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Ball A, Hadland S, Rodean J, Hall M, Mendoza J, Ahrens K. Trends in Substance-Related Visits Among Youth to US Children's Hospitals, 2016-2021: An Analysis of the Pediatric Health Information System Database. J Adolesc Health 2024:S1054-139X(24)00106-X. [PMID: 38530681 DOI: 10.1016/j.jadohealth.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE This study evaluates recent trends in substance-related visits among youth visiting children's hospitals. METHODS We conducted a cross-sectional study of substance-related visits to pediatric hospitals within the Pediatric Health Information System database of youth aged 12-21 years from 2016 through 2021. Substance-related visits were defined as acute visits for International Classification of Diseases, 10th Revision Clinical Modification codes related to substance 'use', dependence, or overdoses for alcohol, cannabis, nicotine, opioids, sedatives, stimulants, hallucinogens, or other substances. Cumulative growth rate and stratified substance-related trends were calculated using generalized estimating equations. Predicted number of visits during the COVID-19 pandemic was generated using an auto-regressive time series analysis. RESULTS There were 106,793 substance-related visits involving 84,632 youth. From 2016 to 2021, substance-related visits increased by 47.9% and increased across all ages, demographics, regions, and payors. Visits of Hispanic youth experienced the greatest percentage growth (63.3%, p < .05) when compared to Non-Hispanic (NH) White (46.2%) or NH Black (49.8%) youth. All substances except sedatives experienced an increase in growth in visits. Cannabis accounted for the largest percentage of visits (52.2%) and experienced the greatest percentage growth during the study period (82.4%, p < .001). During the pandemic, publicly insured, female, NH Black, and Hispanic youth experienced a greater-than-predicted number of substance-related visits. DISCUSSION Substance-related visits to children's hospitals are increasing for all demographics and nearly all substances. There were substantial increases in visits for most minoritized youth with a disproportionate rise among Hispanic youth. Visits over the pandemic were concentrated among publicly insured, female, NH Black, and Hispanic youth. Equitable large-scale investment is needed to address the rising morbidity of substance use among adolescents.
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Affiliation(s)
- Alexis Ball
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, Washington.
| | - Scott Hadland
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Mass General Hospital/Harvard Medical School, Boston, Massachusetts
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jason Mendoza
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, Washington; Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kym Ahrens
- Division of Adolescent Medicine, Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington
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Douglas CM, Ahrens K, Dombrowski JC, Rodean J, Coker TR. Racial and Ethnic Differences in Chlamydia and Gonorrhea Testing Locations Among Medicaid-Insured Youth. J Adolesc Health 2024; 74:381-384. [PMID: 37804298 PMCID: PMC10841468 DOI: 10.1016/j.jadohealth.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infections are common among 15- to 24-year-olds, with Black and Hispanic youth disproportionately affected. Understanding where youth receive CT/GC testing is necessary to address disparities in CT/GC care. Our objective was to identify if differences exist in CT/GC testing locations by race and ethnicity. METHODS We used 2019 MarketScan Medicaid data to examine CT/GC testing location by youth race and ethnicity. RESULTS There were 418,623 CT/GC tests during the study period. Tests were most frequently ordered at medical offices for all races and ethnicities, although less frequently for Black (37.6%) and Hispanic (37.3%) than for White youth (49.3%). Black youth were frequently tested in emergency departments (19.6%), while Hispanic youth were frequently tested in Federally Qualified Health Centers (19.0%). DISCUSSION We found significant racial and ethnic disparities in the location of CT/GC testing among Medicaid-insured-youth; these findings should be used to guide strategies that address inequities in CT/GC care.
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Affiliation(s)
| | - Kym Ahrens
- University of Washington School of Medicine, Seattle Children's Research Institute, Seattle, Washington
| | | | | | - Tumaini R Coker
- University of Washington School of Medicine, Seattle Children's Research Institute, Seattle, Washington
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Earlywine JJ, Bagley SM, Rodean J, Zima BT, Chadi N, Leslie DL, Hadland SE. Medications for Alcohol Use Disorder and Retention in Care in Medicaid-Enrolled Youth, 2014-2019. J Adolesc Health 2023; 73:845-851. [PMID: 37256254 PMCID: PMC10593088 DOI: 10.1016/j.jadohealth.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/27/2022] [Accepted: 03/14/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care. METHODS This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period ≥ 60 days without claims) was studied using Cox regression. RESULTS Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged ≥ 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged ≥ 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years. DISCUSSION This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse.
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Affiliation(s)
- Joel J Earlywine
- Mathematica, Seattle, Washington; Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Sarah M Bagley
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts; Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts; Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - Bonnie T Zima
- UCLA-Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, California
| | - Nicholas Chadi
- Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Douglas L Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts; Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts; Division of Adolescent and Young Adult Medicine, Mass General for Children, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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Hotz A, Sprecher E, Bastianelli L, Rodean J, Stringfellow I, Barkoudah E, Cohen LE, Estrada C, Graham R, Greenwood J, Kyle J, Mann N, Pinkham M, Solari T, Rosen R, Saleeb S, Shah AS, Watters K, Wells S, Berry JG. Categorization of a Universal Coding System to Distinguish Use of Durable Medical Equipment and Supplies in Pediatric Patients. JAMA Netw Open 2023; 6:e2339449. [PMID: 37874565 PMCID: PMC10599121 DOI: 10.1001/jamanetworkopen.2023.39449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/05/2023] [Indexed: 10/25/2023] Open
Abstract
Importance Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES. Objective To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid. Design, Setting, and Participants This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023. Exposure DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems). Main Outcomes and Measures The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC). Results Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs. Conclusions and Relevance In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.
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Affiliation(s)
- Arda Hotz
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Eli Sprecher
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lucia Bastianelli
- Cerebral Palsy and Spasticity Center, Boston Children's Hospital, Boston, Massachusetts
| | | | - Isabel Stringfellow
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Elizabeth Barkoudah
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Laurie E. Cohen
- Division of Pediatric Endocrinology & Diabetes, The Children’s Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Carlos Estrada
- Department of Urology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Robert Graham
- Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Greenwood
- Department of Physical Therapy and Occupational Therapy Services, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Nina Mann
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, Boston Children’s Hospital, Boston, Massachusetts
| | - Maria Pinkham
- Department of Physical Therapy and Occupational Therapy Services, Boston Children’s Hospital, Boston, Massachusetts
| | - Toni Solari
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Rachel Rosen
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Susan Saleeb
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Ankoor S. Shah
- Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Karen Watters
- Department of Otolaryngology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Sarah Wells
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jay G. Berry
- Complex Care, Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Ramgopal S, Rodean J, Alpern ER, Hall M, Chaudhari PP, Marin JR, Shah SS, Freedman SB, Eltorki M, Badaki-Makun O, Shapiro DJ, Rhine T, Morse RB, Neuman MI. Ambulatory follow-up among publicly insured children discharged from the emergency department. Acad Emerg Med 2023; 30:721-730. [PMID: 36809681 DOI: 10.1111/acem.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. METHODS We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. RESULTS We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). CONCLUSIONS One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tara Rhine
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rustin B Morse
- Department of Pediatrics, Center for Clinical Excellence, Nationwide Children's Hospital, The Ohio State University College of Medicine, Ohio, Columbus, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Ding L, Rodean J, Leyenaar JK, Coon ER, Mahant S, Gill PJ, Cabana MD, Kaiser SV. Characterization of Birth Hospitalizations in the United States. Hosp Pediatr 2023; 13:426-439. [PMID: 37013702 DOI: 10.1542/hpeds.2022-006931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
OBJECTIVES A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations. METHODS We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression). RESULTS In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million). CONCLUSIONS Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.
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Affiliation(s)
- Lucky Ding
- Department of Pediatrics, University of California, San Francisco, California
| | | | - JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Eric R Coon
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Sanjay Mahant
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J Gill
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael D Cabana
- Department of Pediatrics, Albert Einstein College of Medicine, and the Children's Hospital at Montefiore, Bronx, New York
| | - Sunitha V Kaiser
- Departments of Pediatrics and Epidemiology and Biostatistics, University of California, San Francisco, California; and
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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Masonbrink AR, Hurley EA, Schuetz N, Rodean J, Rupe E, Lewis K, Boncoeur MD, Miller MK. Sexual behaviors, contraception use and barriers among adolescents and young adults in rural Haiti. BMC Womens Health 2023; 23:137. [PMID: 36973773 PMCID: PMC10045756 DOI: 10.1186/s12905-023-02268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Adolescents and young adults (AYAs) in Haiti experience a high unintended pregnancy rate, in part due to unmet contraception needs. Little is known about AYA opinions of and experiences with contraception that may explain remaining gaps in coverage. We aimed to describe barriers and facilitators to contraception use among AYAs in Haiti. METHODS We conducted a cross-sectional survey and semi-structured qualitative interviews with a convenience sample of AYA females aged 14-24 in two rural communities in Haiti. The survey and semi-structured interviews assessed demographics, sexual health and pregnancy prevention behaviors and explored contraception opinions and experiences according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control. We used descriptive statistics to report means and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through inductive coding and team debriefing. RESULTS Among 200 survey respondents, 94% reported any past vaginal sexual activity, and 43% reported ever being pregnant. A large majority were trying to avoid pregnancy (75%). At last sexual activity, 127 (64%) reported use of any contraceptive method; Among them, condoms were the most common method (80%). Among those with previous condom use, most reported use less than half the time (55%). AYAs were concerned about parental approval of birth control use (42%) and that their friends might think they are looking for sex (29%). About one-third felt uncomfortable going to a clinic to ask for birth control. In interviews, AYAs desired pregnancy prevention but frequently noted concerns about privacy and parental, community and healthcare provider judgement for seeking care for reproductive health needs. AYAs also noted a lack of contraception knowledge, evident by frequent misconceptions and associated fears. CONCLUSION Among AYAs in rural Haiti, a large majority were sexually active and desire pregnancy avoidance, but few were using effective contraception due to numerous concerns, including privacy and fear of judgement. Future efforts should address these identified concerns to prevent unintended pregnancy and improve maternal and reproductive health outcomes in this population.
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Affiliation(s)
- Abbey R Masonbrink
- Children's Mercy Hospital, Kansas City, MO, US.
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, US.
- Department of Pediatrics, Children's Mercy Kansas City, 2401 Gilham Rd, Kansas City, MO, 64108, US.
| | - Emily A Hurley
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, US
- Division of Health Services and Outcomes Research, Children's Mercy, Kansas City, MO, US
- Department of Population Health, University of Kansas Medical Center, Kansas City, MO, US
| | - Nikolaus Schuetz
- Division of Health Services and Outcomes Research, Children's Mercy, Kansas City, MO, US
| | | | - Emily Rupe
- University of Kansas School of Medicine, Wichita, KS, US
| | - Kemi Lewis
- Children's Mercy Hospital, Kansas City, MO, US
| | | | - Melissa K Miller
- Children's Mercy Hospital, Kansas City, MO, US
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, US
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Garrity BM, Perrin JM, Rodean J, Houtrow AJ, Shelton C, Stille C, McLellan S, Coleman C, Mann M, Kuhlthau K, Desmarais A, Berry JG. Annual Days With a Health Care Encounter for Children and Youth Enrolled in Medicaid: A Multistate Analysis. Acad Pediatr 2023; 23:441-447. [PMID: 35863733 DOI: 10.1016/j.acap.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To assess the number of days that children experienced a health care encounter and associations between chronic condition types and health care encounters. METHODS Retrospective analysis of data from 5,082,231 children ages 0 to 18 years enrolled in Medicaid during 2017 in 12 US states contained in the IBM Watson Marketscan Medicaid Database. We counted and categorized enrollees' encounter days, defined as unique days a child had a health care visit, by type of health service. We used International Classification of Disease-10 diagnosis code categories from Agency for Healthcare Research and Quality's Chronic Condition Indicator System to identify chronic mental and physical health conditions. RESULTS Median (interquartile range [IQR]) annual encounter days was 6 (2-13). Children in the 91st to 98th and ≥99th percentiles for encounter days experienced a median of 49 (IQR 38-70) and 229 (IQR 181, 309) days, respectively; these children accounted for 52.6% of days for the cohort. As encounter days increased from the 25th to >90th percentile, the percentage of children with co-existing mental and physical health conditions increased from <0.1% to 47.4% (P < .001). Outpatient visits accounted for a total of 68.3% and 62.2% of days for children the 91st to 98th and ≥99th percentiles. CONCLUSION Ten percent of children enrolled in Medicaid averaged health care encounters at least 1 day per week; 1% experienced health care encounters on most weekdays. Further investigation is needed to understand how families perceive frequent health care encounters, including how to facilitate their children's care in the most feasible way.
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Affiliation(s)
- Brigid M Garrity
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass.
| | - James M Perrin
- Division of General Academic Pediatrics, MassGeneral Hospital for Children (JM Perrin), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
| | | | - Amy J Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh (AJ Houtrow), Pittsburgh, Pa
| | - Charlene Shelton
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo
| | - Christopher Stille
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo; General Academic Pediatrics, Children's Hospital Colorado (C Stille), Denver, Colo
| | - Sarah McLellan
- Health Resources and Services Administration, Maternal and Child Health Bureau (S McLellan), Rockville, Md
| | - Cara Coleman
- Family Voices National (C Coleman), Washington, DC
| | - Marie Mann
- Health Resources and Services Administration (M Mann), Rockville, Md
| | - Karen Kuhlthau
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School (K Kuhlthau), Boston, Mass
| | - Anna Desmarais
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
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Hoffmann JA, Krass P, Rodean J, Bardach NS, Cafferty R, Coker TR, Cutler GJ, Hall M, Morse RB, Nash KA, Parikh K, Zima BT. Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics 2023; 151:e2022057383. [PMID: 36775807 PMCID: PMC10187982 DOI: 10.1542/peds.2022-057383] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/14/2023] Open
Abstract
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.
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Affiliation(s)
- Jennifer A. Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Polina Krass
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA
| | | | - Naomi S. Bardach
- Department of Pediatrics and Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco
| | - Rachel Cafferty
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Tumaini R. Coker
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children’s Research Institute, Seattle, Washington
| | - Gretchen J. Cutler
- Children’s Minnesota Research Institute, Children’s Minnesota, Minneapolis, MN
| | | | - Rustin B. Morse
- Department of Pediatrics, The Ohio State University, Columbus, Ohio
- Nationwide Children’s Hospital, Center for Clinical Excellence, Columbus, Ohio
| | - Katherine A. Nash
- Department of Pediatrics, New York Presbyterian Morgan Stanley Childrens Hospital, Columbia University, New York City, New York
| | - Kavita Parikh
- Division of Hospital Medicine, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Bonnie T. Zima
- Center for Health Services and Society, UCLA-Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, California
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Dunbar PJ, Sobotka SA, Rodean J, Pulcini CD, Macy ML, Thomson J, Harris D, Coller RJ, Desmarais A, Hall M, Berry JG. Prevalence of and Spending on Ear, Nose, Throat, and Respiratory Infections Among Children With Chronic Complex Conditions. Acad Pediatr 2023; 23:434-440. [PMID: 36122827 PMCID: PMC10767753 DOI: 10.1016/j.acap.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/25/2022] [Accepted: 07/01/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Ear, nose, throat, and respiratory infections (ENTRI) may affect children with complex chronic conditions (CCC) differently than their peers. We compared ENTRI prevalence and spending in children with and without CCCs. METHODS Retrospective analysis of 3,880,456 children ages 0-to-18 years enrolled in 9 US state Medicaid programs in 2018 contained in the IBM Watson Marketscan Database. Type and number of CCCs were distinguished with Feudtner's system. ENTRI prevalence, defined as ≥1 healthcare encounters for ENTRI, and Medicaid spending on ENTRI were compared by CCC using chi-square tests and logistic regression. RESULTS ENTRIs were greater in children with vs. without a CCC (57.7% vs 43.5% [P < .001]). Children with a CCC (5.5%, n = 213,425) accounted for nearly one-fourth ($145.8 million [US]) of total spending on ENTRI. Aside from throat and sinus infection, ENTRI prevalence increased with number of CCCs (P < .001). For example, as number of CCCs increased from zero to ≥3, lower-airway infection increased from 12.5% to 37.5%, P < .001 (OR 4.10; 95% CI 3.95-4.26). ENTRI spending attributable to inpatient care increased from 9.7% to 92.8% (P < .001) as the number of CCCs increased from zero to ≥3. CONCLUSION Most children with a CCC pursued care for ENTRI in 2018 and these children accounted for a disproportionate share of ENTRI spending. Children with multiple CCCs had a high prevalence of lower-airway infection; most of their ENTRI spending was for inpatient care. Providers can use these findings to counsel patients and families and to inform future investigations on how best to manage ENTRI in children with CCCs.
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Affiliation(s)
- Peter J Dunbar
- Department of Medicine, Brigham and Women's Hospital (PJ Dunbar), Boston, Mass.
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago (SA Sobotka), Chicago, Ill
| | - Jonathan Rodean
- Children's Hospital Association (J Rodean and M Hall), Lenexa, Kans
| | - Christian D Pulcini
- Department of Surgery and Pediatrics, University of Vermont Medical Center and Children's Hospital (CD Pulcini), Burlington
| | - Michelle L Macy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University (ML Macy), Chicago, Ill
| | - Joanna Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center (J Thomson), Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (J Thomson), Ohio
| | | | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health (RJ Coller), Madison
| | - Anna Desmarais
- Complex Care, Department of Medicine, Division of General Pediatrics, Boston Children's Hospital (A Desmarais), Mass
| | - Matthew Hall
- Children's Hospital Association (J Rodean and M Hall), Lenexa, Kans
| | - Jay G Berry
- Complex Care, Department of Medicine, Division of General Pediatrics, Boston Children's Hospital (A Desmarais), Mass
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Tyris J, Rodean J, Kulesa J, Dixon G, Bhansali P, Gayle T, Akani D, Magyar M, Tamaskar N, Parikh K. Social Risks and Health Care Utilization Among a National Sample of Children With Asthma. Acad Pediatr 2023; 23:130-139. [PMID: 35940571 DOI: 10.1016/j.acap.2022.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Prior studies using single-center populations have established associations between social risks and health care utilization among children with asthma. We aimed to evaluate associations between social risks and health care utilization among a nationally representative sample of children with asthma. STUDY DESIGN In this cross-sectional study, we utilized the 2018-2019 National Survey of Children's Health to identify children 2 to 17 years old with asthma. Using the Healthy People (HP) 2030 social determinants of health (SDOH) framework, we identified 31 survey items assessing 18 caregiver-identified social risks as exposure variables and classified them into the 5 HP SDOH domains (Economy, Education, Health care, Community, and Environment). Primary outcome was caregiver-reported health care utilization. Associations between individual social risks and total number of SDOH domains experienced with health care utilization were assessed. RESULTS The weighted study population included 8.05 million children, 96% of whom reported ≥1 social risk. Fourteen social risks, spanning all 5 SDOH domains, were significantly associated with increased health care utilization. The 3 risks with the highest adjusted odds ratios (aOR) of health care utilization included: experiencing discrimination (aOR 3.26 [95% confidence interval (CI): 1.75, 6.08]); receiving free/reduced lunch (aOR 2.16, [95% CI 1.57, 2.98]); and being a victim of violence (aOR 2.11, [95% CI 1.11, 4]). Children with risks across more SDOH domains reported significantly higher health care utilization. CONCLUSIONS Among our national population of children with asthma, social risks are prevalent and associated with increased health care utilization, highlighting their potential contribution to pediatric asthma morbidity.
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Affiliation(s)
- Jordan Tyris
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC.
| | | | - John Kulesa
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Gabrina Dixon
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Priti Bhansali
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tamara Gayle
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Damilola Akani
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Matthew Magyar
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Nisha Tamaskar
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kavita Parikh
- Division of Hospital Medicine (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), Children's National Hospital, Washington, DC; Department of Pediatrics (J Tyris, J Kulesa, G Dixon, P Bhansali, T Gayle, D Akani, M Magyar, N Tamaskar, and K Parikh), George Washington University School of Medicine and Health Sciences, Washington, DC
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Rupe ER, Rodean J, Hurley EA, Miller MK, Boncoeur MD, Masonbrink AR. Menstrual health among adolescents and young adults in rural Haiti. Reprod Health 2022; 19:227. [PMID: 36539795 PMCID: PMC9764460 DOI: 10.1186/s12978-022-01533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Adolescent and young adult (AYA) females in low- and middle-income countries often face disparities in menstrual health (MH). Poor MH and lack of sexual and reproductive health education leads to school absenteeism, increasing risk for adverse psychosocial and educational outcomes. Further, disasters (e.g., earthquakes) are linked with unsafe living environments and sanitation facilities for women. We sought to describe MH perspectives and practices among AYAs in rural Haiti. METHODS We conducted a cross-sectional survey in two rural communities in Haiti. AYA females aged 14-24 years completed questions on demographics, the Menstrual Practice Needs Scale (36 items; MPNS-36) and the Menstrual Practices Questionnaire (4 items). We performed descriptive statistics and Chi square or Fisher's Exact tests to compare responses among sub-groups. RESULTS Among 200 respondents, the median age was 20 years (IQR 17-22). 51% (95% CI 44%, 58%; 102/200) were currently attending school at least 3 days/week and 97% (94%, 99%; 193/200) were not married. According to the MPNS-36, 68% (62%, 74%; 136/200) of participants had unmet MH needs. Seventy-one (77%) reused some of their menstrual materials during their last menstruation. During their last menstruation, 44% (37%, 50%; 87/200) reported they often or always skipped school because they had their menses, and 31% (25%, 37%; 62/200) sometimes skipped. Many felt always or often worried that someone or something would harm them while they were changing their menstrual materials at home and at school. CONCLUSIONS Among AYAs in rural Haiti, three-quarters reported menses-related school absenteeism and two-thirds had unmet MH needs. AYA females often lacked a safe environment to change their menstrual materials. Given recent disasters in Haiti, (August 2021 earthquake), safe environments for MH are critically needed to offset risk for poor psychosocial and health outcomes. Future efforts to improve MH among AYAs in Haiti are needed to ensure access to MH resources and school attendance.
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Affiliation(s)
- Emily R. Rupe
- grid.266515.30000 0001 2106 0692University of Kansas School of Medicine, 1010 N Kansas St., Wichita, KS 67214 USA
| | - Jonathan Rodean
- grid.429588.aChildren’s Hospital Association, Lenexa, KS USA
| | - Emily A. Hurley
- grid.239559.10000 0004 0415 5050Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Melissa K. Miller
- grid.239559.10000 0004 0415 5050Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | | | - Abbey R. Masonbrink
- grid.239559.10000 0004 0415 5050Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO USA ,grid.266756.60000 0001 2179 926XUniversity of Missouri-Kansas City School of Medicine, Kansas City, MO USA
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13
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Zima BT, Edgcomb JB, Rodean J, Cochran SD, Harle CA, Pathak J, Tseng CH, Bussing R. Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders. Psychiatr Serv 2022; 73:1202-1209. [PMID: 35611510 PMCID: PMC9633407 DOI: 10.1176/appi.ps.202100582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19–related school closure orders. METHODS This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3–17 years in 44 U.S. children’s hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. RESULTS Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. CONCLUSIONS Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children’s hospitals after COVID-19–related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.
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Affiliation(s)
- Bonnie T Zima
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Juliet Beni Edgcomb
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Jonathan Rodean
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Susan D Cochran
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Christopher A Harle
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Jyotishman Pathak
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Chi-Hong Tseng
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
| | - Regina Bussing
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles (Zima, Edgcomb); Children's Hospital Association, Lenexa, Kansas (Rodean); Fielding School of Public Health, UCLA, Los Angeles (Cochran); Department of Psychiatry, University of Florida, Gainesville (Harle, Bussing); Department of Healthcare Policy and Research, Weill Cornell Medicine, New York City (Pathak); Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles (Tseng)
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Wells JM, Rodean J, Cook L, Sills MR, Neuman MI, Kornblith AE, Jain S, Hirsch AW, Goyal MK, Fleegler EW, DeLaroche AM, Aronson PL, Leonard JC. Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19. Pediatrics 2022; 150:188520. [PMID: 35836331 DOI: 10.1542/peds.2021-054545] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHODS We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods. RESULTS Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%). CONCLUSIONS Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.
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Affiliation(s)
- Jordee M Wells
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Lawrence Cook
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Marion R Sills
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron E Kornblith
- Departments of Emergency Medicine and Pediatrics, University of California San Francisco, San Francisco, California
| | - Shobhit Jain
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, District of Columbia
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy M DeLaroche
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Julie C Leonard
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Cutler GJ, Bergmann KR, Doupnik SK, Hoffmann JA, Neuman MI, Rodean J, Zagel AL, Zima BT. Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic. Acad Pediatr 2022; 22:889-891. [PMID: 35351651 PMCID: PMC8957359 DOI: 10.1016/j.acap.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Gretchen J Cutler
- Children's Minnesota Research Institute, Children's Minnesota (GJ Cutler), Minneapolis, Minn.
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota (KR Bergmann), Minneapolis, Minn
| | - Stephanie K Doupnik
- Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia (SK Doupnik), Philadelphia, Pa
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (JA Hoffmann), Chicago, Ill
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School (MI Neuman), Boston, Mass
| | | | - Alicia L Zagel
- Fairview Pharmacy Services (AL Zagel), Minneapolis, Minn
| | - Bonnie T Zima
- UCLA Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles (BT Zima), Los Angeles, Calif
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Kazmir S, Pierce MC, Simonton K, Rodean J, Neuman MI, Simon NJE, Alpern ER. Pediatric Emergency Department Testing for Gonorrhea and Chlamydia in Children. Pediatr Emerg Care 2022; 38:247-252. [PMID: 35639429 DOI: 10.1097/pec.0000000000002637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to describe trends in the utilization of nucleic acid amplification (NAAT) testing for gonorrhea and chlamydia in US pediatric emergency departments. Nucleic acid amplification has been recommended over genital culture by the American Academy of Pediatrics and Centers for Disease Control and Prevention for children evaluated for sexual abuse. METHODS We conducted a multicenter study of children aged 12 months to 11 years tested for gonorrhea and chlamydia between 2004 and 2018 at 22 hospitals in the Pediatric Health Information System. We included patients diagnosed with maltreatment concerns and/or genitourinary (GU) symptoms. The primary outcome was prevalence of testing with NAAT, culture, or both. We analyzed groups based on patient sex, as well as diagnoses of maltreatment versus GU symptoms. RESULTS A total of 36,312 visits were analyzed. Visits were 73.4% girls and 26.6% boys. During the study period, there was an increase in use of NAAT-only testing for girls (49.3% to 94.3%; P < 0.001) and boys (54.5% to 96.1%; P < 0.001). There was a decrease in use of culture alone for girls (40% to 1.6%; P < 0.001) and boys (38.7% to 0.8%; P < 0.001). Use of both tests in the same encounter was higher among children diagnosed with maltreatment than GU symptoms, regardless of sex (P < 0.001). CONCLUSIONS Over a 14-year period, downtrend of culture use with increase in NAAT was observed, suggesting general adherence to evidence-based guidelines. Almost 10% of children diagnosed with maltreatment continued to be tested with culture. This could indicate provider concerns regarding test accuracy, legal admissibility, or lack of test availability.
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Affiliation(s)
| | | | | | | | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Norma-Jean E Simon
- From the Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital
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17
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Chaudhari PP, Rodean J, Spurrier RG, Hall M, Marin JR, Ramgopal S, Alpern ER, Shah SS, Freedman SB, Cohen E, Morse RB, Neuman MI. Epidemiology and management of abdominal injuries in children. Acad Emerg Med 2022; 29:944-953. [PMID: 35373473 DOI: 10.1111/acem.14497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although more guideline-adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra-abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI. METHODS We conducted a cross-sectional study of 33 hospitals in the Pediatric Health Information System. We included children aged <18 years evaluated in the emergency department from 2010 to 2019 with IAI, as defined by ICD coding, and who underwent an abdominal computed tomography (CT). Our primary outcome was abdominal surgery. We categorized IAI by organ system and described resource utilization data. We used generalized linear regression to calculate adjusted hospital-level proportions of abdominal surgery, with a random effect for hospital. RESULTS We studied 9265 children with IAI. Median (IQR) age was 9.0 (6.0-13.0) years. Abdominal surgery was performed in 16% (n = 1479) of children, with the lowest proportion of abdominal surgery observed in children aged <5 years. Liver (38.6%) and spleen (32.1%) were the most common organs injured. A total of 3.1% of children with liver injuries and 2.8% with splenic injuries underwent abdominal surgery. Although there was variation in rates of surgery across hospitals (p < 0.001), only three of 33 hospitals had rates that were statistically different from the aggregate mean of 16%. CONCLUSIONS Most children with IAI are managed nonoperatively, and most children's hospitals manage children with IAI similarly. These data can be used to inform future benchmarking efforts across hospitals to assess concordance with guidelines for the management of children with IAI.
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Affiliation(s)
- Pradip P. Chaudhari
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California Los Angeles California USA
| | | | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Matt Hall
- Children's Hospital Association Lenexa Kansas USA
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics and Institute of Health Policy, Management & Evaluation The University of Toronto and ICES Toronto Ontario Canada
| | - Rustin B. Morse
- Center for Clinical Excellence Nationwide Children's Hospital Columbus Ohio USA
| | - Mark I. Neuman
- Division of Emergency Medicine Boston Children's Hospital and Harvard Medical School Boston Massachusetts USA
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18
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Gill PJ, Anwar MR, Rodean J, Meier J, Mahant S. Priority clinical conditions in pediatric ambulatory surgery. J Pediatr Surg 2022; 57:554-556. [PMID: 34749981 DOI: 10.1016/j.jpedsurg.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter J Gill
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.
| | | | | | - Jeremy Meier
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, UT, United States
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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19
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Daggett A, Wyly DR, Stewart T, Phillips P, Newell C, Lee BR, Burns A, Sharma N, Shastri N, Rodean J, El Feghaly RE. Improving Emergency Department Use of Safety-Net Antibiotic Prescriptions for Acute Otitis Media. Pediatr Emerg Care 2022; 38:e1151-e1158. [PMID: 35226640 DOI: 10.1097/pec.0000000000002525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute otitis media (AOM) is the most common reason for pediatric antibiotic prescriptions. The 2013 American Academy of Pediatrics' AOM guidelines recommend observation for nonsevere AOM. Our aim was to increase the percentage safety-net antibiotic prescription (SNAP) offered to patients 6 months of age or older diagnosed with AOM in 2 pediatric emergency departments (EDs) from a baseline of 0.5% to 15% in 20 months. METHODS This is a quality improvement study at a quaternary pediatric medical center with 2 locations, both with EDs. A random chart review revealed that 27.5% of patients diagnosed with AOM in the ED would qualify for a SNAP, but only 0.5% were offered it. Quality improvement interventions were designed to improve safety-net antibiotic prescribing. Both EDs conducted multiple interventions, including algorithm development, provider education, and electronic medical record aids. The primary outcome measure was the percentage of patients offered a SNAP for AOM. RESULTS A total of 8226 children 6 months of age or older were diagnosed with AOM in our 2 EDs during the 20-month intervention period. The percentage offered a SNAP increased at both EDs. One ED had a single shift in the mean to 7.9%, whereas the other had 2 shifts in the mean, an initial shift to 5.1% and a second to 7.3%. Providers consistently used the algorithm and electronic medical record aids. CONCLUSIONS Safety-net antibiotic prescriptions in conjunction with parent education was effective in reducing the use of immediate antibiotic prescriptions in children with AOM in 2 pediatric EDs. Offering a SNAP can reduce unnecessary use of antibiotics, which in turn may decrease antibiotic-related adverse events and antibiotic resistance.
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20
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Abstract
This cross-sectional study ranks the prevalent diagnoses among hospitalized children and related costs by hospital type.
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Affiliation(s)
- Sunitha V. Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco
| | | | - Eric R. Coon
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Sanjay Mahant
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J. Gill
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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21
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Pulcini CD, Coller RJ, Macy ML, Alpern E, Harris D, Rodean J, Hall M, Chung PJ, Berry JG. Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions. Pediatr Emerg Care 2022; 38:e856-e862. [PMID: 34009894 DOI: 10.1097/pec.0000000000002437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC. METHODS A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit. RESULTS Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]). CONCLUSIONS Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.
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Affiliation(s)
- Christian D Pulcini
- From the Department of Surgery and Pediatrics, University of Vermont Medical Center and Children's Hospital, University of Vermont Larner College of Medicine, Burlington, VT
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Elizabeth Alpern
- Division of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Paul J Chung
- Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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22
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Berry JG, Rodean J, Leahy I, Rangel S, Johnson C, Crofton C, Staffa SJ, Hall M, Methot C, Desmarais A, Ferrari L. Hospital Volumes of Inpatient Pediatric Surgery in the United States. Anesth Analg 2021; 133:1280-1287. [PMID: 34673726 DOI: 10.1213/ane.0000000000005748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States. METHODS Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues' system. RESULTS The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3-29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1-13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1-24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%-32.0% [P < .001]) and the percentage of children with a CCC increased (11.2%-60.0% [P < .001]). CONCLUSIONS Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.
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Affiliation(s)
- Jay G Berry
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Rodean
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Izabela Leahy
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Shawn Rangel
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Connor Johnson
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Charis Crofton
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Steven J Staffa
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Matt Hall
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Craig Methot
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Anna Desmarais
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lynne Ferrari
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Perioperative, and Pain Medicine
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23
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Warniment A, Steuart R, Rodean J, Hall M, Chinchilla S, Shah SS, Thomson J. Variation in Bacterial Respiratory Culture Results in Children With Neurologic Impairment. Hosp Pediatr 2021; 11:e326-e333. [PMID: 34716209 DOI: 10.1542/hpeds.2020-005314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To examine bacterial respiratory cultures in children with neurologic impairment (NI) (eg, cerebral palsy), both with and without tracheostomies, who were hospitalized with acute respiratory infections (ARIs) (eg, pneumonia) and to compare culture results across hospitals and age groups. METHODS This multicenter retrospective cohort study included ARI hospitalizations for children aged 1 to 18 years with NI between 2007 and 2012 who had a bacterial respiratory culture obtained within 2 days of admission. Data from 5 children's hospitals in the Pediatric Health Information System Plus database were used. Organisms consistent with oral flora and nonspeciated organisms were omitted from analysis. The prevalence of positive respiratory culture results and the prevalence of organisms identified were compared across hospitals and age groups and in subanalyses of children with and without tracheostomies by using generalized estimating equations to account for within-patient clustering. RESULTS Of 4900 hospitalizations, 693 from 485 children had bacterial respiratory cultures obtained. Of these, 54.5% had positive results, although this varied across hospitals (range 18.6%-83.2%; P < .001). Pseudomonas aeruginosa and Staphylococcus aureus were the most commonly identified organisms across hospitals and age groups and in patients with and without tracheostomies. Large variation in growth prevalence was identified across hospitals but not age groups. CONCLUSIONS The bacteriology of ARI in hospitalized children with NI differs from that of otherwise healthy children. Significant variation in prevalence of positive bacterial respiratory culture results and organism growth were observed across hospitals, which may be secondary to local environmental factors and microbiology reporting practices.
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Affiliation(s)
| | | | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | - Samir S Shah
- Divisions of Hospital Medicine.,Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics
| | - Joanna Thomson
- Divisions of Hospital Medicine .,Department of Pediatrics
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24
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Berry JG, Perrin JM, Hoover C, Rodean J, Agrawal RK, Kuhlthau KA. Health Care Insurance Adequacy for Children and Youth With Special Health Care Needs. Pediatrics 2021; 148:peds.2020-039891. [PMID: 34535570 DOI: 10.1542/peds.2020-039891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jay G Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - James M Perrin
- Division of General Academic Pediatrics, MassGeneral Hospital for Children and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | | | - Rishi K Agrawal
- Ann & Robert H. Lurie Children's Hospital of Chicago, and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karen A Kuhlthau
- Division of General Academic Pediatrics, MassGeneral Hospital for Children and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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25
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Marin JR, Rodean J, Mannix RC, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury. J Pediatr 2021; 235:178-183.e1. [PMID: 33894265 DOI: 10.1016/j.jpeds.2021.04.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/22/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
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Affiliation(s)
- Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | | | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the USC, Los Angeles, CA
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics, Toronto, Ontario, Canada; Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Stephen B Freedman
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Harold K Simon
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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26
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Gill PJ, Anwar MR, Thavam T, Hall M, Rodean J, Kaiser SV, Srivastava R, Keren R, Mahant S. Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals. JAMA Netw Open 2021; 4:e2117816. [PMID: 34309667 PMCID: PMC8314139 DOI: 10.1001/jamanetworkopen.2021.17816] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. OBJECTIVES To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. MAIN OUTCOMES AND MEASURES The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. RESULTS There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). CONCLUSIONS AND RELEVANCE This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.
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Affiliation(s)
- Peter J. Gill
- Department of Pediatrics, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Thaksha Thavam
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | | | - Sunitha V. Kaiser
- Department of Pediatrics and Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Ron Keren
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sanjay Mahant
- Department of Pediatrics, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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27
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Clark NA, Rodean J, Mestre M, Rangarajan HG, Samuels-Kalow M, Satwani P, Stanek JR, Wolfe ID, Michelson KA. Pandemic-Related Shifts in New Patients Admitted to Children's Hospitals. Hosp Pediatr 2021; 11:e142-e151. [PMID: 34074712 DOI: 10.1542/hpeds.2021-005876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES During the coronavirus disease 2019 pandemic, professional organizations recommended preferential transfer of pediatric patients from general hospitals to children's hospitals. Patients previously receiving all care at other facilities would be new to children's hospitals. As a proxy for care consolidation, we sought to describe changes in new patient encounters at children's hospitals and test associations between local severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) incidences and new patient encounters. METHODS This retrospective cohort study included patients aged 6 months to 18 years admitted to children's hospitals from March 15, 2019, to June 30, 2019 (control) and 2020 (pandemic period). Primary outcome was odds ratio of being a new versus established patient by study period. Generalized linear models estimated odds of being a new patient with adjustment for diagnosis. Analyses were also stratified by local SARS-CoV-2 transmission. RESULTS There were 205 283 encounters (45.3% new patients). New patients were more common in the pandemic period than in the control (46.4 vs 44.7%, OR 1.07, 95% confidence interval [CI]: 1.05 to 1.09). After adjusting for diagnosis, pandemic new patients were no more common than control new patients (adjusted odds ratio 1.00, 95% CI: 0.98 to 1.02). Compared with hospitals experiencing low local SARS-CoV-2 transmission, admission encounters at both medium and high transmission hospitals were more likely to be new (adjusted odds ratio 1.08, 95% CI: 1.03 to 1.14 and 1.09, 95% CI: 1.03 to 1.15, respectively). CONCLUSIONS During the early coronavirus disease 2019 pandemic, proportional increases in new patients to children's hospitals appeared to be due to changes in diagnoses but were also associated with local SARS-CoV-2 transmission. Pediatric care consolidation may have occurred; how this may have impacted outcomes for hospitalized children is unclear.
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Affiliation(s)
- Nicholas A Clark
- Division of Hospital Medicine, Children's Mercy Kansas City, Kansas City, Missouri .,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | | | - Marcos Mestre
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida
| | - Hemalatha G Rangarajan
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Prakash Satwani
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Joseph R Stanek
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ian D Wolfe
- Clinical Ethics Department, Children's Minnesota, Minneapolis, Minnesota
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Abstract
This cross-sectional study assesses the specificity of the Pediatric Clinical Classification System and Healthcare Cost and Utilization Project diagnosis categories for clinical classification in pediatric inpatient settings.
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Affiliation(s)
- Peter J. Gill
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | | | - Thaksha Thavam
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | | | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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29
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DeLaroche AM, Rodean J, Aronson PL, Fleegler EW, Florin TA, Goyal M, Hirsch AW, Jain S, Kornblith AE, Sills MR, Wells JM, Neuman MI. Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic. Pediatrics 2021; 147:peds.2020-039628. [PMID: 33361360 DOI: 10.1542/peds.2020-039628] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency department (ED) visits is not well characterized. We aimed to describe the epidemiology of pediatric ED visits and resource use during the pandemic. METHODS We conducted a cross-sectional study using the Pediatric Health Information System for ED visits to 27 US children's hospitals during the COVID-19 pandemic period (March 15, 2020, to August 31, 2020) and a 3-year comparator period (March 15 to August 31, 2017-2019). ED visit rates, patient and visit characteristics, resource use, and ED charges were compared between the time periods. We specifically evaluated changes in low-resource-intensity visits, defined as ED visits that did not result in hospitalization or medication administration and for which no laboratory tests, diagnostic imaging, or procedures were performed. RESULTS ED visit rates decreased by 45.7% (average 911 026 ED visits over 2017-2019 vs 495 052 visits in 2020) during the pandemic. The largest decrease occurred among visits for respiratory disorders (70.0%). The pandemic was associated with a relative increase in the proportion of visits for children with a chronic condition from 23.7% to 27.8% (P < .001). The proportion of low-resource-intensity visits decreased by 7.0 percentage points, and total charges decreased by 20.0% during the pandemic period. CONCLUSIONS The COVID-19 pandemic was associated with a marked decrease in pediatric ED visits across a broad range of conditions; however, the proportional decline of poisoning and mental health visits was less pronounced. The impact of decreased visits on patient outcomes warrants further research.
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Affiliation(s)
- Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan;
| | | | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric W Fleegler
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Monika Goyal
- Department of Pediatrics, Children's National Hospital and The George Washington University, Washington, District of Columbia
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Shobhit Jain
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Aaron E Kornblith
- Division of Emergency Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Marion R Sills
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado; and
| | - Jordee M Wells
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, College of Medicine, The Ohio State University Columbus, Ohio
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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Davis TK, Bryant KA, Rodean J, Richardson T, Selvarangan R, Qin X, Neu A, Warady BA. Variability in Culture-Negative Peritonitis Rates in Pediatric Peritoneal Dialysis Programs in the United States. Clin J Am Soc Nephrol 2021; 16:233-240. [PMID: 33462084 PMCID: PMC7863662 DOI: 10.2215/cjn.09190620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES International guidelines suggest a target culture-negative peritonitis rate of <15% among patients receiving long-term peritoneal dialysis. Through a pediatric multicenter dialysis collaborative, we identified variable rates of culture-negative peritonitis among participating centers. We sought to evaluate whether specific practices are associated with the variability in culture-negative rates between low- and high-culture-negative rate centers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Thirty-two pediatric dialysis centers within the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative contributed prospective peritonitis data between October 1, 2011 and March 30, 2017. Clinical practice and patient characteristics were compared between centers with a ≤20% rate of culture-negative peritonitis (low-rate centers) and centers with a rate >20% (high-rate centers). In addition, centers completed a survey focused on center-specific peritoneal dialysis effluent culture techniques. RESULTS During the 5.5 years of observation, 1113 patients had 1301 catheters placed, totaling 19,025 patient months. There were 620 episodes of peritonitis in 378 patients with 411 catheters; cultures were negative in 165 (27%) peritonitis episodes from 125 (33%) patients and 128 (31%) catheters. Low-rate centers more frequently placed catheters with a downward-facing exit site and two cuffs (P<0.001), whereas high-rate centers had more patients perform dialysis themselves without the assistance of an adult care provider (P<0.001). The survey demonstrated that peritoneal dialysis effluent culture techniques were highly variable across centers. No consistent practice or technique helped to differentiate low- and high-rate centers. CONCLUSIONS Culture-negative peritonitis is a frequent complication of maintenance peritoneal dialysis in children. Despite published recommendations for dialysis effluent collection and culture methods, great variability in culture techniques and procedures exists among individual dialysis programs and respective laboratory processes.
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Affiliation(s)
- T. Keefe Davis
- Department of Pediatrics, Division of Pedatric Nephrology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kristina A. Bryant
- Department of Pediatrics, Division of Infectious Diseases, University of Louisville, Louisville, Kentucky
| | | | | | - Rangaraj Selvarangan
- Department of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, Missouri
| | - Xuan Qin
- Department of Laboratory Medicine, Division of Microbiology, Seattle Children’s, Seattle, Washington
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bradley A. Warady
- Department of Pediatrics, Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
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31
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Schechter S, Jaladanki S, Rodean J, Jennings B, Genies M, Cabana MD, Kaiser SV. Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative. BMJ Qual Saf 2021; 30:876-883. [PMID: 33468549 DOI: 10.1136/bmjqs-2020-012292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/04/2021] [Accepted: 01/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative. METHODS We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach. RESULTS We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening. CONCLUSIONS The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.
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Affiliation(s)
- Sarah Schechter
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sravya Jaladanki
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | | | | | - Marquita Genies
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael D Cabana
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Children's Hospital at Montefiore (CHAM), Bronx, New York, USA
| | - Sunitha Vemula Kaiser
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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32
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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33
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Larson IA, Rodean J, Richardson T, Bergman D, Morehous J, Colvin JD. Agreement of Provider and Parent Perceptions of Complex Care Medical Homes After a Care Management Intervention. J Pediatr Health Care 2021; 35:91-98. [PMID: 32958456 DOI: 10.1016/j.pedhc.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/29/2020] [Accepted: 08/01/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Children with medical complexity frequently lack coordinated and family-centered care and are best cared for in a medical home. METHOD We assessed concordance between provider and family perceptions of care management improvements during a prospective, 3-year study of nine complex care clinics and 42 primary care clinics. Using a pre-post design, we compared provider and parent perceptions of changes in care coordination and family-centered care responses using paired t tests, Spearman rank correlations, and linear regression. RESULTS Provider scores significantly increased in every domain (range: 14.1 points [data management], 23.0 points [chronic care management]; p < .001). Parent perceptions improved only for shared decision making improved significantly (2.2 points, p < .01). DISCUSSION These results indicate that it is possible to improve the medical home for children with medical complexity through a quality improvement initiative, but that provider perception of the improvement may be greater than parents' perceptions.
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Abstract
This cross-sectional study uses data from the 2017 National Survey of Children’s Health to assess whether social challenges increase with higher medical condition complexity among US children.
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Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Paul J. Chung
- Department of Pediatrics, David Geffen School of Medicine at UCLA (University of California at Los Angeles) and Mattel Children’s Hospital, Los Angeles
| | | | - Michelle Macy
- Department of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Deborah E. Linares
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
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35
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018. JAMA Pediatr 2020; 174:e202209. [PMID: 32761186 PMCID: PMC7400208 DOI: 10.1001/jamapediatrics.2020.2209] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. Objective To evaluate changes over time and hospital variation in advanced imaging use. Design, Setting, and Participants This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. Exposures Imaging. Main Outcomes and Measures The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. Results There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period. Conclusions and Relevance This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.
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Affiliation(s)
- Jennifer R. Marin
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Alberta Children’s Hospital Research Institute, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada ,Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Doupnik SK, Rodean J, Feinstein J, Gay JC, Simmons J, Bettenhausen JL, Markham JL, Hall M, Zima BT, Berry JG. Health Care Utilization and Spending for Children With Mental Health Conditions in Medicaid. Acad Pediatr 2020; 20:678-686. [PMID: 32017995 PMCID: PMC7340572 DOI: 10.1016/j.acap.2020.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 01/22/2020] [Accepted: 01/29/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine how characteristics vary between children with any mental health (MH) diagnosis who have typical spending and the highest spending; to identify independent predictors of highest spending; and to examine drivers of spending groups. METHODS This retrospective analysis utilized 2016 Medicaid claims from 11 states and included 775,945 children ages 3 to 17 years with any MH diagnosis and at least 11 months of continuous coverage. We compared demographic characteristics and Medicaid expenditures based on total health care spending: the top 1% (highest-spending) and remaining 99% (typical-spending). We used chi-squared tests to compare the 2 groups and adjusted logistic regression to identify independent predictors of being in the top 1% highest-spending group. RESULTS Children with MH conditions accounted for 55% of Medicaid spending among 3- to 17-year olds. Patients in the highest-spending group were more likely to be older, have multiple MH conditions, and have complex chronic physical health conditions (P <.001). The highest-spending group had $164,003 per-member-per-year (PMPY) in total health care spending, compared to $6097 PMPY in the typical-spending group. Ambulatory MH services contributed the largest proportion (40%) of expenditures ($2455 PMPY) in the typical-spending group; general health hospitalizations contributed the largest proportion (36%) of expenditures ($58,363 PMPY) in the highest-spending group. CONCLUSIONS Among children with MH conditions, mental and physical health comorbidities were common and spending for general health care outpaced spending for MH care. Future research and quality initiatives should focus on integrating MH and physical health care services and investigate whether current spending on MH services supports high-quality MH care.
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Affiliation(s)
- Stephanie K. Doupnik
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, and PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, PA, and The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
| | - Jonathan Rodean
- Children’s Hospital Association, Washington, DC and Lenexa, KS
| | - James Feinstein
- Department of Pediatrics, Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO
| | - James C. Gay
- Monroe Carell Children’s Hospital at Vanderbilt and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Julia Simmons
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Jessica L. Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Matt Hall
- Children’s Hospital Association, Washington, DC and Lenexa, KS
| | - Bonnie T. Zima
- UCLA-Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA
| | - Jay G. Berry
- Department of Medicine, Division of General Pediatrics, Complex Care Service, Boston Children’s Hospital and Harvard Medical School, Boston, MA
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Canares TL, Friedman A, Rodean J, Burns RR, Berkowitz D, Hall M, Alpern E, Montalbano A. Pediatric outpatient utilization by differing Medicaid payment models in the United States. BMC Health Serv Res 2020; 20:532. [PMID: 32532270 PMCID: PMC7291721 DOI: 10.1186/s12913-020-05409-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization. METHODS This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively. RESULTS Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS. CONCLUSIONS The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.
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Affiliation(s)
- Therese L Canares
- Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans St, Suite G-1509, Baltimore, MD, 21287, USA.
| | - Ari Friedman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jonathan Rodean
- Department of Analytics, Children's Hospital Association, 16011 College Blvd, Lenexa, Kansas, 66219, USA
| | - Rebecca R Burns
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 62, Chicago, IL, 60611, USA
| | - Deena Berkowitz
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Matt Hall
- Department of Analytics, Children's Hospital Association, 16011 College Blvd, Lenexa, Kansas, 66219, USA
| | - Elizabeth Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Ave, Box 62, Chicago, IL, 60611, USA
| | - Amanda Montalbano
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, 20300 East Valley View Pkwy, Independence, MO, 64057, USA
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Zima BT, Gay JC, Rodean J, Doupnik SK, Rockhill C, Davidson A, Hall M. Classification System for International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision Pediatric Mental Health Disorders. JAMA Pediatr 2020; 174:620-622. [PMID: 32202603 PMCID: PMC7091372 DOI: 10.1001/jamapediatrics.2020.0037] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/28/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Bonnie T. Zima
- UCLA Center for Health Services & Society, UCLA-Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles
| | - James C. Gay
- Monroe Carell Jr Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Carol Rockhill
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
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Bardach NS, Doupnik SK, Rodean J, Zima BT, Gay JC, Nash C, Tanguturi Y, Coker TR. ED Visits and Readmissions After Follow-up for Mental Health Hospitalization. Pediatrics 2020; 145:peds.2019-2872. [PMID: 32404433 DOI: 10.1542/peds.2019-2872] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A national quality measure in the Child Core Set is used to assess whether pediatric patients hospitalized for a mental illness receive timely follow-up care. In this study, we examine the relationship between adherence to the quality measure and repeat use of the emergency department (ED) or repeat hospitalization for a primary mental health condition. METHODS We used the Truven MarketScan Medicaid Database 2015-2016, identifying hospitalizations with a primary diagnosis of depression, bipolar disorder, psychosis, or anxiety for patients aged 6 to 17 years. Primary predictors were outpatient follow-up visits within 7 and 30 days. The primary outcome was time to subsequent mental health-related ED visit or hospitalization. We conducted bivariate and multivariate analyses using Cox proportional hazard models to assess relationships between predictors and outcome. RESULTS Of 22 844 hospitalizations, 62.0% had 7-day follow-up, and 82.3% had 30-day follow-up. Subsequent acute use was common, with 22.4% having an ED or hospital admission within 30 days and 54.8% within 6 months. Decreased likelihood of follow-up was associated with non-Hispanic or non-Latino black race and/or ethnicity, fee-for-service insurance, having no comorbidities, discharge from a medical or surgical unit, and suicide attempt. Timely outpatient follow-up was associated with increased subsequent acute care use (hazard ratio [95% confidence interval]: 7 days: 1.20 [1.16-1.25]; 30 days: 1.31 [1.25-1.37]). These associations remained after adjusting for severity indicators. CONCLUSIONS Although more than half of patients received follow-up within 7 days, variations across patient population suggest that care improvements are needed. The increased hazard of subsequent use indicates the complexity of treating these patients and points to potential opportunities to intervene at follow-up visits.
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Affiliation(s)
- Naomi S Bardach
- Department of Pediatrics and .,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Stephanie K Doupnik
- Department of Pediatrics, University of Pennsylvania and Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Bonnie T Zima
- Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, California
| | | | - Carol Nash
- Department of Research, Franciscan Children's, Boston, Massachusetts; and
| | - Yasas Tanguturi
- Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tumaini R Coker
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Research Institute, Seattle, Washington
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40
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Kaiser SV, Jennings B, Rodean J, Cabana MD, Garber MD, Ralston SL, Fassl B, Quinonez R, Mendoza JC, McCulloch CE, Parikh K. Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study. Pediatrics 2020; 145:peds.2019-3026. [PMID: 32376727 DOI: 10.1542/peds.2019-3026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals. METHODS We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics. RESULTS Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome. CONCLUSIONS Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California;
| | | | | | - Michael D Cabana
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Matthew D Garber
- Department of Pediatrics, College of Medicine, University of Florida, Jacksonville, Florida
| | - Shawn L Ralston
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Bernhard Fassl
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Ricardo Quinonez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joanne C Mendoza
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia; and
| | - Charles E McCulloch
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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Burns RR, Alpern ER, Rodean J, Canares T, Lee BR, Hall M, Montalbano A. Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid. JAMA Netw Open 2020; 3:e204185. [PMID: 32374396 PMCID: PMC7203605 DOI: 10.1001/jamanetworkopen.2020.4185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/04/2020] [Indexed: 11/30/2022] Open
Abstract
Importance Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.
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Affiliation(s)
- Rebecca R. Burns
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Jonathan Rodean
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
| | - Therese Canares
- Division of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian R. Lee
- Health Outcomes and Health Services Research, Children’s Mercy, Kansas City, Missouri
| | - Matt Hall
- Division of Analytics, Children’s Hospital Association, Lenexa, Kansas
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Bergman DA, Keller D, Kuo DZ, Lerner C, Mansour M, Stille C, Richardson T, Rodean J, Hudak M. Costs and Use for Children With Medical Complexity in a Care Management Program. Pediatrics 2020; 145:peds.2019-2401. [PMID: 32229620 DOI: 10.1542/peds.2019-2401] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) comprise only 6% of the pediatric population, account for ∼40% of pediatric health care spending, and provide an important opportunity for cost saving. Savings in this group can have an important impact on pediatric health care costs. The objective of this study was to assess the impact of a multicenter care management program on spending and use in CMC. DESIGN AND METHODS We conducted a prospective cohort analysis of a population of 4530 CMC enrolled in a learning collaborative designed to improve care for CMC ages 0 to 21 years identified using 3M Clinical Risk Group categories 5b through 9. The primary outcome was total per-member per-year standardized spending; secondary outcomes included inpatient and emergency department (ED) spending and use. We used a 1:1 propensity score match to compare enrolled patients to eligible nonenrolled patients and statistical process control methods to analyze spending and usage rates. RESULTS Comparison with the matched group showed a 4.6% (95% confidence interval [CI]: 1.9%-7.3%) decrease in total per-member per-year spending (P < .001), a 7.7% (95% CI: 1.2%-13.5%) decrease in inpatient spending (P = .04), and an 11.6% (95% CI: 3.9%-18.4%) decrease in ED spending (P = .04). Statistical process control analysis showed a decrease in hospitalization rate and ED visits. CONCLUSIONS CMC enrolled in a learning collaborative showed significant decreases in total spending and a significant decrease in the number of hospitalizations and ED visits. Additional research is needed to determine more specific causal factors for the results and if these results are sustainable over time and replicable in other settings.
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Affiliation(s)
- David A Bergman
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;
| | - David Keller
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Dennis Z Kuo
- Department of Pediatrics, School of Medicine, University at Buffalo, Buffalo, New York
| | | | - Mona Mansour
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christopher Stille
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | | | - Mark Hudak
- Department of Pediatrics, College of Medicine, University of Florida, Jacksonville, Florida
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Alinsky RH, Zima BT, Rodean J, Matson PA, Larochelle MR, Adger H, Bagley SM, Hadland SE. Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults. JAMA Pediatr 2020; 174:e195183. [PMID: 31905233 PMCID: PMC6990723 DOI: 10.1001/jamapediatrics.2019.5183] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown. OBJECTIVE To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4 039 216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019. EXPOSURES Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids. MAIN OUTCOMES AND MEASURES Receipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified. RESULTS Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100 000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20 700 per 100 000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83). CONCLUSIONS AND RELEVANCE After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.
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Affiliation(s)
- Rachel H. Alinsky
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Bonnie T. Zima
- Semel Institute for Neuroscience and Human Behavior, UCLA (University of California, Los Angeles), Los Angeles
| | | | - Pamela A. Matson
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marc R. Larochelle
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Hoover Adger
- Division of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sarah M. Bagley
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts,Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts,Department of Pediatrics, Boston Medicine Center, Boston, Massachusetts,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Scott E. Hadland
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Boston Medicine Center, Boston, Massachusetts,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
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Marsenic O, Rodean J, Richardson T, Swartz S, Claes D, Day JC, Warady B, Neu A. Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative. Pediatr Nephrol 2020; 35:135-143. [PMID: 31654224 DOI: 10.1007/s00467-019-04384-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE. METHODS Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques. RESULTS Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001). CONCLUSIONS Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.
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MESH Headings
- Adolescent
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/etiology
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/standards
- Catheterization, Central Venous/statistics & numerical data
- Central Venous Catheters/adverse effects
- Central Venous Catheters/standards
- Central Venous Catheters/statistics & numerical data
- Child
- Child, Preschool
- Female
- Guideline Adherence/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Intersectoral Collaboration
- Kidney Failure, Chronic/therapy
- Male
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Program Evaluation
- Prospective Studies
- Quality Improvement/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/instrumentation
- Renal Dialysis/standards
- Renal Dialysis/statistics & numerical data
- Sepsis/epidemiology
- Sepsis/etiology
- Standard of Care/organization & administration
- Standard of Care/statistics & numerical data
- Young Adult
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Affiliation(s)
- Olivera Marsenic
- Pediatric Nephrology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | | | | | | | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | | | - Alicia Neu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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45
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Coller RJ, Rodean J, Linares DE, Chung PJ, Pulcini C, Hall M, Alpern E, Mosquera R, Casto E, Berry JG. Variation in Hospitalization Rates Following Emergency Department Visits in Children with Medical Complexity. J Pediatr 2019; 214:113-120.e1. [PMID: 31540760 DOI: 10.1016/j.jpeds.2019.07.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/21/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate factors associated with admission from emergency department (ED) encounters for children with medical complexity (CMC) and to quantify the hospital admission rate as well as variation in adjusted hospital admission rates across EDs. STUDY DESIGN Retrospective study of 271 806 visits to 37 EDs in freestanding children's hospitals from January 1, 2014, to June 30, 2017, for patients of all ages with a complex chronic condition. Associations between patient demographic, clinical, and health services characteristics and the likelihood of hospital admission were identified using generalized linear models, which were then used to calculate adjusted hospital admission rates. RESULTS Hospital admission occurred with 25.7% of ED visits. Characteristics with the greatest aOR of hospitalization were ≥3 compared with 0 prior hospitalizations in 365 days (4.7; 95% CI, 4.5-4.9), ED arrival overnight compared with during workday 3.2 (95% CI, 3.1-3.3)], and ≥6 vs 0-1 chronic conditions (1.6; 95% CI, 1.5-1.6). Adjusted hospital admission rates varied significantly (P < .001) across EDs (21.1% [10th percentile]) and 30.0% [90th percentile]). Significant variation remained when excluding low-intensity ED visits, excluding hospitalizations requiring surgery and/or intensive care, or restricting the cohort to overnight ED arrival and to children with ≥3 prior hospitalizations. CONCLUSIONS CMC are frequently admitted from the ED. Substantial variation in CMC hospital admission rates across EDs exists after case-mix adjustment.
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Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Deborah E Linares
- Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Division of Research, Rockville, MD
| | - Paul J Chung
- Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA
| | - Christian Pulcini
- Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS; Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Elizabeth Alpern
- Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ricardo Mosquera
- Department of Pediatrics, University of Texas Medical School, Houston, TX
| | - Elizabeth Casto
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Chadi N, Rodean J, Earlywine JJ, Zima BT, Bagley SM, Levy S, Hadland SE. Treatment for Nicotine Use Disorder Among Medicaid-Enrolled Adolescents and Young Adults. JAMA Pediatr 2019; 173:1103-1105. [PMID: 31545354 PMCID: PMC6763988 DOI: 10.1001/jamapediatrics.2019.3200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study assesses use of nicotine replacement therapy, varenicline, and sustained-release bupropion for adolescents and young adults with nicotine use disorder who are enrolled in Medicaid.
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Affiliation(s)
- Nicholas Chadi
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts,Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada566633
| | - Jonathan Rodean
- Department of Analytics, Children’s Hospital Association, Lenexa, Kansas
| | | | - Bonnie T. Zima
- Center for Health Services & Society, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles
| | - Sarah M. Bagley
- Section of General Internal Medicine, Department of Medicine and Division of General Pediatrics, Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sharon Levy
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott E. Hadland
- Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
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47
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Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, Simon HK, Marin JR, Samuels-Kalow M, Alpern ER, Morse RB, Shah SS, Peltz A, Neuman MI. Low-Value Diagnostic Imaging Use in the Pediatric Emergency Department in the United States and Canada. JAMA Pediatr 2019; 173:e191439. [PMID: 31157877 PMCID: PMC6547126 DOI: 10.1001/jamapediatrics.2019.1439] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. OBJECTIVE To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. DESIGN, SETTING, AND PARTICIPANTS This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. EXPOSURES Diagnostic imaging use. MAIN OUTCOME AND MEASURES Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. RESULTS A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. CONCLUSIONS AND RELEVANCE Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.
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Affiliation(s)
- Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics and Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pediatrics, Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada
| | | | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Stephen B. Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Section of Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia,Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Alon Peltz
- Yale School of Medicine, New Haven, Connecticut
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, Boston, Massachusetts
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48
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Feinstein JA, Rodean J, Hall M, Doupnik SK, Gay JC, Markham JL, Bettenhausen JL, Simmons J, Garrity B, Berry JG. Outpatient Prescription Opioid Use in Pediatric Medicaid Enrollees With Special Health Care Needs. Pediatrics 2019; 143:e20182199. [PMID: 31138667 PMCID: PMC6626319 DOI: 10.1542/peds.2018-2199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although potentially dangerous, little is known about outpatient opioid exposure (OE) in children and youth with special health care needs (CYSHCN). We assessed the prevalence and types of OE and the diagnoses and health care encounters proximal to OE in CYSHCN. METHODS This is a retrospective cohort study of 2 597 987 CYSHCN aged 0-to-18 years from 11 states, continuously enrolled in Medicaid in 2016, with ≥1 chronic condition. OE included any filled prescription (single or multiple) for opioids. Health care encounters were assessed within 7 days before and 7 and 30 days after OE. RESULTS Among CYSHCN, 7.4% had OE. CYSHCN with OE versus without OE were older (ages 10-18 years: 69.4% vs 47.7%), had more chronic conditions (≥3 conditions: 49.1% vs 30.6%), and had more polypharmacy (≥5 other medication classes: 54.7% vs 31.2%), P < .001 for all. Most (76.7%) OEs were single fills with a median duration of 4 days (interquartile range: 3-6). The most common OEs were acetaminophen-hydrocodone (47.5%), acetaminophen-codeine (21.5%), and oxycodone (9.5%). Emergency department visits preceded 28.8% of OEs, followed by outpatient surgery (28.8%) and outpatient specialty care (19.1%). Most OEs were preceded by a diagnosis of infection (25.9%) or injury (22.3%). Only 35.1% and 62.2% of OEs were associated with follow-up visits within 7 and 30 days, respectively. CONCLUSIONS OE in CYSHCN is common, especially with multiple chronic conditions and polypharmacy. In subsequent studies, researchers should examine the appropriateness of opioid prescribing, particularly in emergency departments, as well as assess for drug interactions with chronic medications and reasons for insufficient follow-up.
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Affiliation(s)
- James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, Colorado;
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Stephanie K Doupnik
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James C Gay
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri; and
| | | | - Julia Simmons
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri; and
| | - Brigid Garrity
- Complex Care Service, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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Cutler GJ, Rodean J, Zima BT, Doupnik SK, Zagel AL, Bergmann KR, Hoffmann JA, Neuman MI. Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit. Acad Pediatr 2019; 19:948-955. [PMID: 31175994 PMCID: PMC7122010 DOI: 10.1016/j.acap.2019.05.132] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/11/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU). STUDY DESIGN Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital. RESULTS From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001). CONCLUSION The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.
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Affiliation(s)
- Gretchen J Cutler
- Children's Minnesota Research Institute (CJ Cutler, AL Zagel), Children's Minnesota, Minneapolis, Minn.
| | | | - Bonnie T Zima
- UCLA Semel Institute for Neuroscience and Human Behavior (B Zima), University of California at Los Angeles, Los Angeles, Calif
| | - Stephanie K Doupnik
- Division of General Pediatrics (SK Doupnik), PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Alicia L Zagel
- Children's Minnesota Research Institute (CJ Cutler, AL Zagel), Children's Minnesota, Minneapolis, Minn
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine (KR Bergman), Children's Minnesota, South, Minneapolis, Minn
| | - Jennifer A Hoffmann
- Division of Emergency Medicine (JA Hoffmann, MI Neuman), Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mark I Neuman
- Division of Emergency Medicine (JA Hoffmann, MI Neuman), Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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50
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Samuels-Kalow M, Neuman MI, Rodean J, Marin JR, Aronson PL, Hall M, Freedman SB, Morse RB, Cohen E, Simon HK, Shah SS, Alpern ER. The Care of Adult Patients in Pediatric Emergency Departments. Acad Pediatr 2019; 19:942-947. [PMID: 30853574 PMCID: PMC6732041 DOI: 10.1016/j.acap.2019.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/11/2019] [Accepted: 03/03/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Adult patients are increasingly receiving care in pediatric emergency departments (PEDs), but little is known about the epidemiology of these visits. The goals of this study were to examine the characteristics of adult patients (≥21 years) treated in PEDs and to describe the variation in resource utilization across centers. METHODS We conducted a cross-sectional study examining visits to 30 PEDs (2012-2016) using the Pediatric Health Information System. Visits were categorized using All Patient Refined Diagnosis Related Groups and compared between age cohorts. We used multivariable logistic models to examine variation in demographics, utilization, testing, treatment, and disposition. RESULTS There were 12,958,626 visits to the 30 PEDs over 5 years; 70,636 (0.6%) were by adults. Compared with children, adult patients had more laboratory testing (49% vs 34%), diagnostic imaging (32% vs 29%), and procedures (48% vs 31%), and they were more often admitted (17% vs 11%) or transferred (21% vs 0.7%) (P < .001 for all). In multivariable analysis, older age, black race, Hispanic ethnicity, and private insurance were associated with decreased odds of admission in adults seen in PEDs. Across PEDs, the admission rates (7%-25%) and transfer rates (6%-46%) for adults varied. CONCLUSIONS Adult patients cared for at PEDs have higher rates of testing, diagnostic imaging, procedures, and admission or transfer. There is wide variation in the care of adults in PEDs, highlighting the importance of further work to identify the optimal approach to adults who present for care in pediatric centers.
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Affiliation(s)
- Margaret Samuels-Kalow
- Department of Emergency Medicine (M Samuels-Kalow), Massachusetts General Hospital, and.
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, Boston, MA
| | | | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh PA
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta GA
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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