Accuracy of Administrative Codes for Distinguishing Positive Pressure Ventilation From High-Flow Nasal Cannula

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis

Importance

Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown.

Objective

To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission.

Design, Setting, and Participants

This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024.

Exposure

Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey.

Main Outcomes and Measures

Proportion of patients with bronchiolitis admitted to the ICU.

Results

A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups.

Conclusions and Relevance

Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

Severity of Illness in Bronchiolitis Amid Unusual Seasonal Pattern During the COVID-19 Pandemic

OBJECTIVE

We aimed to characterize recent trends in bronchiolitis at US children's hospitals and to compare severity of illness in bronchiolitis in the most recent year to the previous seasonal epidemics.

METHODS

This is a cross-sectional study of visits for bronchiolitis in infants <24 months old from October 2016 to September 2021 at 46 US children's hospitals participating in the Pediatric Health Information Systems database. Study years were defined by 12-month periods beginning in October to account for typical winter epidemics that crossover calendar years. We used logistic and Fourier Poisson regression models to examine trends in outcomes and compare seasonality, respectively.

RESULTS

The study included 389 411 emergency visits for bronchiolitis. Median age of infants with bronchiolitis was higher in October 2020 to September 2021 compared to previous epidemics (8 and 6 months, respectively, P < .001) The odds of hospitalization, ICU admission, invasive mechanical ventilation, and noninvasive ventilation did not differ in October 2020 to September 2021 compared to previous epidemics from October 2016 to September 2020 (all P > .05 for unadjusted models and models adjusted for age). Seasonality varied significantly among these 2 periods (P < .001).

CONCLUSIONS

Although the seasonality of bronchiolitis differed in October 2020 to September 2021, severity of illness in infants with bronchiolitis was consistent with previous epidemics.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals

IMPORTANCE

Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined.

OBJECTIVE

To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019.

EXPOSURE

Hospitalization for bronchiolitis.

MAIN OUTCOMES AND MEASURES

Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost.

RESULTS

A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity.

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Noninvasive Ventilation and Outcomes in Bronchiolitis

OBJECTIVES

Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest.

DESIGN

Multicenter retrospective cross-sectional study.

SETTING

Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database.

PATIENTS

Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0).

CONCLUSIONS

In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.

Trends in Bronchiolitis ICU Admissions and Ventilation Practices: 2010-2019

OBJECTIVES

To determine the changes in ICU admissions, ventilatory support, length of stay, and cost for patients with bronchiolitis in the United States.

METHODS

Retrospective cross-sectional study of the Pediatric Health Information Systems database. All patients age <2 years admitted with bronchiolitis and discharged between January 1, 2010 and December 31, 2019, were included. Outcomes included proportions of annual ICU admissions, invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and cost.

RESULTS

Of 203 859 admissions for bronchiolitis, 39 442 (19.3%) were admitted to an ICU, 6751 (3.3%) received IMV, and 9983 (4.9%) received NIV. ICU admissions for bronchiolitis doubled from 11.7% in 2010 to 24.5% in 2019 (P < .001 for trend), whereas ICU admissions for all children in Pediatric Health Information Systems <2 years of age increased from 16.0% to 21.1% during the same period (P < .001 for trend). Use of NIV increased sevenfold from 1.2% in 2010 to 9.5% in 2019 (P < .001 for trend). Use of IMV did not significantly change (3.3% in 2010 to 2.8% in 2019, P = .414 for trend). In mixed-effects multivariable logistic regression, discharge year was a significant predictor of NIV (odds ratio: 1.24; 95% confidence interval [CI]: 1.23-1.24) and ICU admission (odds ratio: 1.09; 95% CI: 1.09-1.09) but not IMV (odds ratio: 1.00; 95% CI: 1.00-1.00).

CONCLUSIONS

The proportions of children with bronchiolitis admitted to an ICU and receiving NIV have substantially increased, whereas the proportion receiving IMV is unchanged over the past decade. Further study is needed to better understand the factors underlying these temporal patterns.

Rates and risk factors of severe respiratory syncytial virus infection in 2008-2016 compared with 1986-1998

AIM

Since the introduction in 1979 of rapid testing using immunofluorescence, we have collected information about children hospitalised for confirmed respiratory syncytial virus (RSV) infection in the northern Stockholm area. We here report hospitalisation rates, risk factors and complications in 2008-2016 compared with 1986-1998.

METHODS

Microbiological laboratory reports and retrospective chart review. Comparison of the two periods was complicated by changing testing routines, with a more sensitive method and increased testing of older children in the late period.

RESULTS

In infants, there was an 12.3% increase in the population-based rate of hospital admission for RSV infection from 12.2 to 13.7/1000. Including all children <5 years, there was a 48% increase from 2.7 to 4.0/1000. The median length of stay remained unchanged at 3 days. The need of intensive care decreased in healthy infants but remained high in older children with comorbidity.

CONCLUSION

Considering the changed diagnosis routines, we believe that the rate of hospital admission of infants for RSV infection was unchanged throughout the observed years. The increased rates of older children with confirmed RSV likely resulted from increased testing of children with risk factors for a complicated course.

A National Approach to Pediatric Sepsis Surveillance

Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of age-dependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment.