertension.

Main Outcomes and Measures

The primary outcome was MACE (a composite of cardiovascular death, stroke, hospitalization for myocardial infarction or unstable angina, or coronary intervention). Time to MACE was evaluated using the Kaplan-Meier method and Cox proportional hazards regression.

Results

A total of 25 605 children (median [IQR] age, 15 [11-17] years; 14 743 male [57.6%]) with hypertension were matched to 128 025 controls without hypertension. Baseline covariates were balanced after propensity score matching, and prior comorbidities were uncommon (hypertension vs control cohort: malignancy, 1451 [5.7%] vs 7908 [6.2%]; congenital heart disease, 1089 [4.3%] vs 5408 [4.2%]; diabetes, 482 [1.9%] vs 2410 [1.9%]). During a median (IQR) of 13.6 (7.8-19.5) years of follow-up, incidence of MACE was 4.6 per 1000 person-years in children with hypertension vs 2.2 per 1000 person-years in controls (hazard ratio, 2.1; 95% CI, 1.9-2.2). Children with hypertension were at higher associated risk of stroke, hospitalization for myocardial infarction or unstable angina, coronary intervention, and congestive heart failure, but not cardiovascular death, compared with nonhypertensive controls.

Conclusions and Relevance

Children diagnosed with hypertension had a higher associated long-term risk of MACE compared with controls without hypertension. Improved detection, follow-up, and control of pediatric hypertension may reduce the risk of adult cardiovascular disease.

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022)

There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.

Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative

We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.

Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings

OBJECTIVE

To assess whether a two-phase intervention was associated with improvements in antibiotic prescribing among nonhospitalized children with community-acquired pneumonia.

STUDY DESIGN

In a large health care organization, a first intervention phase was implemented in September 2020 directed at antibiotic choice and duration for children 2 months through 17 years of age with pneumonia. Activities included clinician education and implementation of a pneumonia-specific order set in the electronic health record. In October 2021, a second phase comprised additional education and order set revisions. A narrow spectrum antibiotic (eg, amoxicillin) was recommended in most circumstances. Electronic health record data were used to identify pneumonia cases and antibiotics ordered. Using interrupted time series analyses, antibiotic choice and duration after phase one (September 2020-September 2021) and after phase two (October 2021-October 2022) were compared with a preintervention prepandemic period (January 2016-early March 2020).

RESULTS

Overall, 3570 cases of community-acquired pneumonia were identified: 3246 cases preintervention, 98 post-phase one, and 226 post-phase two. The proportion receiving narrow spectrum monotherapy increased from 40.6% preintervention to 68.4% post-phase one to 69.0% post-phase two (P < .001). For children with an initial narrow spectrum antibiotic, duration decreased from preintervention (mean duration 9.9 days, SD 0.5 days) to post-phase one (mean 8.2, SD 1.9) to post-phase two (mean 6.8, SD 2.3) periods (P < .001).

CONCLUSIONS

A two-phase intervention with educational sessions combined with clinical decision support was associated with sustained improvements in antibiotic choice and duration among children with community-acquired pneumonia.

Predicting Dental General Anesthesia Use among Children with Behavioral Health Conditions

OBJECTIVES

To evaluate how different data sources affect the performance of machine learning algorithms that predict dental general anesthesia use among children with behavioral health conditions.

STUDY DESIGN

Observational study using claims data.

METHODS

Using Medicaid claims from Partners For Kids (2013-2019), electronic medical record data, and the Ohio Child Opportunity Index, we conducted a retrospective cohort study of 12,410 children with behavioral health diagnoses. Four lasso-regularized logistic regression models were developed to predict dental general anesthesia use, each incorporating different data sources. Lift scores, or the ratio of positive predictive value to base case prevalence, were used to compare models, and a lift score of 2.5 was considered minimally acceptable for risk prediction.

RESULTS

Dental general anesthesia use ranged from 3.2% to 3.9% across models, which made it difficult for the machine learning models to achieve high positive predictive value. Model performance was best when either the electronic medical record (lift = 2.59) or Ohio Child Opportunity Index (lift = 2.56), but not both (lift = 2.34) or neither (lift = 1.87), was used.

CONCLUSIONS

Incorporating additional data sources improved machine learning model performance, and 2 models achieved satisfactory performance. The model using electronic medical record data could be applied in hospital-based settings, and the model using the Ohio Child Opportunity Index could be more valuable in community-based settings.

KNOWLEDGE TRANSFER STATEMENT

Machine learning was applied to satisfactorily predict which children with behavioral health diagnoses would require dental treatment under general anesthesia. Incorporating electronic medical record data or area-level social determinants of health data, but not both, improved the performance of the machine learning predictions. The 2 highest performing models could be applied by hospitals using medical record data or by organizations using area-level social determinants of health data to risk stratify the pediatric behavioral health population.

Mortality after paediatric emergency calls for patients with or without pre-existing comorbidity: a nationwide population based cohort study

BACKGROUND

Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively.

METHODS

Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits.

RESULTS

Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity.

CONCLUSION

In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services.

Post-Acute Cardiovascular Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Project

Background

The risk of cardiovascular outcomes in the post-acute phase of SARS-CoV-2 infection has been quantified among adults and children. This paper aimed to assess a multitude of cardiac signs, symptoms, and conditions, as well as focused on patients with and without congenital heart defects (CHDs), to provide a more comprehensive assessment of the post-acute cardiovascular outcomes among children and adolescents after COVID-19.

Methods

This retrospective cohort study used data from the RECOVER consortium comprising 19 US children's hospitals and health institutions between March 2020 and September 2023. Every participant had at least a six-month follow-up after cohort entry. Absolute risks of incident post-acute COVID-19 sequelae were reported. Relative risks (RRs) were calculated by contrasting COVID-19-positive with COVID-19-negative groups using a Poisson regression model, adjusting for demographic, clinical, and healthcare utilization factors through propensity scoring stratification.

Results

A total of 1,213,322 individuals under 21 years old (mean[SD] age, 7.75[6.11] years; 623,806 male [51.4%]) were included. The absolute rate of any post-acute cardiovascular outcome in this study was 2.32% in COVID-19 positive and 1.38% in negative groups. Patients with CHD post-SARS-CoV-2 infection showed increased risks of any cardiovascular outcome (RR, 1.63; 95% confidence interval (CI), 1.47-1.80), including increased risks of 11 of 18 post-acute sequelae in hypertension, arrhythmias (atrial fibrillation and ventricular arrhythmias), myocarditis, other cardiac disorders (heart failure, cardiomyopathy, and cardiac arrest), thrombotic disorders (thrombophlebitis and thromboembolism), and cardiovascular-related symptoms (chest pain and palpitations). Those without CHDs also experienced heightened cardiovascular risks after SARS-CoV-2 infection (RR, 1.63; 95% CI, 1.57-1.69), covering 14 of 18 conditions in hypertension, arrhythmias (ventricular arrhythmias and premature atrial or ventricular contractions), inflammatory heart disease (pericarditis and myocarditis), other cardiac disorders (heart failure, cardiomyopathy, cardiac arrest, and cardiogenic shock), thrombotic disorders (pulmonary embolism and thromboembolism), and cardiovascular-related symptoms (chest pain, palpitations, and syncope).

Conclusions

Both children with and without CHDs showed increased risks for a variety of cardiovascular outcomes after SARS-CoV-2 infection, underscoring the need for targeted monitoring and management in the post-acute phase.

What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives

OBJECTIVES

Data on inpatient safety are documented by hospital staff through incident reporting (IR) systems. Safety observations from families or patients are rarely captured. The Family Input for Quality and Safety (FIQS) study created a mobile health tool for pediatric patients and their families to anonymously report safety observations in real time during hospitalization. The study objectives were to describe these observations and identify domains salient to safety.

METHODS

In this observational study, we analyzed pediatric patient safety reports from June 2017 to April 2018. Participants were: English-speaking family members and hospitalized patients ≥13 years old. The analysis had two stages: 1) assessment of whether narratives met established safety event criteria and whether there were companion IRs; 2) thematic analysis to identify domains.

RESULTS

Of 248 enrolled participants, 58 submitted 120 narrative reports. Of the narratives, 68 (57%) met safety event criteria, while only one (0.8%) corresponded to a staff-reported IR. 25% of narratives shared positive feedback about patient safety efforts; 75% shared constructive feedback. We identified domains particularly salient to safety: 1) patients and families as safety actors; 2) emotional safety; 3) system-centered care; and 4) shared safety domains, including medication, communication, and environment of care. Some domains capture data that is otherwise difficult to obtain (#1-3), while others fit within standard healthcare safety domains (#4).

CONCLUSIONS

Patients and families observe and report salient safety events that can fill gaps in IR data. Healthcare leaders should consider incorporating patient and family observations-collected with an option for anonymity and eliciting both positive and constructive comments.

What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

Vitamin K Prescribing Trends Among Critically Ill Children Hospitalized for Sepsis: A Multicenter Observational Cohort Study

Objective: Vitamin K (VK) is commonly prescribed for pediatric sepsis-induced coagulopathy without trial-derived evidence to support its use for this indication. The purpose of this study was to characterize national prescribing trends for VK in this population. Patients and Methods: This is a multicenter retrospective cohort study using the Pediatric Health Information System registry including children 0 to 17 years of age hospitalized for sepsis in the pediatric intensive care unit from January 2016 through December 2022. The primary outcome was overall, annual, and center-specific VK prescribing rates. Descriptive data included demographics, length of stay, and rates of VK deficiency, hepatic insufficiency, red blood cell (RBC) transfusion, venous thromboembolism (VTE), and mortality. VK prescribing trends were assessed using Joinpoint regression. Descriptive statistics employed included Wilcoxon rank-sum, student's t, and chi-square tests. Results: Of the 31 221 encounters studied, 4539 (14.6%) were prescribed VK (median center-specific rate: 14.2%; interquartile range [IQR]: 8.8-21%) with a linear annual trend decreasing from 17.3% in 2016 to 13.3% in 2022 (-0.6%/year, r2 = .661). Those prescribed VK had greater rates of hepatic dysfunction (20.5% vs 3.1%), RBC transfusion (26.5% vs 11.2%), VTE (12.5% vs 4.6%), mortality (17.1% vs 4.4%), and median length of stay (16 [IQR: 8-33] vs 8 [4-15] days) (all P < .001). VK deficiency was diagnosed in 0.2% of encounters. Conclusions: In this multicenter retrospective cohort, VK prescribing was common among critically ill children diagnosed with sepsis. Phased trials are needed to demonstrate clinical efficacy and safety for VK in this population.

Recovery Trajectories in Children Requiring 3 or More Days of Invasive Ventilation

OBJECTIVES

To characterize health-related quality of life (HRQL) and functional recovery trajectories and risk factors for prolonged impairments among critically ill children receiving greater than or equal to 3 days of invasive ventilation.

DESIGN

Prospective cohort study.

SETTING

Quaternary children's hospital PICU.

PATIENTS

Children without a preexisting tracheostomy who received greater than or equal to 3 days of invasive ventilation, survived hospitalization, and completed greater than or equal to 1 postdischarge data collection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated 144 children measuring HRQL using proxy-report Pediatric Quality of Life Inventory and functional status using the Functional Status Scale (FSS) reflecting preillness baseline, PICU and hospital discharge, and 1, 3, 6, and 12 months after hospital discharge. They had a median age of 5.3 years (interquartile range, 1.1-13.0 yr), 58 (40%) were female, 45 (31%) had a complex chronic condition, and 110 (76%) had normal preillness FSS scores. Respiratory failure etiologies included lung disease ( n = 49; 34%), neurologic failure ( n = 23; 16%), and septic shock ( n = 22; 15%). At 1-month postdischarge, 68 of 122 (56%) reported worsened HRQL and 35 (29%) had a new functional impairment compared with preillness baseline. This improved at 3 months to 54 (46%) and 24 (20%), respectively, and remained stable through the remaining 9 months of follow-up. We used interaction forests to evaluate relative variable importance including pairwise interactions and found that therapy consultation within 3 days of intubation was associated with better HRQL recovery in older patients and those with better preillness physical HRQL. During the postdischarge year, 76 patients (53%) had an emergency department visit or hospitalization, and 62 (43%) newly received physical, occupational, or speech therapy.

CONCLUSIONS

Impairments in HRQL and functional status as well as health resource use were common among children with acute respiratory failure. Early therapy consultation was a modifiable characteristic associated with shorter duration of worsened HRQL in older patients.

Unplanned Readmissions in Children with Medical Complexity in Saudi Arabia: A Large Multicenter Study

Background

Children with medical complexity (CMC) account for a substantial proportion of healthcare spending, and one-third of their expenditures are due to readmissions. However, knowledge regarding the healthcare-resource utilization and characteristics of CMC in Saudi Arabia is limited.

Objectives

To describe hospitalization patterns and characteristics of Saudi CMC with an unplanned 30-day readmission.

Methodology

This retrospective study included Saudi CMC (aged 0-14 years) who had an unplanned 30-day readmission at six tertiary centers in Riyadh, Jeddah, Dammam, Alahsa, and Almadina between January 2016 and December 2020. Hospital-based inclusion criteria focused on CMC with multiple complex chronic conditions (CCCs) and technology assistance (TA) device use. CMC were compared across demographics, clinical characteristics, and hospital-resource utilization.

Results

A total of 9139 pediatric patients had unplanned 30-day readmission during the study period, of which 680 (7.4%) met the inclusion criteria. Genetic conditions were the most predominant primary pathology (66.3%), with one-third of cases (33.7%) involving the neuromuscular system. During the index admission, pneumonia was the most common diagnosis (33.1%). Approximately 35.1% of the readmissions were after 2 weeks. Pneumonia accounted for 32.5% of the readmissions. After readmission, 16.9% of patients were diagnosed with another CCC or received a new TA device, and the in-hospital mortality rate was 6.6%.

Conclusion

The rate of unplanned 30-day readmissions in children with medical complexity in Saudi Arabia is 7.4%, which is lower than those reported from developed countries. Saudi children with CCCs and TA devices were readmitted approximately within similar post-discharge time and showed distinct hospitalization patterns associated with specific diagnoses. To effectively reduce the risk of 30-day readmissions, targeted measures must be introduced both during the hospitalization period and after discharge.

Vaccine Effectiveness Against Long COVID in Children

OBJECTIVES

Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years.

METHODS

This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination.

RESULTS

The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months.

CONCLUSIONS

This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data.

Which low urgent triaged febrile children are suitable for a fast track? An observational European study

BACKGROUND

The number of paediatric patients visiting the ED with non-urgent problems is increasing, leading to poor patient flow and ED crowding. Fast track aims to improve the efficiency of evaluation and discharge of low acuity patients. We aimed to identify which febrile children are suitable for a fast track based on presenting symptoms and management.

METHODS

This study is part of the Management and Outcome of Fever in children in Europe study, which is an observational study including routine data of febrile children <18 years attending 12 European EDs. We included febrile, low urgent children (those assigned a triage acuity of either 'standard' or 'non-urgent' using the Manchester Triage System) and defined children as suitable for fast track when they have minimal resource use and are discharged home. Presenting symptoms consisted of neurological (n=237), respiratory (n=8476), gastrointestinal (n=1953) and others (n=3473, reference group). Multivariable logistic regression analyses regarding presenting symptoms and management (laboratory blood testing, imaging and admission) were performed with adjustment for covariates: patient characteristics, referral status, previous medical care, previous antibiotic use, visiting hours and ED setting.

RESULTS

We included 14 139 children with a median age of 2.7 years (IQR 1.3-5.2). The majority had respiratory symptoms (60%), viral infections (50%) and consisted of self-referrals (69%). The neurological group received imaging more often (adjusted OR (aOR) 1.8, 95% CI 1.1 to 2.9) and were admitted more frequently (aOR 1.9, 95% CI 1.4 to 2.7). The respiratory group had fewer laboratory blood tests performed (aOR 0.6, 95% CI 0.5 to 0.7), were less frequently admitted (aOR 0.6, 95% CI 0.5 to 0.7), but received imaging more often (aOR 1.8, 95% CI 1.6 to 2.0). Lastly, the gastrointestinal group had more laboratory blood tests performed (aOR 1.2. 95% CI 1.1 to 1.4) and were admitted more frequently (aOR 1.4, 95% CI 1.2 to 1.6).

CONCLUSION

We determined that febrile children triaged as low urgent with respiratory symptoms were most suitable for a fast track. This study provides evidence for which children could be triaged to a fast track, potentially improving overall patient flow at the ED.

Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors

Importance

Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care).

Objective

To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs).

Design, Setting, and Participants

This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022.

Exposure

Setting of telemedicine visit as PCP vs DTC.

Main Outcomes and Measures

The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes.

Results

In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]).

Conclusions and Relevance

Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.

Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty

PURPOSE

Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery.

METHODS

This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification.

FINDINGS

Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects.

CONCLUSIONS

Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.

Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes

OBJECTIVE

To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types.

METHODS

Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes.

RESULTS

Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors).

CONCLUSIONS

Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.

Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program

OBJECTIVE

Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program.

METHODS

Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests.

RESULTS

Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100).

CONCLUSIONS

The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.

A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system

BACKGROUND

Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable.

OBJECTIVE

To understand how US child welfare agencies define, identify, and track CMC.

PARTICIPANTS AND SETTING

Child welfare agencies across the US.

METHODS

Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses.

RESULTS

Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data.

CONCLUSIONS

Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.

Racial Disparities in Failure to Rescue after Pediatric Heart Surgeries in the US

OBJECTIVE

To identify the trend in failure to rescue (FTR) and risk factors contributing to racial disparities in FTR after pediatric heart surgery using contemporary nationwide data.

STUDY DESIGN

We identified 85 267 congenital heart surgeries in patients <18 years of age from 2009 to 2019 using the Kid's Inpatient Database. The primary outcome was FTR. A mixed-effect logistic regression model with hospital random intercept was used to identify independent predictors of FTR.

RESULTS

Among 36 753 surgeries with postoperative complications, the FTR was 7.3%. The FTR decreased from 7.4% in 2009 to 6.3% in 2019 (P = .02). FTR was higher among Black than White children for all years. The FTR was higher among girls (7.2%) vs boys (6.6%), children aged <1 (9.6%) vs 12-17 years (2.4%), and those of Black (8.5%) vs White race (5.9%) (all P < .05). Black race was associated with a higher FTR odds (OR, 1.40; 95% CI, 1.20-1.65) after adjusting for demographics, medical complexity, nonelective admission, and hospital surgical volume. Higher hospital volume was associated with a lower odds of FTR for all racial groups, but fewer Black (19.7%) vs White (31%) children underwent surgery at high surgical volume hospitals (P < .001). If Black children were operated on in the same hospitals as White children, the racial differences in FTR would decrease by 47.3%.

CONCLUSIONS

Racial disparities exist in FTR after pediatric heart surgery in the US. The racial differences in the location of care may account for almost half the disparities in FTR.

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children

OBJECTIVE

This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years.

METHODS

This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex.

RESULTS

Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion.

CONCLUSIONS

This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Family Presence at the PICU Bedside: A Single-Center Retrospective Cohort Study

OBJECTIVES

To determine factors associated with bedside family presence in the PICU and to understand how individual factors interact as barriers to family presence.

DESIGN

Mixed methods study.

SETTING

Tertiary children's hospital PICU.

SUBJECTS

Five hundred twenty-three children of less than 18 years enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2011 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Quantitative: Family was documented every 2 hours. Exposures included patient and illness characteristics and family demographic and socioeconomic characteristics. We used multivariable logistic regression to identify factors associated with presence of less than 80% and stratified results by self-reported race. Longer PICU length of stay (LOS), public insurance, and complex chronic conditions (C-CD) were associated with family presence of less than 80%. Self-reported race modified these associations; no factors were associated with lower bedside presence for White families, in contrast with multiple associations for non-White families including public insurance, C-CD, and longer LOS. Qualitative: Thematic analysis of social work notes for the 48 patients with family presence of less than 80% matched on age, LOS, and diagnosis to 48 patients with greater than or equal to 95% family presence. Three themes emerged: the primary caregiver's prior experiences with the hospital, relationships outside of the hospital, and additional stressors during the hospitalization affected bedside presence.

CONCLUSIONS

We identified sociodemographic and illness factors associated with family bedside presence in the PICU. Self-reported race modified these associations, representing racism within healthcare. Family presence at the bedside may help identify families facing greater disparities in healthcare access.

Accuracy of the Exeter Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns Index for Identifying Children With Complex Chronic Medical Conditions in the Clinical Setting

OBJECTIVE

Our objective was to determine the accuracy of a point-of-care instrument, the Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns (HOMES) instrument, in identifying patients with complex chronic conditions (CCCs) compared to an algorithm used to identify patients with CCCs within large administrative data sets.

METHODS

We compared the HOMES to Feudtner's CCCs classification system. Using administrative algorithms, we categorized primary care patients at a children's hospital into 3 categories: no chronic conditions, non-complex chronic conditions, and CCCs. We randomly selected 100 patients from each category. HOMES scoring was completed for each patient. We performed an optimal cut-point analysis on 80% of the sample to determine which total HOMES score best identified children with ≥1 CCC and ≥2 CCCs. Using the optimal cut points and the remaining 20% of the study population, we determined the odds and area under the curve (AUC) of having ≥1 CCC and ≥2 CCCs.

RESULTS

The median (interquartile range [IQR]) age was 4 (IQR: 0, 8). Using optimal cut points of ≥7 for ≥1 CCC and ≥11 for ≥2 CCCs, the odds of having ≥1 CCC was 19 times higher than lower scores (odds ratio [OR] 19.1 [95% confidence interval [CI]: 9.75, 37.5]) and of having ≥2 CCCs was 32 times higher (OR 32.3 [95% CI: 12.9, 50.6]). The AUCs were 0.76 for ≥1 CCC (sensitivity 0.82, specificity 0.80) and 0.74 for ≥2 CCCs (sensitivity 0.92, specificity 0.74).

CONCLUSIONS

The HOMES accurately identified patients with CCCs.

Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity

OBJECTIVE

Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality.

METHODS

In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider.

RESULTS

Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS.

CONCLUSIONS

Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.

Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic

BACKGROUND

The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries.

RESEARCH DESIGN

Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19.

RESULTS

Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users.

CONCLUSIONS

TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.

Uncertainty and the NICU Experience: A Qualitative Evaluation of Family and Provider Perspectives

There is limited information regarding caregiver and provider perspectives on uncertainty across the continuum of the neonatal intensive care unit (NICU) experience. Open-ended semi-structured interviews were conducted with providers and English- and Spanish-speaking caregivers of infants with a history of admission to a quaternary safety-net NICU. Major themes were generated using inductive-deductive thematic analysis. Seventy-six individuals participated in the study: 47 caregivers and 29 providers. The median gestational age of the infants was 29 weeks and 85% were classified as having chronic complex disease per the Pediatric Medical Complexity Algorithm. Most providers were neonatologists (37%) and nurses (27%) and more than half had over ten years of experience. A conceptual model of caregiver uncertainty was developed and key domains included drivers of uncertainty and its impact, and factors influencing coping and adaptation. Our analysis found a positive association between caregiver information gathering, clinical continuity, support systems, maternal mental health supports, and witnessing a child's progress and the development of adjustment to chronic uncertainty. These results suggest key areas for intervention that can promote parental adaptation to the uncertainty inherent in the NICU experience.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update

BACKGROUND

General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals.

OBJECTIVE

Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings.

DESIGNS, SETTING, AND PARTICIPANTS

This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays.

INTERVENTION

Not applicable.

MAIN OUTCOME AND MEASURES

Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates.

RESULTS

There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.

How are children with medical complexity being identified in epidemiological studies? A systematic review

BACKGROUND

There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies.

METHODS

PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths.

RESULTS

Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles).

CONCLUSIONS

CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.

Socioeconomic and Clinical Demography of Dental Missed Care Opportunities

INTRODUCTION

Missed care opportunities (MCOs) contribute to poor health outcomes, and pediatric dental patients are particularly vulnerable; identifying associated patient characteristics will help inform development of targeted interventional programs.

OBJECTIVE

To assess socioeconomic and demographic disparities associated with MCOs among children in an urban pediatric hospital's dental clinic. MCOs lead to a lack of continuous care and increased emergent needs, so understanding MCOs is required to achieve equitable pediatric dental health.

METHODS

A retrospective 2-y (2019-2020) cohort of MCOs in children 1 to 17 y old, with scheduled dental visits. MCOs were defined as appointments not attended or canceled and not rescheduled prior to initial scheduled visit. Multivariable mixed-effects logistic regression models with patient-level clustering assessed the associations of demographics, neighborhood-level socioeconomic factors (using social vulnerability index [SVI]), and clinic characteristics with MCOs.

RESULTS

Of 30,095 visits, 30.9% were MCOs. Multivariable logistic regression estimated increased likelihood of MCOs in Black/non-Hispanic (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32) and Hispanic (OR, 1.18; 95% CI, 1.06-1.31) patients, patients with public insurance (OR, 1.25; 95% CI, 1.15-1.36) or no insurance (OR, 1.46; 95% CI, 1.15-1.85), patients with complex chronic conditions (OR, 1.11; 95% CI, 1.03-1.19), visits scheduled during the COVID-19 pandemic (OR, 9.48; 95% CI, 8.89-10.11), appointments with wait days over 21 d (OR, 4.07; 95% CI, 3.49-4.74), and children from neighborhoods of high social vulnerability (75th percentile SVI) (OR, 1.08; 95% CI, 1.01-1.16).

CONCLUSIONS

Children with highest dental MCOs were from neighborhoods with high SVI, had public insurance, and were from marginalized populations. MCOs contribute to inequities in overall health; hence, interventions that address barriers related to characteristics associated with pediatric dental MCOs are needed.

KNOWLEDGE TRANSFER STATEMENT

Missed care opportunities contribute to poor health outcomes; identifying associated patient characteristics will help inform development of targeted interventional programs. Providing these findings to stakeholders will better impart understanding access barriers and drive research and program development. Dissemination of this information in the form of altering appointment practices will better accommodate specific patient population needs.

Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial

BACKGROUND

Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period.

OBJECTIVE

We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes.

DESIGNS, SETTINGS, AND PARTICIPANTS

We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care.

INTERVENTION

We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families.

MAIN OUTCOME AND MEASURES

Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time.

RESULTS

This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

Importance

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood.

Objective

To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity.

Design, Setting, and Participants

This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023.

Exposures

Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals.

Main Outcomes and Measures

The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009.

Results

The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year.

Conclusions and Relevance

Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure

BACKGROUND

Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience.

METHODS

Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated.

RESULTS

The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery.

CONCLUSIONS

A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.

Associations Between Mental and Physical Illness Comorbidity and Hospital Utilization

OBJECTIVE

Characterize the prevalence of chronic physical illness types and mental illness and their comorbidity among adolescents and young adults (AYA) and assess the association of comorbidity on hospital utilization.

METHODS

This study features a population-level sample of 61 339 insurance-eligible AYA with an analytic sample of 49 089 AYA (aged 12-21) in Vermont's 2018 all-payer database. We used multiple logistic regressions to examine the associations between physical illness types and comorbid mental illness and emergency department (ED) use and inpatient hospitalization.

RESULTS

The analytic sample was 50% female, 63% Medicaid, and 43% had ≥1 chronic illness. Mental illness was common (31%) and highly comorbid with multiple physical illnesses. Among AYA with pulmonary illness, those with comorbid mental illness had 1.74-times greater odds (95% confidence interval [CI]: 1.49-2.05, P ≤.0005) of ED use and 2.9-times greater odds (95% CI: 2.05-4.00, P ≤.0005) of hospitalization than those without mental illness. Similarly, comorbid endocrine and mental illness had 1.84-times greater odds of ED use (95% CI: 1.39-2.44, P ≤.0005) and 2.1-times greater odds of hospitalization (95% CI: 1.28-3.46, P = .003), comorbid neurologic and mental illness had 1.36-times greater odds of ED use (95% CI: 1.18-1.56, P ≤.0005) and 2.4-times greater odds of hospitalization (95% CI: 1.73-3.29, P ≤.0005), and comorbid musculoskeletal and mental illness had 1.38-times greater odds of ED use (95% CI: 1.02-1.86, P = .04) and 2.1-times greater odds of hospitalization (95% CI: 1.20-3.52, P = .01).

CONCLUSIONS

Comorbid physical and mental illness was common. Having a comorbid mental illness was associated with greater ED and inpatient hospital utilization across multiple physical illness types.

Emergency medical services utilisation among febrile children attending emergency departments across Europe: an observational multicentre study

Children constitute 6-10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37-61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1-42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1-59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1-0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4-1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05).  Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented. What is Known: •Children constitute around 6-10% of all patients attending the emergency department by emergency medical services. •Discordant EMS use occurs in 37-61% of all children, with fever as most common presenting symptom for discordant EMS use in children. What is New: •There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1-59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED. •Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.

Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care

OBJECTIVE

The goal of this study was to examine the association between self-reported social needs and postpartum depression (PPD) symptoms of mothers screened in pediatric primary care clinics.

METHODS

This retrospective cohort study used electronic health record data from 3616 pediatric patients (age 0-6 months), whose mothers completed the Edinburgh Postpartum Depression Scale (EPDS) and a social needs screening in a large pediatric primary care network between April 2021 and February 2022. Mothers were screened for four self-reported social needs (food, housing, transportation, and utilities). Logistic regression evaluated the association between the report of any social need and a positive EPDS screen (≥ 10), adjusting for demographic and clinical characteristics and ZIP code-level poverty.

RESULTS

Overall, 8.6% of mothers screened positive for PPD and 10.0% reported any social needs. The odds of a positive depression screen were significantly higher among mothers who reported any social need compared to those not reporting a social need (OR 4.18, 95% CI 3.11-5.61). The prevalence of all depressive symptoms on the EPDS was significantly higher among those who reported any social need, relative to those reporting no needs. Mothers reporting any social needs were significantly more likely to report thoughts of self-harm (6.9% vs 1.5%, P < .005).

CONCLUSIONS

Self-report of social need was significantly associated with positive PPD screens during infant well-child visits. Social needs may be a target of future interventions addressing PPD in pediatric settings. Improving care for social needs may have added benefit of alleviating the risk of PPD.

Counseling on the Need for Folic Acid in Adolescents With Epilepsy

Background and Objectives

Folic acid is an important supplement to take for women with epilepsy on antiseizure medications (ASMs). Determination of baseline counseling given to women with epilepsy and the association with folic acid being recommended were evaluated. Factors surrounding the association were reviewed.

Methods

An exploratory retrospective review of women with epilepsy seen at a large Midwestern pediatric institution was performed between January 2018 and January 2020.

Results

Patients who received preconception counseling were more likely to be given a recommendation to take folic acid. Patients on more than 1 ASM were likely to receive counseling. Patient age and race were associated with having folic acid recommended.

Discussion

Providing preconception counseling for women with epilepsy is associated with an increased recommendation and prescription of folic acid. Further evaluation into possible disparities to receiving a folic acid recommendation is needed.

Urban-rural disparities in interfacility transfers for children during COVID-19

PURPOSE

We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling.

FINDINGS

Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168.

CONCLUSIONS

Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.

Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample

Objective

The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs.

Methods

We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes.

Results

Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%).

Conclusions and Relevance

The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.

Measuring Pediatric Palliative Care Quality: Challenges and Opportunities

Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.

Integrated host/microbe metagenomics enables accurate lower respiratory tract infection diagnosis in critically ill children

BACKGROUNDLower respiratory tract infection (LRTI) is a leading cause of death in children worldwide. LRTI diagnosis is challenging because noninfectious respiratory illnesses appear clinically similar and because existing microbiologic tests are often falsely negative or detect incidentally carried microbes, resulting in antimicrobial overuse and adverse outcomes. Lower airway metagenomics has the potential to detect host and microbial signatures of LRTI. Whether it can be applied at scale and in a pediatric population to enable improved diagnosis and treatment remains unclear.METHODSWe used tracheal aspirate RNA-Seq to profile host gene expression and respiratory microbiota in 261 children with acute respiratory failure. We developed a gene expression classifier for LRTI by training on patients with an established diagnosis of LRTI (n = 117) or of noninfectious respiratory failure (n = 50). We then developed a classifier that integrates the host LRTI probability, abundance of respiratory viruses, and dominance in the lung microbiome of bacteria/fungi considered pathogenic by a rules-based algorithm.RESULTSThe host classifier achieved a median AUC of 0.967 by cross-validation, driven by activation markers of T cells, alveolar macrophages, and the interferon response. The integrated classifier achieved a median AUC of 0.986 and increased the confidence of patient classifications. When applied to patients with an uncertain diagnosis (n = 94), the integrated classifier indicated LRTI in 52% of cases and nominated likely causal pathogens in 98% of those.CONCLUSIONLower airway metagenomics enables accurate LRTI diagnosis and pathogen identification in a heterogeneous cohort of critically ill children through integration of host, pathogen, and microbiome features.FUNDINGSupport for this study was provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute (UG1HD083171, 1R01HL124103, UG1HD049983, UG01HD049934, UG1HD083170, UG1HD050096, UG1HD63108, UG1HD083116, UG1HD083166, UG1HD049981, K23HL138461, and 5R01HL155418) as well as by the Chan Zuckerberg Biohub.

Healthcare Utilization Among Children Receiving Permanent Supportive Housing

BACKGROUND AND OBJECTIVES

Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH.

METHODS

We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort.

RESULTS

We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts.

CONCLUSIONS

Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.

Cardiovascular outcomes in children with Kawasaki disease: a population-based cohort study

BACKGROUND

The risk of cardiovascular events after Kawasaki disease (KD) remains uncertain. Our objective was to determine the risk of cardiovascular events and mortality after KD.

METHODS

Population-based retrospective cohort study using Ontario health administrative databases (0-18 years; 1995-2018).

EXPOSURE

pediatric KD hospitalizations. Each case was matched to 100 non-exposed controls.

PRIMARY OUTCOME

major adverse cardiac events (MACE; cardiovascular death, myocardial infarction, or stroke composite).

SECONDARY OUTCOMES

composite cardiovascular events and mortality. We determined incidence rates and adjusted hazard ratios (aHR) using multivariable Cox models.

RESULTS

Among 4597 KD survivors, 79 (1.7%) experienced MACE, 632 (13.8%) composite cardiovascular events, and 9 (0.2%) died during 11-year median follow-up. The most frequent cardiovascular events among KD survivors were ischemic heart disease (4.6 events/1000 person-years) and arrhythmias (4.5/1000 person-years). KD survivors were at increased risk of MACE between 0-1 and 5-10 years, and composite cardiovascular events at all time periods post-discharge. KD survivors had a lower mortality risk throughout follow-up (aHR 0.36, 95% CI 0.19-0.70).

CONCLUSION

KD survivors are at increased risk of post-discharge cardiovascular events but have a lower risk of death, which justifies enhanced cardiovascular disease surveillance in these patients.

IMPACT

Among 4597 Kawasaki disease (KD) survivors, 79 (1.7%) experienced major adverse cardiac events (MACE) and 632 (13.8%) had composite cardiovascular events during 11-year median follow-up. KD survivors had significantly higher risks of post-discharge MACE and cardiovascular events versus non-exposed children. Only nine KD survivors (0.2%) died during follow-up, and the risk of mortality was significantly lower among KD survivors versus non-exposed children. Childhood KD survivors should receive preventative counseling and cardiovascular surveillance, aiming to mitigate adult cardiovascular disease.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol

BACKGROUND

Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices.

METHODS

We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data.

DISCUSSION

Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities.

TRIAL REGISTRATION

NCT05591586.

Clinical Characteristics and Outcomes of Children With SARS-CoV-2 Infection During the Delta and Omicron Variant-Dominant Periods in Korea

BACKGROUND

Data on the clinical characteristics of pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant infection are limited. We aimed to evaluate the clinical features and outcomes of children with SARS-CoV-2 infection before and after omicron variant dominance in Korea.

METHODS

A multicenter retrospective cohort study was conducted in hospitalized patients aged ≤ 18 years with laboratory-confirmed SARS-CoV-2 infection at five university hospitals in South Korea. The study periods were divided into the delta (from August 23, 2021 to January 2, 2022) and omicron (from January 30 to March 31, 2022).

RESULTS

In total, 612 hospitalized patients were identified (211, delta; 401, omicron). During the omicron and delta periods, the proportions of individuals with serious illness (moderate, severe, and critical severity) were 21.2% and 11.8%, respectively (P = 0.034). Compared with the delta period, the proportions of patients with moderate illness increased significantly in the age groups of 0-4 years (14.2% vs. 3.4%) and 5-11 years (18.6% vs. 4.2%) during the omicron period. During the two periods, the proportions of patients with complex chronic diseases (delta, 16.0% vs. 4.3%, P = 0.040; omicron, 27.1% vs. 12.7%; P = 0.002), respiratory diseases except for asthma (delta, 8.0% vs. 0.0%, P = 0.013; omicron, 9.4% vs. 1.6%; P = 0.001), and neurologic diseases (delta, 28.0% vs. 3.2%, P < 0.001; omicron, 40.0% vs. 5.1%, P < 0.001) were significantly higher in patients with serious illness than in those with non-serious illness. During the delta period, the risk for serious illness was higher among patients with obesity (adjusted odds ratio [aOR], 8.18; 95% confidence interval [CI], 2.80-27.36) and neurologic diseases (aOR, 39.43; 95% CI, 6.90-268.3) and aged 12-18 years (aOR, 3.92; 95% CI, 1.46-10.85). However, the presence of neurologic disease (aOR, 9.80; 95% CI, 4.50-22.57) was the only risk factor for serious illness during the omicron period. During the omicron period, the proportions of patients with croup (11.0% vs. 0.5%) and seizures (13.2% vs. 2.8%) increased significantly compared with the delta period.

CONCLUSION

Compared with the delta period, the proportions of young children and patients with complex comorbidities were higher during the omicron period in Korea. Patients with complex chronic diseases, especially neurologic diseases, had a high risk of severe coronavirus disease 2019 in the two distinct variant-dominant periods.

Follow-up After Pediatric Mental Health Emergency Visits

OBJECTIVES

To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.

METHODS

We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).

RESULTS

Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.

CONCLUSIONS

Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Early Peanut Introduction in Primary Care: Evaluation of a Multicomponent Intervention

OBJECTIVE

To determine whether a multicomponent intervention focused on early peanut introduction was associated with a lower peanut allergy incidence in young children.

METHODS

The study cohort comprised all children born January 1, 2013 through December 31, 2018 receiving care at a large health care organization. Intervention activities occurred over 16 months and included provider educational programs, electronic health record tools, and new patient instructions. We used an interrupted time series design to assess whether peanut allergy incidence differed across 3 time periods (preintervention, interim, postintervention) among high- and low-risk children. The primary outcome was incident peanut allergy by age 24 months, defined as peanut allergy in the allergy field or active problem list plus a positive supportive test. Severe eczema and/or egg allergy presence defined high-risk. Because the study was conducted as part of routine care, it was not feasible to measure what counseling clinicians provided, or how and when parents fed their children peanut-containing foods.

RESULTS

In a cohort of 22,571 children, the percent with peanut allergy by age 24 months was 17.3% (116 of 671) among high-risk and 0.8% (181 of 21,900) among low-risk children. In multivariate analyses, the adjusted peanut allergy rate per 100 person-years was not significantly different across study periods among high-risk (9.6 preintervention, 11.7 interim, and 9.9 postintervention, P = .70) or low-risk (0.5 preintervention, 0.7 interim, and 0.5 postintervention, P = .17) children.

CONCLUSIONS

In a community-based setting, the incidence of peanut allergy did not decline following a multicomponent intervention focused on early peanut introduction.

Sumatriptan as a First-Line Treatment for Headache in the Pediatric Emergency Department

BACKGROUND

Headache is a common presenting condition for patients seen in the pediatric emergency department (ED). Intranasal (IN) sumatriptan is a well-tolerated and safe abortive treatment for migraine headache, but it is infrequently administered in pediatric EDs. In this study we characterize an ED migraine pathway that uses IN sumatriptan as a first-line treatment.

METHODS

We performed retrospective chart analysis from a single center, reviewing a cohort of patients treated on an ED migraine pathway between October 2016 and February 2020. We reviewed patient demographics, clinical characteristics, treatment patterns, change in pain scores, sumatriptan prescriptions at discharge, length of stay (LOS), ED charges, and unexpected return visits.

RESULTS

A total of 558 patients (aged six to 21 years, 66% female) were included in this study. Overall, the median pretreatment pain score was 7 (interquartile range [IQR]: 5 to 8) and the median post-treatment pain score was 2 (IQR: 0 to 4). Forty-eight percent of patients received IN sumatriptan in the ED, and 36% of those who received sumatriptan were prescribed oral sumatriptan at discharge. When intravenous (IV) access was obtained for headache management, this was associated with a significantly longer LOS and higher ED charges.

CONCLUSIONS

IN sumatriptan shows promise as a feasible and potentially effective first-line treatment for pediatric migraine in the ED that could reduce the need for IV therapies, shorten LOS, and lower ED charges. Further research is needed to determine the efficacy of IN sumatriptan relative to other common first-line therapies used to treat pediatric migraine in the ED.