Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux.

PURPOSE: Dextranomer/hyaluronic acid (Deflux) has been increasingly used for the treatment of vesicoureteral reflux (VUR). Experience has shown that injecting more volume of material is necessary to achieve greater success. We evaluate trends in the number of vials being used to treat VUR using a multi-institutional database and data from patients treated at our own institution. METHODS: Children of age 0-19 years in the Pediatric Health Information System (PHIS) database from 2003 to 2008 were extracted with a VUR diagnosis (ICD-9 593.7x) and subureteric injection procedure code (CPT 52327). We identified children with reflux treated with endoscopic injection at Seattle Children's Hospital from 2005 to 2008. Hospital trends of the number of vials used were evaluated using multivariate linear regression. RESULTS: From 2003 to 2008, we identified 4,078 endoscopic injection procedures in PHIS. There was a 33% increase in the average number of vials used per patient (p < 0.0001) with more than a threefold increase in the number of patients receiving three or more vials per procedure. All institutions increased the average vials used per patient with the most pronounced increase at the highest-volume centers. These trends were also present in the 186 children treated at our own institution. CONCLUSION: Over the study period there was an increase in the number of vials of dextranomer/hyaluronic acid being used per patient to treat children with VUR. This practice may improve success rates but will increase the cost of treatment due to the inherent expense of the material.

Surgical management of congenital ureteropelvic junction obstruction: a Pediatric Health Information System database study.

PURPOSE: Although laparoscopic pyeloplasty has gained popularity, to our knowledge no multi-institutional study has evaluated the prevalence of this approach in children. We used a multicenter database to determine trends in the treatment of congenital ureteropelvic junction obstruction. MATERIALS AND METHODS: The Pediatric Health Information System database contains data on 37 freestanding hospitals for children across the United States. We extracted data on 0 to 19-year-old patients from 2001 to 2006 with the ICD-9 diagnosis code for congenital ureteropelvic junction obstruction and the procedure code for the correction of ureteropelvic junction obstruction. We identified laparoscopic cases based on hospital charges for 1) laparoscope, 2) trocar, 3) insufflating needle or 4) insufflator and tubing. Data were then analyzed using the chi-square and Student t tests to determine management trends. RESULTS: We identified 2,353 patients, of whom 2,177 (92.5%) underwent open pyeloplasty and 176 (7.5%) underwent laparoscopic pyeloplasty. The percent of pediatric pyeloplasties performed laparoscopically increased from 2001 to 2003 (2.53% to 9.73%) and has since remained stable. Patients undergoing laparoscopic pyeloplasty were significantly older than those in the open group (age 8.2 vs 3.3 years, p <0.0001). Average hospital charges were significantly higher in the laparoscopic group than in the open group ($23,295.71 vs $16,467.49, p <0.05). There was no significant difference in terms of race, gender or length of stay. CONCLUSIONS: The percent of pediatric pyeloplasties performed laparoscopically has increased with time. However, laparoscopic pyeloplasty is associated with higher hospital charges than open surgery without a significant decrease in length of stay.

Variation in inpatient resource utilization and management of apparent life-threatening events.

OBJECTIVE: To report national variations in diagnostic approaches to apparent life-threatening events (ALTEs) and resource utilization. STUDY DESIGN: Using the Pediatric Health Information System, we studied children who were age 3 days to 5 months at admission and were discharged with an International Classification of Diseases, Ninth Revision (ICD-9) code potentially identifiable as ALTE. Multiple analysis of variance was used to determine whether the variances in adjusted charges, length of stay (LOS), and diagnostic studies were hospital-related after controlling for other covariates. Logistic regression was used to study the association of readmission rates with discharge diagnosis and specific diagnostic studies. RESULTS: The study group comprised 12,067 patients, with a mean LOS of 4.4 days (standard deviation +/- 5.6 days) and mean adjusted charges of $15,567 ($28,510) per admission. The mean in-hospital mortality rate was 0.56% (n = 68), and the rate of 30-day readmission was 2.5%. The most common discharge diagnoses were gastroesophageal reflux 36.9% (48.3%) and lower respiratory tract infection 30.8% (46.2%). Mean LOS, total adjusted charges, and use of diagnostic studies varied considerably across hospitals, and hospital-level differences were a significant contributor to the variance of these outcomes after controlling for covariates (P < .001). There was an increased likelihood of readmission for patients discharged with a diagnosis of cardiovascular disorders (odds ratio [OR] = 1.68; 95% confidence interval [CI] = 1.30 to 2.16) and gastroesophageal reflux (OR = 1.32; 95% CI = 1.03 to 1.69) compared with other discharge diagnoses. CONCLUSIONS: There is considerable hospital-based variation in care for patients hospitalized for conditions potentially identifiable as ALTE, particularly in the evaluation and diagnosis of gastroesophageal reflux, which may contribute to adverse clinical and financial outcomes. An evidence-based national standard of care for ALTE is needed, as are multi-institutional initiatives to study different diagnostic and management strategies and their effect on patient outcomes.

The conversion to metered-dose inhaler with valved holding chamber to administer inhaled albuterol: a pediatric hospital experience.

BACKGROUND: Metered-dose inhalers with valved holding chambers (MDI-VHCs) have been shown to be equivalent to small-volume nebulizers (SVNs) for the delivery of bronchodilators in children. At Seattle Children's Hospital and Regional Medical Center we sought to implement the conversion from SVN to MDI-delivered albuterol in nonintubated patients receiving intermittent treatments. METHODS: There were 4 distinct interventions used to plan and implement this conversion program: (1) literature review, (2) product selection, (3) policy and operational changes, and (4) staff training. Bronchodilator administration guidelines and clinical pathways for asthma and bronchiolitis were revised to recommend MDI-VHC use in lieu of SVNs. Computerized physician order sets were amended to indicate MDI-VHC as the preferred method of delivering inhaled albuterol in children with asthma and bronchiolitis. Data from administrative case mix files and computerized medication delivery systems were used to assess the impact of our program. RESULTS: MDI-VHC utilization increased from 25% to 77% among all non-intensive-care patients receiving albuterol, and from 10% to 79% among patients with asthma (p < 0.001). Duration of stay among patients with asthma was unchanged after conversion to MDI-VHC (p = 0.53). CONCLUSIONS: Our program was very successful at promoting the use of MDI-VHC for the administration of albuterol in our pediatric hospital. Duration of stay among patients with asthma did not change during or since the implementation of this program.

Newborn care by pediatric hospitalists in a community hospital: effect on physician productivity and financial performance.

OBJECTIVE: To describe financial outcomes and physician productivity associated with the inclusion of well-newborn services in a pediatric hospitalist program in a community hospital. DESIGN: Retrospective review of professional billing records and physician activity logs for newborn and inpatient care, consultations, and procedures. SETTING: Pediatric hospitalist program in a community hospital during a 24-month period from August 1, 2002, through July 31, 2004. MAIN EXPOSURES: Newborn care. MAIN OUTCOME MEASURES: Financial productivity. RESULTS: Pediatric hospitalists provided daily rounds and on-call services for inpatients and newborns with an average daily census of 3.1 inpatients and 7.9 newborns. Annual work relative value units production was 1508, and gross charges were $162,920 per staffed full-time equivalent. With mean work relative value unit production of 13.8 relative value units per day and average payment rates of $45 per total relative value unit, professional fees from inpatient and newborn care ($873 per day) did not cover salary, benefit, and practice expenses ($1460 per day), necessitating hospital support to cover annual program deficits of $206,744. Without the professional fees derived from newborn care, annual program deficits would have been $345,100, or $95,861 per staffed full-time equivalent. CONCLUSIONS: Community hospital pediatric hospitalist programs with dedicated 24-hour staffing and a low inpatient census can be expected to operate at a substantial financial deficit if hospitalist care is limited to inpatient care and procedures. Financial performance of these programs may be improved by expanding the role of the pediatric hospitalist to include newborn care.

Augmentation cystoplasty rates at children's hospitals in the United States: a pediatric health information system database study.

PURPOSE: We identified augmentation cystoplasty rates in children with spina bifida at children's hospitals enrolled in the Pediatric Health Information System database. MATERIALS AND METHODS: The Pediatric Health Information System database tabulates demographic and diagnostic patient data from 35 children's hospital centers in the United States. Between October 1999 and September 2004 we extracted data on 0 to 19-year-old patients with International Classification of Diseases-9 diagnosis codes for spina bifida. The International Classification of Diseases-9 procedure code for augmentation cystoplasty was cross-referenced with these patients to determine the total number of patients with augmentation, total population augmentation rates and individual institution rates of bladder augmentation. RESULTS: Staff at enrolled pediatric medical centers submitted inpatient data accounting for 9,059 beds servicing an aggregate metropolitan population of 82 million individuals. In the 5-year period 12,925 unique spina bifida patient encounters were identified, including 665 patients who underwent augmentation cystoplasty. The mean 5-year institutional number of augmentations performed in children with spina bifida was 20 (range 1 to 121) and the mean annual number of augmentations performed per institution was 4. The overall augmentation rate at 33 hospitals contributing data for the full years 2000 to 2003 was 5.4% (range 0.5% to 16.3%, p <0.0001). The male-to-female ratio of those who underwent augmentation was 1:1.2. Median length of stay in children with augmentation was 7 days (mean 9). The median age of children with augmentation was 10.4 years, that is 11.3 years in boys and 9.8 years in girls. The difference in mean age was statistically significant (p <0.003). At institutions where 10 or more augmentations were performed in 5 years (mean 27) mean patient age at operation was 10.1 years. This was significantly younger than the mean patient age of 12.3 years at hospitals where fewer than 10 augmentations (mean 5) were done in 5 years (p <0.05). CONCLUSIONS: Clinical management for neurogenic bladder conditions has evolved to emphasize nonoperative management. Several studies suggest that aggressive early intervention improves bladder compliance and may protect renal function. However, results from the Pediatric Health Information System database demonstrate no change in augmentation rates during this time and they demonstrate significant interinstitutional variability. To our knowledge this represents the largest series of augmentation cystoplasty in children with spina bifida to date.

The evolution of vesicoureteral reflux management in the era of dextranomer/hyaluronic acid copolymer: a pediatric health information system database study.

PURPOSE: Since Food and Drug Administration approval of Deflux, injection therapy for vesicoureteral reflux has increased. Little data exist on the effect that injection therapy has had on the incidence of ureteral reimplantation and total vesicoureteral reflux procedures. We used the Pediatric Health Information System database to define practice trends for vesicoureteral reflux therapy. MATERIALS AND METHODS: From 2002 to 2004 we extracted data on 0 to 19-year-old patients with International Classification of Diseases-9 diagnosis codes for vesicoureteral reflux, and procedure codes for ureteral reimplantation and subureteral injection therapy. Of 37 hospitals enrolled in Pediatric Health Information System 18 submitted ambulatory surgery and inpatient data. Data on the total number of patients who underwent reimplantation and injection were analyzed using linear regression analysis for trend. RESULTS: We identified a total of 4,570 procedures performed in 1,948 patients treated with injection therapy and in 2,483 treated with reimplantation. The mean number of injections per institution yearly increased from 17 to 66 from 2002 to 2004 or 288%, while the mean number of reimplantations yearly was not statistically different from 2002 to 2004 (p = 0.02 and 0.09, respectively). In addition, the annual mean number of vesicoureteral reflux procedures per institution increased from 75 to 116 or 55% (p <0.05), primarily due to the increased number of injections. CONCLUSIONS: With the introduction of a new, minimally invasive procedure for reflux therapy the number of procedures for reflux has increased, while open surgery rates have remained stable. This may be explained by public and clinician acceptance of a newer injection material that is safe and increasingly successful. To our knowledge this represents the largest series of patients treated for vesicoureteral reflux in the United States.

Variation in inpatient diagnostic testing and management of bronchiolitis.

OBJECTIVES: We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage. METHODS: We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children's hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001-September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group (<3 months and 3-11 months). RESULTS: A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40-3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants. CONCLUSIONS: Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated.