Hospitalization Outcomes for Rural Children with Mental Health Conditions.

OBJECTIVE: To identify where rural children with mental health conditions are hospitalized and to determine differences in outcomes based on location of hospitalization. STUDY DESIGN: This is a retrospective cohort analysis of US rural children aged 0-18 years with a mental health hospitalization between January 1, 2014, and November 30, 2014, using the 2014 Agency for Healthcare Research and Quality's Nationwide Readmissions Database. Hospitalizations for rural children were categorized by children's hospitals, metropolitan non-children's hospitals, or rural hospitals. Associations between hospital location and outcomes were assessed with logistic (readmission) and negative binomial regression (length of stay [LOS]) models. Classification and regression trees (CART) were used to describe the characteristics of most common hospitalizations at a rural hospital. RESULTS: Of 21 666 mental health hospitalizations of rural children, 20.6% were at rural hospitals. After adjustment for clinical and demographic characteristics, LOS was higher at metropolitan non-children's and children's hospitals compared with rural hospitals (LOS: adjusted rate ratio [aRR], 1.35 [95% CI 1.29-1.41] and 1.33 [95% CI, 1.25-1.41]; P < .01 for all). The 30-day readmission was lower at metropolitan non-children's and children's hospitals compared with rural hospitals (aOR, 0.73 [95% CI, 0.63-0.84] and 0.59 [95% CI, 0.48-0.71]; P < .001 for all). Adolescent males living in poverty with externalizing behavior disorder had the highest percentage of hospitalization at rural hospitals (69.4%). CONCLUSIONS: Although hospitalizations at children's and metropolitan non-children's hospitals were longer, patient outcomes were more favorable.

Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery.

BACKGROUND: Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. METHODS: A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. RESULTS: Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. CONCLUSIONS: The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.

Factors That Drive Annual Variation in Pediatric Elbow Fracture Occurrence, Severity, and Resource Utilization.

BACKGROUND: Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR). METHODS: Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization. RESULTS: Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures. CONCLUSION: Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Acute kidney injury risk-based screening in pediatric inpatients: a pragmatic randomized trial.

BACKGROUND: Pediatric acute kidney injury (AKI) is common and associated with increased morbidity, mortality, and length of stay. We performed a pragmatic randomized trial testing the hypothesis that AKI risk alerts increase AKI screening. METHODS: All intensive care and ward admissions of children aged 28 days through 21 years without chronic kidney disease from 12/6/2016 to 11/1/2017 were included. The intervention alert displayed if calculated AKI risk was > 50% and no serum creatinine (SCr) was ordered within 24 h. The primary outcome was SCr testing within 48 h of AKI risk > 50%. RESULTS: Among intensive care admissions, 973/1909 (51%) were randomized to the intervention. Among those at risk, more SCr tests were ordered for the intervention group than for controls (418/606, 69% vs. 361/597, 60%, p = 0.002). AKI incidence and severity were the same in intervention and control groups. Among ward admissions, 5492/10997 (50%) were randomized to the intervention, and there were no differences between groups in SCr testing, AKI incidence, or severity of AKI. CONCLUSIONS: Alerts based on real-time prediction of AKI risk increased screening rates in intensive care but not pediatric ward settings. Pragmatic clinical trials provide the opportunity to assess clinical decision support and potentially eliminate ineffective alerts.

Pericardial effusion following hematopoietic stem cell transplantation in children: Incidence, risk factors, and outcomes.

PCE is a complication of HSCT that has previously been described in small single-center studies. This study aimed to assess the frequency of, risk factors for, and outcomes of children with a PCE following HSCT across a large multi-center cohort. All patients ≤21 years undergoing first HSCT (1/2005-9/2015) were identified from the Pediatric Health Information System. ICD-9 codes were used to identify patients with a PCE during or following the transplant encounter. Multivariable modeling assessed risk factors for developing a PCE and assessed the impact of PCE on patient outcome. Of 10 455 included patients, 739 (7.1%) developed a PCE (median 69 days post-HSCT, interquartile range 33-165 days). PCE developed more commonly in allogeneic vs autologous HSCT recipients (9.1% vs 2.9%, P < .001). Among allogeneic HSCT recipients, independent risk factors for PCE included thrombotic microangiopathy (AHR 2.94, 95% CI 2.16-4.00), heart failure (AHR 2.07, 95% CI 1.61-2.66), PCE pre-HSCT (AHR 1.92, 95% CI 1.19-3.09), arrhythmia (AHR 1.76, 95% CI 1.44-2.16), graft-versus-host disease (AHR 1.31, 95% CI 1.05-1.62), female sex (AHR 1.28, 95% CI 1.07-1.52), and malignancy (AHR 1.28, 95% CI 1.02-1.60). Allogeneic HSCT patients with PCE demonstrated worse survival than those without PCE (5-year survival 50.8% vs 76.9%, P < .001). PCE was independently associated with mortality (AHR 1.96, 95% CI 1.62-2.37) following allogeneic HSCT and was not impacted by pericardial intervention. PCE occurs more commonly in patients following allogeneic (vs autologous) HSCT and is associated with inferior outcomes.

Timing and Causes of Common Pediatric Readmissions.

OBJECTIVE: To evaluate and compare readmission causes and timing within the first 30 days after hospitalization for 3 acute and 3 chronic common pediatric conditions. STUDY DESIGN: Data from the 2013 to 2014 Nationwide Readmissions Database were used to examine the daily percentage of readmissions occurring on days 1-30 and the leading causes of readmission after hospitalization for 3 acute (appendicitis, bronchiolitis/croup, and gastroenteritis) and 3 chronic (asthma, epilepsy, and sickle cell) conditions for patients aged 1-17 years (n = 2 753 488). Data were analyzed using Cox proportional hazards regression. RESULTS: The 30-day readmission rates ranged from 2.6% (SE, 0.1) after hospitalizations for appendectomy to 19.1% (SE, 0.5) after hospitalizations for sickle cell anemia. More than 50% of 30-day readmissions after acute conditions occurred within 15 days after discharge, whereas readmissions after chronic conditions occurred more uniformly throughout the 30 days after discharge. Higher numbers of patient comorbidities were associated with increased risk of readmission at days 1-7, 8-15, and 16-30 after discharge for all conditions examined. Most 30-day readmissions after chronic conditions were for the same diagnosis or closely related conditions as the index admission (67% for asthma, 65% for seizure disorder, and 82% for sickle cell anemia) in contrast with 50% or fewer readmissions after acute conditions (46% for appendectomy, 47% for bronchiolitis/croup, and 19% for gastroenteritis). CONCLUSIONS: The timing and causes of pediatric readmissions vary greatly across pediatric conditions. To be effective, strategies for reducing readmissions need to account for the index diagnosis to better target the highest risk period and causes for readmission.

Postacute Care after Pediatric Hospitalizations for a Primary Mental Health Condition.

OBJECTIVES: To determine the proportion of US children hospitalized for a primary mental health condition who are discharged to postacute care (PAC); whether PAC discharge is associated with demographic, clinical, and hospital characteristics; and whether PAC use varies by state. STUDY DESIGN: Retrospective cohort study of a nationally representative sample of US acute care hospitalizations for children ages 2-20 years with a primary mental health diagnosis, using the 2009 and 2012 Kids' Inpatient Databases. Discharge to PAC was used as a proxy for transfer to an inpatient mental health facility. We derived adjusted logistic regression models to assess the association of patient and hospital characteristics with discharge to PAC. RESULTS: In 2012, 14.7% of hospitalized children (n = 248 359) had a primary mental health diagnosis. Among these, 72% (n = 178 214) had bipolar disorder, depression, or psychosis, of whom 4.9% (n = 8696) were discharged to PAC. The strongest predictors of PAC discharge were homicidal ideation (aOR, 24.9; 96% CI, 4.1-150.4), suicide and self-injury (aOR, 15.1; 95% CI, 11.7-19.4), and substance abuse-related medical illness (aOR, 5.0; 95% CI, 4.5-5.6). PAC use varied widely by state, ranging from 2.2% to 36.3%. CONCLUSIONS: The majority of children hospitalized primarily for a mood disorder or psychosis were not discharged to PAC, and safety-related conditions were the primary drivers of the relatively few PAC discharges. There was substantial state-to-state variation. Target areas for quality improvement include improving access to PAC for children hospitalized for mood disorders or psychosis and equitable allocation of appropriate PAC resources across states.

Measuring the Value of a Clinical Practice Guideline for Children With Perforated Appendicitis.

OBJECTIVE: To determine the incremental cost-effectiveness of a clinical practice guideline (CPG) compared with "usual care" for treatment of perforated appendicitis in children. Secondary objective was to compare cost analyses using hospital accounting system data versus data in the Pediatric Health Information System (PHIS). BACKGROUND: Value-based surgical care (outcomes relative to costs) is frequently touted, but outcomes and costs are rarely measured together. METHODS: During an 18-month period, 122 children with perforated appendicitis at a tertiary referral children's hospital were treated using an evidence-based CPG. Clinical outcomes and costs for the CPG cohort were compared with patients in the 30-month period before CPG implementation (n = 191 children). RESULTS: With CPG-directed care, intra-abdominal abscess rate decreased from 0.24 to 0.10 (adjusted risk ratio 0.44, 95% confidence interval [CI] 0.26-0.75). The rate of any adverse event decreased from 0.30 to 0.23 (adjusted risk ratio 0.82, 95% CI 0.58-1.17). Mean total hospital costs per patient (hospital accounting system) decreased from $16,466 to $10,528 (adjusted absolute difference-$5451, 95% CI -$7755 to -$3147), leading to estimated adjusted total savings of $665,022 during the study period. Costs obtained from the PHIS database also showed reduction with CPG-directed care (-$6669, 95% CI -$8949 to -$4389 per patient). In Bayesian cost-effectiveness analyses, likelihood that CPG was the dominant strategy was 91%. CONCLUSIONS: An evidence-based CPG increased the value of surgical care for children with perforated appendicitis by improving outcomes and lowering costs. Hospital cost accounting data and pre-existing cost data within the PHIS database provided similar results.

Rates and impact of potentially preventable readmissions at children's hospitals.

OBJECTIVE: To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals. STUDY DESIGN: A total of 1 719 617 hospitalizations for 1 531 828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions. RESULTS: The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year). CONCLUSIONS: Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs.

Children's hospitals with shorter lengths of stay do not have higher readmission rates.

OBJECTIVE: To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates. STUDY DESIGN: Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression. RESULTS: Mean LOS was <3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all <5%. Condition-specific readmission rates for complex patients ranged from <1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10). CONCLUSION: In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.

Essential Concepts for Reducing Bias in Observational Studies.

Randomized controlled trials (RCTs) are the gold standard study design for clinical research, as prospective randomization, at least in theory, balances any differences that can exist between groups (including any differences not measured as part of the study) and isolates the studied treatment effect. Any remaining imbalances after randomization are attributable to chance. However, there are many barriers to conducting RCTs within pediatric populations, including lower disease prevalence, high costs, inadequate funding, and additional regulatory requirements. Researchers thus frequently use observational study designs to address many research questions. Observational studies, whether prospective or retrospective, do not involve randomization and thus have more potential for bias when compared with RCTs because of imbalances that can exist between comparison groups. If these imbalances are associated with both the exposure of interest and the outcome, then failure to account for these imbalances may result in a biased conclusion. Understanding and addressing differences in sociodemographic and/or clinical characteristics within observational studies are thus necessary to reduce bias. Within this Method/ology submission we describe techniques to minimize bias by controlling for important measurable covariates within observational studies and discuss the challenges and opportunities in addressing specific variables.

Positive Predictive Value of ICD-10 Codes to Identify Acute Suicidal and Self Harm Behaviors.

OBJECTIVE: The accuracy of diagnosis codes to identify suicidal behaviors, including suicide ideation (SI) and self-harm (SH) events, is unknown. The objective of this study was to determine the positive predictive value (PPV) of International Classification of Disease, 10th Revision codes to identify SI/SH events that may be used in studies using administrative and claims data. METHODS: We performed a secondary analysis of a cross-sectional study of children 5 to 17 years of age hospitalized at 2 US children's hospitals with a discharge diagnosis of a neuropsychiatric event, including an SI or SH event. A true International Classification of Disease, 10th Revision SI or SH diagnosis was defined as SI or SH present on admission and directly related to hospitalization as compared with physician record review. PPV with 95% confidence intervals (CIs) were calculated overall and stratified by diagnosis order and age (5 to 11 years vs 12 to 17 years). RESULTS: There were 376 children or adolescents with a discharge diagnosis of an SI or SH event. The median age was 14 years, and the majority of individuals were female (58%), non-Hispanic White (69%), and privately insured (57%). A total of 332 confirmed SI/SH cases were identified with a PPV of 0.88 (95% CI 0.85-0.91). PPVs were similar when stratified by diagnosis order: primary 0.94 (95% 0.88-0.97) versus secondary 0.86 (95% CI 81-90). PPVs were also similar in adolescents (0.89, CI 0.85-0.92) compared with children (0.84, 95% CI 0.74-0.91). CONCLUSIONS: The use of these validated code sets to identify SI or SH events may minimize misclassification in future studies of suicidal and self-harm hospitalizations.

Characteristics Associated With Serious Self-Harm Events in Children and Adolescents.

OBJECTIVES: To identify patterns of psychiatric comorbidity among children and adolescents with a serious self-harm event. METHODS: We studied children aged 5 to 18 years hospitalized with a neuropsychiatric event at 2 children's hospitals from April 2016 to March 2020. We used Bayesian profile regression to identify distinct clinical profiles of risk for self-harm events from 32 covariates: age, sex, and 30 mental health diagnostic groups. Odds ratios (ORs) and 95% credible intervals (CIs) were calculated compared with a reference profile with the overall baseline risk of the cohort. RESULTS: We included 1098 children hospitalized with a neuropsychiatric event (median age 14 years [interquartile range (IQR) 11-16]). Of these, 406 (37%) were diagnosed with a self-harm event. We identified 4 distinct profiles with varying risk for a self-harm diagnosis. The low-risk profile (median 0.035 [IQR 0.029-0.041]; OR 0.08, 95% CI 0.04-0.15) was composed primarily of children aged 5 to 9 years without a previous psychiatric diagnosis. The moderate-risk profile (median 0.30 [IQR 0.27-0.33]; reference profile) included psychiatric diagnoses without depressive disorders. Older female adolescents with a combination of anxiety, depression, substance, and trauma disorders characterized the high-risk profile (median 0.69 [IQR 0.67-0.70]; OR 5.09, 95% CI 3.11-8.38). Younger males with mood and developmental disorders represented the very high-risk profile (median 0.76 [IQR 0.73-0.79]; OR 7.21, 95% CI 3.69-15.20). CONCLUSIONS: We describe 4 separate profiles of psychiatric comorbidity that can help identify children at elevated risk for a self-harm event and subsequent opportunities for intervention.

A Pediatric Hospital Medicine Primer for Performing Research Using Administrative Data.

Provider- and claims-focused administrative databases are powerful tools for conducting health services research, and these studies often have good generalizability owing to diversity of hospitals from which samples are derived. In this research methods article, we describe administrative data and how available provider- and claims-focused administrative databases can be used to conduct health services research. We describe common observational study designs using administrative data and provide real-world examples. We highlight the strengths and weaknesses of studies conducted using administrative data and describe methodological considerations to reduce bias and improve the rigor of observational studies using administrative data. Finally, we provide guidance on the types of study questions suitable for observational study designs using administrative data.

Pediatric emergency department to primary care transfer protocol: Transforming access for patients' needs.

BACKGROUND: Previous interventions to reduce emergency department (ED) overutilization from non-urgent visits have shown little success. At our hospital, we created an ED to primary care clinic (PCC) transfer protocol for non-urgent ED visits of established patients. Our study analyzed the impact of this protocol on patient encounters. METHODS: Chart reviews were conducted for a retrospective cohort of transfers from the ED to PCC from 9/01/17-8/31/18. Primary outcomes included length of stay (LOS), cost, and need for return to the ED. Cost savings were calculated by comparing encounters with identical primary diagnoses in the ED with internal technical and professional financial data. Secondary outcomes were final diagnoses and primary care services provided. RESULTS: 374 patient encounters were transferred from ED to PCC. The five most common diagnoses were viral upper respiratory infection (n=80, 21.4%), dermatologic diagnoses (n=37, 9.9%), acute otitis media (n=35, 9.4%), pharyngitis (n=34, 9.1%), and influenza (n=34, 9.1%). Overall, total cost savings equaled approximately $100,000. For the top 10 diagnoses, costs were reduced from $29-$46 per $100 of ED costs and LOS was reduced by a mean of 49 min/encounter. For 9 of these 10 conditions, costs exceeded reimbursement in both settings; however, evaluation in PCC versus ED reduced the loss of revenue by 10-68%. Sixty-four encounters (17.1%) received additional primary care services. There were no safety events or inappropriate transfers. CONCLUSIONS: This protocol provided a safe, efficient method for patients to be evaluated in their medical home while reducing non-urgent emergency visits in the ED. LEVEL OF EVIDENCE: VI.

Financial Implications of Short Stay Pediatric Hospitalizations.

BACKGROUND: Observation status (OBS) stays incur similar costs to low-acuity, short-stay inpatient (IP) hospitalizations. Despite this, payment for OBS is likely less and may represent a financial liability for children's hospitals. Thus, we described the financial outcomes associated with OBS stays compared to similar IP stays by hospital and payer. METHODS: We conducted a retrospective cohort study of clinically similar pediatric OBS and IP encounters at 15 hospitals contributing to the revenue management program in 2017. Clinical and demographic characteristics were described. For each hospitalization, the cost coverage ratio (CCR) was calculated by dividing revenue by estimated cost of hospitalization. Differences in CCR were evaluated using Wilcoxon rank sum tests and results were stratified by billing designation and payer. CCR for OBS and IP stays were compared by institution, and the estimated increase in revenue by billing OBS stays as IP was calculated. RESULTS: OBS was assigned to 70 981 (56.9%) of 124 789 hospitalizations. Use of OBS varied across hospitals (8%-86%). For included hospitalizations, OBS stays were more likely than IP stays to result in financial loss (57.0% vs 35.7%). OBS stays paid by public payer had the lowest median CCR (0.6; interquartile range [IQR], 0.2-0.9). Paying OBS stays at the median IP rates would have increased revenue by $167 million across the 15 hospitals. CONCLUSIONS: OBS stays were significantly more likely to result in poor financial outcomes than similar IP stays. Costs of hospitalization and billing designations are poorly aligned and represent an opportunity for children's hospitals and payers to restructure payment models.

Identifying Acute Neuropsychiatric Events in Children and Adolescents.

OBJECTIVES: The objective of this study was to develop and validate an approach to accurately identify incident pediatric neuropsychiatric events (NPEs) requiring hospitalization by using administrative data. METHODS: We performed a cross-sectional, multicenter study of children 5 to 18 years of age hospitalized at two US children's hospitals with an NPE. We developed and evaluated 3 NPE identification algorithms: (1) primary or secondary NPE International Classification of Diseases, 10th Revision diagnosis alone, (2) NPE diagnosis, the NPE was present on admission, and the primary diagnosis was not malignancy- or surgery-related, and (3) identical to algorithm 2 but without requiring the NPE be present on admission. The positive predictive value (PPV) of each algorithm was calculated overall and by diagnosis field (primary or secondary), clinical significance, and NPE subtype. RESULTS: There were 1098 NPE hospitalizations included in the study. A total of 857 confirmed NPEs were identified for algorithm 1, yielding a PPV of 0.78 (95% confidence interval [CI] 0.76-0.80). Algorithm 2 (n = 846) had an overall PPV of 0.89 (95% CI 0.87-0.91). For algorithm 3 (n = 938), the overall PPV was 0.86 (95% CI 0.83-0.88). PPVs varied by diagnosis order, NPE clinical significance, and subtype. The PPV for critical clinical significance was 0.99 (0.97-0.99) for all 3 algorithms. CONCLUSIONS: We identified a highly accurate method to identify neuropsychiatric adverse events in children and adolescents. The use of these approaches will improve the rigor of future studies of NPE, including the necessary evaluations of medication adverse events, infections, and chronic conditions.

Variation in Condition-Specific Readmission Rates Across US Children's Hospitals.

OBJECTIVE: Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention. METHODS: Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals. RESULTS: The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities. CONCLUSIONS: Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates.