Predicting emergency department visits among children with asthma in two academic medical systems

Objective: To develop and validate a predictive algorithm that identifies pediatric patients at risk of asthma-related emergencies, and to test whether algorithm performance can be improved in an external site via local retraining.Methods: In a retrospective cohort at the first site, data from 26 008 patients with asthma aged 2-18 years (2012-2017) were used to develop a lasso-regularized logistic regression model predicting emergency department visits for asthma within one year of a primary care encounter, known as the Asthma Emergency Risk (AER) score. Internal validation was conducted on 8634 patient encounters from 2018. External validation of the AER score was conducted using 1313 pediatric patient encounters from a second site during 2018. The AER score components were then reweighted using logistic regression using data from the second site to improve local model performance. Prediction intervals (PI) were constructed via 10 000 bootstrapped samples.Results: At the first site, the AER score had a cross-validated area under the receiver operating characteristic curve (AUROC) of 0.768 (95% PI: 0.745-0.790) during model training and an AUROC of 0.769 in the 2018 internal validation dataset (p = 0.959). When applied without modification to the second site, the AER score had an AUROC of 0.684 (95% PI: 0.624-0.742). After local refitting, the cross-validated AUROC improved to 0.737 (95% PI: 0.676-0.794; p = 0.037 as compared to initial AUROC).Conclusions: The AER score demonstrated strong internal validity, but external validity was dependent on reweighting model components to reflect local data characteristics at the external site.

Impact of Telemedicine on Delivery of Pediatric Inflammatory Bowel Disease Care

OBJECTIVES

Outpatient inflammatory bowel disease (IBD) care shifted from office visits (OVs) to a model with integrated telemedicine during the 2020 COVID-19 pandemic. We describe the impact of this shift on delivery of pediatric IBD care.

METHODS

We collected electronic medical record data from office and telemedicine visits for pediatric patients with IBD at a single center from April 2019 to December 2020. We compared visit volume, duration, and test ordering between 2019 and 2020, and between OV and telemedicine, and assessed for differences in telemedicine adoption by sociodemographic factors.

RESULTS

Visit volume was maintained between 2019 and 2020. Median overall appointment time was shorter for telemedicine versus OV [46 (interquartile range, IQR 35-72) vs 62 (IQR 51-80) minutes; P < 0.001] with no significant difference in time spent with provider [28 (IQR 21-41) vs OV 30 (IQR 24-39) minutes; P = 0.08]. Accounting for drive time, telemedicine visits were 2.6 times shorter than office visits in 2020 ( P < 0.001). In univariate analyses, there was no difference in telemedicine utilization by race or gender. Variables significantly associated with telemedicine were older age, English as primary language, being non-Hispanic, commercial insurance, living in an area of very high opportunity, and having a longer drive time to the office ( P < 0.05 for all comparisons). In multivariate analyses, visits among patients with commercial insurance were significantly more likely to be conducted via telemedicine ( P = 0.02). Among those with a telemedicine visit, multivariate analyses demonstrated multiracial patients were significantly more likely to have video visits (vs audio-only; P = 0.02), while patients with public insurance, no or missing insurance, and whose primary language was Arabic were significantly less likely to have video visits ( P < 0.05 for all comparisons).

CONCLUSIONS

Integrated telemedicine allowed for continued delivery of pediatric IBD care and significantly decreased appointment time. While telemedicine may improve access for those who live further from the office, concerns remain about the introduction of disparities.

The Impact of the COVID-19 Pandemic on Pediatric Bicycle Injury

Bicycling is a common childhood activity that is associated with significant injury risk. This study's aim was to assess pediatric bicycle injury epidemiology and impacts of the COVID-19 pandemic. We conducted a cross-sectional evaluation of patients age < 18 years presenting with bicycle injury to a pediatric trauma center. A pre-pandemic period (1 March 2015-29 February 2020) was compared to the pandemic period (1 March 2020-28 February 2021). A total of 611 injury events for children < 18 years were included (471 pre-pandemic events and 140 pandemic events). The relative frequency of pandemic injuries was greater than pre-pandemic injuries (p < 0.001), resulting in a 48% increase in pandemic period injuries versus the pre-pandemic average (141 pandemic vs. 94.4/year pre-pandemic). Individuals of female sex represented a larger proportion of injuries in the pandemic period compared to the pre-pandemic period (37% pandemic vs. 28% pre-pandemic, p = 0.035). Injuries were more common on weekends versus weekdays (p = 0.01). Time series analysis showed a summer seasonality trend. Localizing injury events to ZIP codes showed regional injury density patterns. During COVID-19, there was an increase in bicycle injury frequency and proportional shift toward more injuries involving individuals of female sex. Otherwise, injury patterns were largely unchanged. These results demonstrate the necessity of safety interventions tailored to community needs.

The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration

OBJECTIVES

Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program.

DESIGN

Retrospective cohort study.

SETTING

Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH.

PATIENTS

All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization.

INTERVENTIONS

We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021.

MEASUREMENTS AND MAIN RESULTS

The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001).

CONCLUSIONS

The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.

Factors associated with psychiatric readmission of children and adolescents in the U.S.: A systematic review of the literature

OBJECTIVE

A systematic review of research assessing factors associated with inpatient psychiatric readmission of children and adolescents.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we searched 8 databases (1994-2018) to identify relevant articles on factors associated with youth psychiatric readmission. Selected articles addressed one or more factors associated with psychiatric readmission for children and adolescents (≤21 years of age) admitted to a psychiatric hospital in the United States for a primary mental health diagnosis. Two authors independently reviewed article abstracts, titles, and text.

RESULTS

Of 7903 retrieved articles, 30 studies met inclusion criteria. Analyzed variables were categorized according to child demographic and clinical characteristics; family, provider, and community characteristics; and treatment and aftercare characteristics. Available studies were markedly heterogeneous in methodology and outcomes. Factors associated with an increased risk of readmission included greater symptom severity, clinical diagnoses such as psychosis and affective disorders, suicidal behavior and self-injury, poor family functioning, and longer lengths of index hospital stay.

CONCLUSIONS

Controlled trials of interventions to improve care and reduce recidivism for psychiatrically hospitalized youth are needed. Future research will benefit from a guiding theoretical framework, more representative samples, and standardized exposure/outcome measures.

Pathogen Loading From Canada Geese Faeces in Freshwater: Potential Risks to Human Health Through Recreational Water Exposure

Canada geese (Branta canadensis) faeces have been shown to contain pathogenic protozoa and bacteria in numerous studies over the past 15 years. Further, increases in both the Canada geese populations and their ideal habitat requirements in the United States (US) translate to a greater presence of these human pathogens in public areas, such as recreational freshwater beaches. Combining these factors, the potential health risk posed by Canada geese faeces at freshwater beaches presents an emerging public health issue that warrants further study. Here, literature concerning human pathogens in Canada geese faeces is reviewed and the potential impacts these pathogens may have on human health are discussed. Pathogens of potential concern include Campylobacter jejuni, Salmonella Typhimurium, Listeria monocytogenes, Helicobacter canadensis, Arcobacter spp., Enterohemorragic Escherichia coli pathogenic strains, Chlamydia psitacci, Cryptosporidium parvum and Giardia lamblia. Scenarios presenting potential exposure to pathogens eluted from faeces include bathers swimming in lakes, children playing with wet and dry sand impacted by geese droppings and other common recreational activities associated with public beaches. Recent recreational water-associated disease outbreaks in the US support the plausibility for some of these pathogens, including Cryptosporidium spp. and C. jejuni, to cause human illness in this setting. In view of these findings and the uncertainties associated with the real health risk posed by Canada geese faecal pathogens to users of freshwater lakes, it is recommended that beach managers use microbial source tracking and conduct a quantitative microbial risk assessment to analyse the local impact of Canada geese on microbial water quality during their decision-making process in beach and watershed management.

Endovascular treatment of abdominal aortic aneurysm

BACKGROUND

Endovascular repair of abdominal aortic aneurysm has become widely used. Supporters claim high success rates, few complications and a dramatically reduced hospital stay. However, endoleak, endotension and reports of endoprosthesis rupture are causes of concern.

METHODS

A Medline search was undertaken to identify articles on endovascular repair of abdominal aortic aneurysm. Additional papers were identified by manual scanning of the references from key articles.

RESULTS AND CONCLUSION

Endoleak is a potentially serious complication of the endovascular technique and occurs in a significant proportion of patients. It is still not possible to judge whether the presence of an endoleak alone signifies failure of treatment, and the long-term durability of prosthetic covered stents is unknown. However, endovascular repair does appear to confer a degree of protection from rupture although patients must be advised of the need for life-long imaging surveillance and, perhaps, further intervention.