To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital rea... more To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). ...
Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinic... more Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinical and cost attributes of pediatric UC and emergency department (ED) visits that did not result in admission. Our study examined 5 925 568 ED and UC visits of children under 19 years old in the 2010 through 2012 Marketscan Medicaid Multi-State Database. Basic demographics, diagnoses, severity, and payments were compared. Between ED and UC visits, χ(2) tests were used for proportions and Wilcoxon rank-sum tests were used for continuous variables. The UC and ED had the same most common diagnoses. Over half the UC visits were low severity. The ED had a higher rate of return within 7 days (8.4% vs 6.9%, P < .001) and follow-up with their primary care physician (22% vs 17.2%, P < .001). Few (<1%) were admitted on return visits from the ED or UC. Payments for UC were significantly less (median $76.90 vs $186.20, P < .001). This continued to hold true when comparing payments for sel...
Performance-measure risk adjustment is of great interest to hospital stakeholders who face substa... more Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood. To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals. Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015. Two risk-adjustment models: a baseline m...
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 16, 2016
Reporting of adverse events (AEs) in clinical trials is critical to understanding treatment safet... more Reporting of adverse events (AEs) in clinical trials is critical to understanding treatment safety, but data on AE accuracy are limited. This study sought to determine the accuracy of AE reporting for pediatric acute myeloid leukemia clinical trials and to test whether an external electronic data source can improve reporting. Reported AEs were evaluated on two trials, Children's Oncology Group AAML03P1 and AAML0531 arm B, with identical chemotherapy regimens but with different toxicity reporting requirements. Chart review for 12 AEs for patients enrolled in AAML0531 at 14 hospitals was the gold standard. The sensitivity and positive predictive values (PPV) of the AAML0531 AE report and AEs detected by review of Pediatric Health Information System (PHIS) billing and microbiology data were compared with chart data. Select AE rates from AAML03P1 and AAML0531 arm B differed significantly and correlated with the targeted toxicities of each trial. Chart abstraction was performed on 20...
Acute care hospitals are challenged to provide efficient, high-quality care to children who have ... more Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children. To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children. Retrospective analysis of 2 423 031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids' Inpatient Database. Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children's characteristics (eg, race/ethnicity and number of chronic conditions)...
Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED ... more Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED visits, but no studies specifically address children with cancer. A retrospective study of Pediatric Health Information System analyzing ED visits for children with cancer, including ED visits within 365 days from the first inpatient encounter with a discharge diagnosis code for malignancy. We defined frequent ED utilizers as those with four or more visits in the year (top 10th percentile). Patient characteristics and ED services (medications, laboratory, or imaging) for discharged children were assessed. Factors associated with being a frequent ED utilizer were examined with multivariable regression. Frequent utilizers accounted for 58% of ED visits. Frequent utilizers differed from infrequent utilizers in terms of type of cancer; 39.3% of frequent utilizers had acute lymphoblastic leukemia (ALL) and 16.0% had central nervous system (CNS) tumors compared with infrequent utilizers (21.9%...
Journal of the Pediatric Infectious Diseases Society, Jan 23, 2016
Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable... more Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT. We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ≥80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We revi...
Children who experience high health care costs are increasingly enrolled in clinical initiatives ... more Children who experience high health care costs are increasingly enrolled in clinical initiatives to improve their health and contain costs. Hospitalization is a significant cost driver. We describe hospitalization trends for children with highest annual inpatient cost (CHIC) and identify characteristics associated with persistently high inpatient costs in subsequent years. Retrospective study of 265 869 children age 2 to 15 years with ≥1 admission in 2010 to 39 children's hospitals in the Pediatric Health Information System. CHIC were defined as the top 10% of total inpatient costs in 2010 (n = 26 574). Multivariate regression and regression tree modeling were used to distinguish individual characteristics and interactions of characteristics, respectively, associated with persistently high inpatient costs (≥80th percentile in 2011 and/or 2012). The top 10% most expensive children (CHIC) constituted 56.9% ($2.4 billion) of total inpatient costs in 2010. Fifty-eight percent (n = 1...
Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumon... more Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia. A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children's hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics. In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspirati...
To determine across and within hospital differences in the predictors of 365-day admission freque... more To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals. Multicenter retrospective cohort analysis of 12 449 children 2-18 years of age with a diagnosis of DKA in 42 US children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. Across children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.
National guidelines for the management of community-acquired pneumonia (CAP) in children were pub... more National guidelines for the management of community-acquired pneumonia (CAP) in children were published in 2011. These guidelines discourage most diagnostic testing for outpatients, as well as repeat testing for hospitalized patients who are improving. We sought to evaluate the temporal trends in diagnostic testing associated with guideline implementation among children with CAP. Children 1 to 18 years old who were discharged with pneumonia after emergency department (ED) evaluation or hospitalization from January 1, 2008 to June 30, 2014 at any of 32 children's hospitals participating in the Pediatric Health Information System were included. We excluded children with complex chronic conditions and those requiring intensive care or who underwent early pleural drainage. We compared use of diagnostic testing (blood culture, complete blood count [CBC], C-reactive protein [CRP], and chest radiography [CXR]) before and after release of the guidelines, and assessed for temporal trends...
Clinical trials data from National Cancer Institute (NCI)-funded cooperative oncology group trial... more Clinical trials data from National Cancer Institute (NCI)-funded cooperative oncology group trials could be enhanced by merging with external data sources. Merging without direct patient identifiers would provide additional patient privacy protections. We sought to develop and validate a matching algorithm that uses only indirect patient identifiers. We merged the data from two Phase III Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Oncology Group (COG) trials for de novo acute myeloid leukemia (AML) with the Pediatric Health Information Systems (PHIS). We developed a stepwise matching algorithm that used indirect identifiers including treatment site, gender, birth year, birth month, enrollment year and enrollment month. Results from the stepwise algorithm were compared against the direct merge method that used date of birth, treatment site, and gender. The indirect merge algorithm was developed on AAML0531 and validated on AAML1031. Of 415 patients enrolled on the AAML0531 trial at PHIS centers, we successfully matched 378 (91.1%) patients using the indirect stepwise algorithm. Comparison to the direct merge result suggested that 362 (95.7%) matches identified by the indirect merge algorithm were concordant with the direct merge result. When validating the indirect stepwise algorithm using the AAML1031 trial, we successfully matched 157 out of 165 patients (95.2%) and 150 (95.5%) of the indirectly merged matches were concordant with the directly merged matches. These data demonstrate that patients enrolled on COG clinical trials can be successfully merged with PHIS administrative data using a stepwise algorithm based on indirect patient identifiers. The merged data sets can be used as a platform for comparative effectiveness and cost effectiveness studies.
Opportunities to improve health care quality and contain spending may differ between high and low... more Opportunities to improve health care quality and contain spending may differ between high and low resource users. This study's objectives were to assess health care and spending among children with Medicaid insurance by their resource use. Retrospective cross-sectional analysis of 2012 Medicaid health administrative data from 10 states of children ages 11 months to 18 years. Subjects were categorized into 4 spending groups, each representing ∼25% of total spending: the least expensive 80% of children (n = 2 868 267), the next 15% expensive (n = 537 800), the next 4% expensive (n = 143 413), and the top 1% (n = 35 853). We compared per-member-per-month (PMPM) spending across the groups using the Kruskal-Wallis test. PMPM spending was $68 (least expensive 80%), $349 (next 15%), $1200 (next 4%), and $6738 (top 1%). Between the least and most expensive groups, percentages of total spending were higher for inpatient (<1% vs 46%) and mental health (7% vs 24%) but lower for emergenc...
To evaluate accuracy of 2 established administrative methods of identifying children with sepsis ... more To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. A total of 130 out of 432 subjects met reference SD of se...
To assess the relationship between hospital volume and intensive care unit (ICU) transfer among h... more To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD). We conducted a retrospective cohort study of 83 477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS. Of 83 477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific vol...
Introduction In this abstract we will study whether common assumptions used to model extracellula... more Introduction In this abstract we will study whether common assumptions used to model extracellular diffusion in biological tissue are valid using Monte Carlo simulations. Diffusion in biological tissues is a process which is affected by the compartment in which the diffusing molecules are situated. More specifically, water molecules are either located within cells, which to a large extent restrict their diffusion, or in the space between cells in which their diffusion is hindered but not ultimately restricted. Most studies in diffusion-weighted MRI have focused on modeling the intracellular compartment correctly, because interesting microstructural parameters, such as cell size, can be learned from these models. However, to estimate these parameters, a model for extracellular diffusion must be estimated as well, as the diffusion-weighted signal contains contributions from both compartments. Moreover, extracellular diffusion is an interesting phenomenon in itself, since it plays an i...
Background: OPAT has been used for nearly 40 years to treat a variety of infections in children. ... more Background: OPAT has been used for nearly 40 years to treat a variety of infections in children. However, evidence demonstrates that OPAT is overused for certain diagnoses (e.g. osteoarticular infections) or antibiotics (e.g. clindamycin) when oral therapy would be appropriate. This may lead to unnecessary costs and complications including emergency department (ED) visits and hospital readmissions. Objective: Describe the diagnoses treated and antimicrobials used for OPAT and the frequency of medical encounters associated with OPAT in a large population of pediatric Medicaid enrollees. Methods: We analyzed 2009-2011 data from the Truven MarketScan Medicaid claims database. MarketScan contains claims data for inpatient and outpatient services, retail prescription drug services, and enrollment information for 6 million Medicaid enrollees from 12 de-identified states. OPAT inclusion criteria required an enrollee to be ≤18 years of age, have an outpatient claim with a healthcare common ...
To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children ho... more To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. 40 257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and total episode of care (including readmissions) ($2624 vs $2856; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.
To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital rea... more To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). ...
Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinic... more Urgent care (UC) is one of the fastest growing venues of health care delivery. We compared clinical and cost attributes of pediatric UC and emergency department (ED) visits that did not result in admission. Our study examined 5 925 568 ED and UC visits of children under 19 years old in the 2010 through 2012 Marketscan Medicaid Multi-State Database. Basic demographics, diagnoses, severity, and payments were compared. Between ED and UC visits, χ(2) tests were used for proportions and Wilcoxon rank-sum tests were used for continuous variables. The UC and ED had the same most common diagnoses. Over half the UC visits were low severity. The ED had a higher rate of return within 7 days (8.4% vs 6.9%, P < .001) and follow-up with their primary care physician (22% vs 17.2%, P < .001). Few (<1%) were admitted on return visits from the ED or UC. Payments for UC were significantly less (median $76.90 vs $186.20, P < .001). This continued to hold true when comparing payments for sel...
Performance-measure risk adjustment is of great interest to hospital stakeholders who face substa... more Performance-measure risk adjustment is of great interest to hospital stakeholders who face substantial financial penalties from readmissions pay-for-performance (P4P) measures. Despite evidence of the association between social determinants of health (SDH) and individual patient readmission risk, the effect of risk adjusting for SDH on readmissions P4P penalties to hospitals is not well understood. To determine whether risk adjustment for commonly available SDH measures affects the readmissions-based P4P penalty status of a national cohort of children's hospitals. Retrospective cohort study of 43 free-standing children's hospitals within the Pediatric Health Information System database in the calendar year 2013. We evaluated hospital discharges from 2013 that met criteria for 3M Health Information Systems' potentially preventable readmissions measure for calendar year 2013. The analysis was conducted from July 2015 to August 2015. Two risk-adjustment models: a baseline m...
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 16, 2016
Reporting of adverse events (AEs) in clinical trials is critical to understanding treatment safet... more Reporting of adverse events (AEs) in clinical trials is critical to understanding treatment safety, but data on AE accuracy are limited. This study sought to determine the accuracy of AE reporting for pediatric acute myeloid leukemia clinical trials and to test whether an external electronic data source can improve reporting. Reported AEs were evaluated on two trials, Children's Oncology Group AAML03P1 and AAML0531 arm B, with identical chemotherapy regimens but with different toxicity reporting requirements. Chart review for 12 AEs for patients enrolled in AAML0531 at 14 hospitals was the gold standard. The sensitivity and positive predictive values (PPV) of the AAML0531 AE report and AEs detected by review of Pediatric Health Information System (PHIS) billing and microbiology data were compared with chart data. Select AE rates from AAML03P1 and AAML0531 arm B differed significantly and correlated with the targeted toxicities of each trial. Chart abstraction was performed on 20...
Acute care hospitals are challenged to provide efficient, high-quality care to children who have ... more Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children. To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children. Retrospective analysis of 2 423 031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids' Inpatient Database. Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children's characteristics (eg, race/ethnicity and number of chronic conditions)...
Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED ... more Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED visits, but no studies specifically address children with cancer. A retrospective study of Pediatric Health Information System analyzing ED visits for children with cancer, including ED visits within 365 days from the first inpatient encounter with a discharge diagnosis code for malignancy. We defined frequent ED utilizers as those with four or more visits in the year (top 10th percentile). Patient characteristics and ED services (medications, laboratory, or imaging) for discharged children were assessed. Factors associated with being a frequent ED utilizer were examined with multivariable regression. Frequent utilizers accounted for 58% of ED visits. Frequent utilizers differed from infrequent utilizers in terms of type of cancer; 39.3% of frequent utilizers had acute lymphoblastic leukemia (ALL) and 16.0% had central nervous system (CNS) tumors compared with infrequent utilizers (21.9%...
Journal of the Pediatric Infectious Diseases Society, Jan 23, 2016
Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable... more Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT. We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ≥80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We revi...
Children who experience high health care costs are increasingly enrolled in clinical initiatives ... more Children who experience high health care costs are increasingly enrolled in clinical initiatives to improve their health and contain costs. Hospitalization is a significant cost driver. We describe hospitalization trends for children with highest annual inpatient cost (CHIC) and identify characteristics associated with persistently high inpatient costs in subsequent years. Retrospective study of 265 869 children age 2 to 15 years with ≥1 admission in 2010 to 39 children's hospitals in the Pediatric Health Information System. CHIC were defined as the top 10% of total inpatient costs in 2010 (n = 26 574). Multivariate regression and regression tree modeling were used to distinguish individual characteristics and interactions of characteristics, respectively, associated with persistently high inpatient costs (≥80th percentile in 2011 and/or 2012). The top 10% most expensive children (CHIC) constituted 56.9% ($2.4 billion) of total inpatient costs in 2010. Fifty-eight percent (n = 1...
Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumon... more Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia. A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children's hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics. In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspirati...
To determine across and within hospital differences in the predictors of 365-day admission freque... more To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals. Multicenter retrospective cohort analysis of 12 449 children 2-18 years of age with a diagnosis of DKA in 42 US children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. Across children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.
National guidelines for the management of community-acquired pneumonia (CAP) in children were pub... more National guidelines for the management of community-acquired pneumonia (CAP) in children were published in 2011. These guidelines discourage most diagnostic testing for outpatients, as well as repeat testing for hospitalized patients who are improving. We sought to evaluate the temporal trends in diagnostic testing associated with guideline implementation among children with CAP. Children 1 to 18 years old who were discharged with pneumonia after emergency department (ED) evaluation or hospitalization from January 1, 2008 to June 30, 2014 at any of 32 children's hospitals participating in the Pediatric Health Information System were included. We excluded children with complex chronic conditions and those requiring intensive care or who underwent early pleural drainage. We compared use of diagnostic testing (blood culture, complete blood count [CBC], C-reactive protein [CRP], and chest radiography [CXR]) before and after release of the guidelines, and assessed for temporal trends...
Clinical trials data from National Cancer Institute (NCI)-funded cooperative oncology group trial... more Clinical trials data from National Cancer Institute (NCI)-funded cooperative oncology group trials could be enhanced by merging with external data sources. Merging without direct patient identifiers would provide additional patient privacy protections. We sought to develop and validate a matching algorithm that uses only indirect patient identifiers. We merged the data from two Phase III Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Oncology Group (COG) trials for de novo acute myeloid leukemia (AML) with the Pediatric Health Information Systems (PHIS). We developed a stepwise matching algorithm that used indirect identifiers including treatment site, gender, birth year, birth month, enrollment year and enrollment month. Results from the stepwise algorithm were compared against the direct merge method that used date of birth, treatment site, and gender. The indirect merge algorithm was developed on AAML0531 and validated on AAML1031. Of 415 patients enrolled on the AAML0531 trial at PHIS centers, we successfully matched 378 (91.1%) patients using the indirect stepwise algorithm. Comparison to the direct merge result suggested that 362 (95.7%) matches identified by the indirect merge algorithm were concordant with the direct merge result. When validating the indirect stepwise algorithm using the AAML1031 trial, we successfully matched 157 out of 165 patients (95.2%) and 150 (95.5%) of the indirectly merged matches were concordant with the directly merged matches. These data demonstrate that patients enrolled on COG clinical trials can be successfully merged with PHIS administrative data using a stepwise algorithm based on indirect patient identifiers. The merged data sets can be used as a platform for comparative effectiveness and cost effectiveness studies.
Opportunities to improve health care quality and contain spending may differ between high and low... more Opportunities to improve health care quality and contain spending may differ between high and low resource users. This study's objectives were to assess health care and spending among children with Medicaid insurance by their resource use. Retrospective cross-sectional analysis of 2012 Medicaid health administrative data from 10 states of children ages 11 months to 18 years. Subjects were categorized into 4 spending groups, each representing ∼25% of total spending: the least expensive 80% of children (n = 2 868 267), the next 15% expensive (n = 537 800), the next 4% expensive (n = 143 413), and the top 1% (n = 35 853). We compared per-member-per-month (PMPM) spending across the groups using the Kruskal-Wallis test. PMPM spending was $68 (least expensive 80%), $349 (next 15%), $1200 (next 4%), and $6738 (top 1%). Between the least and most expensive groups, percentages of total spending were higher for inpatient (<1% vs 46%) and mental health (7% vs 24%) but lower for emergenc...
To evaluate accuracy of 2 established administrative methods of identifying children with sepsis ... more To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. A total of 130 out of 432 subjects met reference SD of se...
To assess the relationship between hospital volume and intensive care unit (ICU) transfer among h... more To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD). We conducted a retrospective cohort study of 83 477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS. Of 83 477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific vol...
Introduction In this abstract we will study whether common assumptions used to model extracellula... more Introduction In this abstract we will study whether common assumptions used to model extracellular diffusion in biological tissue are valid using Monte Carlo simulations. Diffusion in biological tissues is a process which is affected by the compartment in which the diffusing molecules are situated. More specifically, water molecules are either located within cells, which to a large extent restrict their diffusion, or in the space between cells in which their diffusion is hindered but not ultimately restricted. Most studies in diffusion-weighted MRI have focused on modeling the intracellular compartment correctly, because interesting microstructural parameters, such as cell size, can be learned from these models. However, to estimate these parameters, a model for extracellular diffusion must be estimated as well, as the diffusion-weighted signal contains contributions from both compartments. Moreover, extracellular diffusion is an interesting phenomenon in itself, since it plays an i...
Background: OPAT has been used for nearly 40 years to treat a variety of infections in children. ... more Background: OPAT has been used for nearly 40 years to treat a variety of infections in children. However, evidence demonstrates that OPAT is overused for certain diagnoses (e.g. osteoarticular infections) or antibiotics (e.g. clindamycin) when oral therapy would be appropriate. This may lead to unnecessary costs and complications including emergency department (ED) visits and hospital readmissions. Objective: Describe the diagnoses treated and antimicrobials used for OPAT and the frequency of medical encounters associated with OPAT in a large population of pediatric Medicaid enrollees. Methods: We analyzed 2009-2011 data from the Truven MarketScan Medicaid claims database. MarketScan contains claims data for inpatient and outpatient services, retail prescription drug services, and enrollment information for 6 million Medicaid enrollees from 12 de-identified states. OPAT inclusion criteria required an enrollee to be ≤18 years of age, have an outpatient claim with a healthcare common ...
To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children ho... more To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. 40 257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) and total episode of care (including readmissions) ($2624 vs $2856; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.
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