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Gutierrez SA, Pathak S, Raghu V, Shui A, Huang CY, Rhee S, McKenzie-Sampson S, Lai JC, Wadhwani SI. Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome. J Pediatr 2024; 265:113819. [PMID: 37940084 PMCID: PMC10847979 DOI: 10.1016/j.jpeds.2023.113819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/27/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (β 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Sagar Pathak
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Vikram Raghu
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Safyer McKenzie-Sampson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
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Goldschmidt ML. Keeping the Culture of CLABSI Elimination Alive. J Pediatr Gastroenterol Nutr 2023; 76:402-403. [PMID: 36705670 DOI: 10.1097/mpg.0000000000003715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Monique L Goldschmidt
- From the Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
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Gibson B, McNiven C, Sebastianski M, Vandermeer B, Persad R, Robinson JL. Systematic Review of Antimicrobial Lock Solutions for Prevention of Bacteremia in Pediatric Patients With Intestinal Failure. J Pediatr Gastroenterol Nutr 2023; 76:410-417. [PMID: 36730306 DOI: 10.1097/mpg.0000000000003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The goal of this systematic review was to determine whether antimicrobial lock (AML) solutions prevent catheter-related bloodstream infections (CRBSI) in children with intestinal failure (IF). METHODS Electronic databases were searched: Ovid MEDLINE (1946-), Ovid Embase (1974-), Wiley Cochrane Library (inception-), and Web of Science Core Collection via Clarivate Analytics (1900-). Randomized and nonrandomized trials, case or cohort studies that studied any AML solution, and used comparator groups were included if they studied children with IF. A meta-analysis compared the rates of CRBSI with AML solutions versus controls, and a Boucher analysis was used to indirectly compare AML solutions. RESULTS Twenty-eight studies met eligibility criteria (1 open label and 27 observational studies). Quality was good (N = 13), fair (N = 9), and poor (N = 6). All but 4 studied ethanol and taurolidine. Of 15 ethanol studies, 11 reported a decrease and 3 reported a trend toward a decreased incidence of CRBSI compared to controls; 1 reported no difference. Of 9 taurolidine studies, 7 reported a decrease and 2 a trend toward decreased CRBSI rates. There was a decrease in CRBSI with ethanol versus control ( P = 0.008) and with taurolidine-citrate versus control ( P < 0.0005). Using Bucher indirect comparison of the pooled estimates from ethanol versus control to taurolidine versus control, the estimated difference was -0.99 (-4.125, 2.27; P = 0.55). CONCLUSIONS There were no randomized trials and over half of the 28 included studies were fair or poor quality. All but 1 reported at least a trend toward reduction in CRBSI. AML solutions appear to prevent CRBSI.
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Affiliation(s)
- Bridget Gibson
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Claire McNiven
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan Sebastianski
- the Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- the Alberta Centre for Health Research Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Rabin Persad
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joan L Robinson
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Sodium Bicarbonate Locks May Be a Safe and Effective Alternative in Pediatric Intestinal Failure: A Pilot Study. J Pediatr Gastroenterol Nutr 2022; 75:304-307. [PMID: 35675704 DOI: 10.1097/mpg.0000000000003506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
This was a retrospective study that compared outcomes in pediatric intestinal failure (IF) patients that were switched from ethanol lock therapy (ELT) to sodium bicarbonate lock therapy (SBLT). The primary outcome was rate of catheter-related blood stream infections (CRBSI). The secondary outcomes were number of hospitalizations, emergency room (ER) visits, central venous catheter (CVC)-related complications. In 4 patients, median rates of CRBSI were 2.77 (interquartile range [IQR] 0.6-5.6) on ELT versus 0 on SBLT per 1000 catheter days ( P = 0.17). The median rates of hospitalizations and ER visits for CVC-related complications were 6.1 (IQR 3.2-10.2) on ELT versus 0 on SBLT (IQR 0-0; P = 0.11) and 2.8 (IQR 2-3.6) on ELT versus 1.8 (IQR 0-3.7) on SBLT per 1000 catheter days ( P = 0.50), respectively. Rates of CVC-related complications were similar. No adverse events were reported. SBLT may be safe and effective for pediatric IF.
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Talathi S, Mezoff E, Galloway D, Rahhal R. Anticipated impact of recent ethanol lock shortage and price increase on practice among pediatric intestinal rehabilitation programs across the United States. JPEN J Parenter Enteral Nutr 2021; 46:319-323. [PMID: 33914379 DOI: 10.1002/jpen.2128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ethanol lock use has been associated with significantly lower rates of central line-associated bloodstream infection (CLABSI) in children with intestinal failure. Concerns have been raised among intestinal rehabilitation program providers regarding the impact of recent changes in cost and availability of ethanol locks in the US. METHODS We conducted a survey among the members of the North American Society For Pediatric Gastroenterology, Hepatology & Nutrition Intestinal Rehabilitation Special Interest Group (NASPGHAN IR-SIG) regarding practice changes among providers to tackle this issue and the anticipated effect on CLABSI rates. RESULTS The results show that the vast majority of US participants use ethanol locks in their population with intestinal failure, with most anticipating or already experiencing reduction in access to ethanol locks. Most worrisome is that more than half of participating programs expect an increase in CLABSI rates in this vulnerable patient population as a consequence of limited access to ethanol locks. CONCLUSION Further multicenter prospective studies to assess the efficacy of alternative locking agents, besides ethanol, are needed in order to have readily available and affordable options for CLABSI prevention in the future.
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Affiliation(s)
- Saurabh Talathi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, OU Center for Pediatric Intestinal Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ethan Mezoff
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David Galloway
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Riad Rahhal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Iowa, Iowa City, Iowa, USA
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Raghu VK, Mezoff EA, Cole CR, Rudolph JA, Smith KJ. Cost-effectiveness of ethanol lock prophylaxis to prevent central line-associated bloodstream infections in children with intestinal failure in the United States. JPEN J Parenter Enteral Nutr 2021; 46:324-329. [PMID: 33908050 DOI: 10.1002/jpen.2130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Central line-associated bloodstream infections (CLABSIs) lead to significant morbidity and mortality in children with intestinal failure (IF). Ethanol lock prophylaxis (ELP) greatly reduces CLABSI frequency with minimal side effects. However, in the United States, a recently approved orphan drug designation for dehydrated alcohol has greatly increased 70% ethanol cost from about $10/day to $1000/day. We examined the cost-effectiveness of ELP in relation to these changes. METHODS We simulated a previously developed IF Markov model over 1 year. Costs were measured in 2020 US dollars and effectiveness in quality-adjusted life-years (QALYs). CLABSI rate with and without ELP was estimated from the largest available comparative observational study. The primary outcome was incremental cost-effectiveness ratio (ICER) between treatments. Secondary outcomes included CLABSI frequency. Sensitivity analyses on all model parameters were performed. RESULTS In the base model, children with IF not using ELP accumulated $131,815 in costs and 0.32 QALYs per patient compared with $437,884 and 0.33 QALYs per patient in those using ELP. The ICER was nearly $17 million/QALY gained. ELP resulted in a 40% reduction in CLABSI frequency. ELP became cost-effective at $68/day and cost-saving at $63/day. Sensitivity analysis identified no other plausible parameter variation to reach the benchmark of $100,000/QALY gained. CONCLUSIONS At the current price, ELP is not cost-effective for CLABSI prevention in children with IF in the United States. This study highlights the critical need for the approval of an affordable lock therapy option to prevent CLABSIs in these children.
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Affiliation(s)
- Vikram Kalathur Raghu
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ethan A Mezoff
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A Rudolph
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Galloway DP, Mathis MS, Wilkinson LT, Venick RS, Wendel D, Cole CR, Martin CA. Effect of the COVID-19 Pandemic on Pediatric Intestinal Failure Healthcare Delivery. JPEN J Parenter Enteral Nutr 2020; 45:50-56. [PMID: 32941671 DOI: 10.1002/jpen.2000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has influenced how healthcare is being provided, particularly in patients whose diagnoses require multidisciplinary care, such as pediatric intestinal failure (IF). We sought to ascertain the effects of the COVID-19 pandemic on healthcare delivery for pediatric patients with IF. METHODS A 20-question survey was administered to members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Intestinal Rehabilitation (IR) Special Interest Group. Input values were "yes" and "no," along with a free-text response. Following a 10-day open survey period, data were divided into cohorts based on patient population size and disease burden by state. Analysis was then performed using the χ2 test application. RESULTS Responses from 29 centers were included in analysis. Centers that followed >50 patients on parenteral nutrition (PN) were more likely to have social workers present in telemedicine visits and observed more central line difficulties among families. Centers located in states with <40,000 reported cases of COVID-19 saw patients less frequently and were more likely to withhold changes to PN prescriptions. Additionally, the survey revealed a significant degree of financial hardship and food insecurity among families. CONCLUSION Many aspects of pediatric IF healthcare delivery have been impacted by the COVID-19 pandemic, both for care providers and caregivers. Despite the availability of telemedicine, IR centers should remain attentive to the global needs of the pediatric IF patient, as well as their families.
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Affiliation(s)
- David P Galloway
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Michelle S Mathis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Linda T Wilkinson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Robert S Venick
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California at Los Angeles, California, Los Angeles, USA
| | - Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington School of Medicine, Washington, Seattle, USA
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
| | - Colin A Martin
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Alabama, Birmingham, USA
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