Trends in Low-Value Care Among Children's Hospitals

BACKGROUND AND OBJECTIVES

Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends.

METHODS

This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC.

RESULTS

There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures.

CONCLUSIONS

LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.

Characteristics and Outcomes of Sepsis Presenting in Inpatient Pediatric Settings

OBJECTIVE

The pediatric sepsis literature lacks studies examining the inpatient setting, yet sepsis remains a leading cause of death in children's hospitals. More information is needed about sepsis arising in patients already hospitalized to improve morbidity and mortality outcomes. This study describes the clinical characteristics, process measures, and outcomes of inpatient sepsis cases compared with emergency department (ED) sepsis cases within the Improving Pediatric Sepsis Outcomes data registry from 46 hospitals that care for children.

METHODS

This retrospective cohort study included Improving Pediatric Sepsis Outcomes sepsis cases from January 2017 to December 2019 with onset in inpatient or ED. We used descriptive statistics to compare inpatient and ED sepsis metrics and describe inpatient sepsis outcomes.

RESULTS

The cohort included 26 855 cases; 8.4% were inpatient and 91.6% were ED. Inpatient cases had higher sepsis-attributable mortality (2.0% vs 1.4%, P = .025), longer length of stay after sepsis recognition (9 vs 5 days, P <.001), more intensive care admissions (57.6% vs 54.1%, P = .002), and greater average vasopressor use (18.0% vs 13.6%, P <.001) compared with ED. In the inpatient cohort, >40% of cases had a time from arrival to recognition within 12 hours. In 21% of cases, this time was >96 hours. Improved adherence to sepsis treatment bundles over time was associated with improved 30-day sepsis-attributable mortality for inpatients with sepsis.

CONCLUSIONS

Inpatient sepsis cases had longer lengths of stay, more need for intensive care, and higher vasopressor use. Sepsis-attributable mortality was significantly higher in inpatient cases compared with ED cases and improved with improved sepsis bundle adherence.

Two-Year Utilization and Expenditures for Children After a Firearm Injury

INTRODUCTION

Firearm injuries are a leading cause of morbidity among children, but data on healthcare utilization and expenditures after injury are limited. This study sought to analyze healthcare encounters and expenditures for 2 years after a nonfatal firearm injury.

METHODS

A retrospective cohort study was conducted between 2020 and 2022 of children aged 0-18 years with International Classification of Diseases, Ninth Revision/ICD-10 diagnosis codes for firearm injury from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included the difference in healthcare encounters and expenditures, including mental health. Descriptive statistics characterized patient demographics and healthcare utilization. Changes in health expenditures were evaluated with Wilcoxon sign rank tests.

RESULTS

Among 911 children, there were 12,757 total healthcare encounters in the year before the index firearm injury, 15,548 1 encounters in the year after (p<0.001), and 10,228 total encounters in the second year (p<0.001). Concomitantly, there was an overall increase of $14.4 million in health expenditures ($11,415 per patient) 1 year after (p<0.001) and a $0.8 million decrease 2 years after the firearm injury (p=0.001). The children with low previous expenditures (majority of sample) had sustained increases throughout the second year after injury. There was a 31% and 37% absolute decrease in mental health utilization and expenditures, respectively, among children 2 years after the firearm injury.

CONCLUSIONS

Children who experience nonfatal firearm injury have an increased number of healthcare encounters and healthcare expenditures in the year after firearm injury, which is not sustained for a second year. Mental health utilization and expenditures remain decreased up to 2 years after a firearm injury. More longitudinal research on the morbidity associated with nonfatal firearm injuries is needed.

Epidemiology and Risk Factors for Hemodialysis Access-Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative

RATIONALE & OBJECTIVE

Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center-level compliance with standardized practices and risk of CA-BSI.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Children enrolled in SCOPE between June 2013 and July 2019.

EXPOSURES

Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time.

OUTCOME

CA-BSIs.

ANALYTICAL APPROACH

Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs.

RESULTS

The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers.

LIMITATIONS

Lack of data on adherence to HD care practices on the individual patient level.

CONCLUSIONS

Improvement in compliance with standardized HD care practices over time may lead to a reduction in dialysis-associated infections.

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions

BACKGROUND

Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions.

OBJECTIVE

Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes.

DESIGNS

We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database.

SETTINGS AND PARTICIPANTS

We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis.

INTERVENTION

We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital.

MAIN OUTCOME AND MEASURES

The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions.

RESULTS

Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions.

CONCLUSION

We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals

IMPORTANCE

The scope of low-value care in children's hospitals is poorly understood.

OBJECTIVE

To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort.

EXPOSURES

Eligible condition-specific hospital encounters.

MAIN OUTCOMES AND MEASURES

The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes.

RESULTS

There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866).

CONCLUSIONS AND RELEVANCE

This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

OBJECTIVE

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury.

METHODS

This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests.

RESULTS

Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury.

CONCLUSIONS

Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Retracted Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included 1) difference in health care encounters for 1 year before and 1 year after injury, 2) difference in health care expenditures, and 3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests. Among 3,296 children, there were 47,660 health care encounters before the injury and 61,660 after. Concomitantly, there was an overall increase of $18.5 million in health expenditures ($5,612 per patient). There was a 40% increase in children qualifying for complex chronic condition status after firearm injury. Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.