Temporal Trends of Respiratory Syncytial Virus-Associated Hospital and ICU Admissions Across the United States.

OBJECTIVES: To describe the regionality and seasonality of respiratory syncytial virus-associated hospital and ICU admissions for 10 consecutive years using a national database. DESIGN: Post hoc analysis of data from an existing national database, Pediatric Health Information System. We modeled the adjusted odds of hospital and ICU admissions for varied seasons (fall, winter, spring, and summer) and regions (Northeast, South, Midwest, and West) using a mixed-effects logistic regression model after adjusting for several patient and center characteristics. SETTING: Forty-two children's hospitals across the Unites States. PATIENTS: Patients 1 day through 24 months old with inpatient admission (ward and/or ICU) for respiratory syncytial virus- associated infection at a Pediatric Health Information System-participating hospital were included (2004-2013). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,937,994 inpatient admissions during the study period, 146,357 children were admitted for respiratory syncytial virus-associated acute respiratory illness. Of these inpatient admissions, 32,470 children(22%) were admitted to ICU during their hospital stay. Overall adjusted odds of respiratory syncytial virus-associated hospital and ICU admissions in recent years (2010-2013) were higher than previous years (2004-2006 and 2007-2009). In recent years, respiratory syncytial virus-associated hospital and ICU admissions have increased in winter and spring seasons. Regionally in recent years, the overall adjusted odds of both respiratory syncytial virus-associated hospital and ICU admissions have increased in the South and West regions. CONCLUSIONS: Wide variations in regional and seasonal patterns in hospital and ICU admissions were noted in children with respiratory syncytial virus-associated acute respiratory illness across the United States. Results from our study help us better understand the seasonality and regionality of respiratory syncytial virus infection in the United States with the goal to decrease the financial impact on our already stressed healthcare system by being better prepared for respiratory syncytial virus season.

Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival?

OBJECTIVE: To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004-2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes. SETTING: Forty-two children's hospitals across the United States. PATIENTS: Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074-48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased. CONCLUSIONS: This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.

Alternative repair strategies for ductal-dependent tetralogy of fallot and short-term postoperative outcomes, a multicenter analysis.

Our aim was to evaluate postoperative morbidity and mortality following initial intervention, comparing primary repair versus palliative shunt in the setting of ductal-dependent tetralogy of Fallot. When neonatal surgical intervention is required, controversy and cross-center variability exists with regard to surgical strategy. The multicenter Pediatric Health Information System database was queried to identify patients with TOF and ductal-dependent physiology, excluding pulmonary atresia. Eight hundred forty-five patients were included-349 (41.3%) underwent primary complete repair, while 496 (58.7%) underwent initial palliation. Palliated patients had significantly higher comorbid diagnoses of genetic syndrome and coronary artery anomalies. Primary complete repair patients had significantly increased morbidity across a number of variables compared to shunt palliation, but mortality rate was equal (6%). Second-stage complete repair was analyzed for 285 of palliated patients, with median inter-stage duration of 231 days (175-322 days). In comparison to primary complete repairs, second-stage repairs had significantly decreased morbidity and mortality. However, cumulative morbidity was higher for the staged patients. Median adjusted billed charges were lower for primary complete repair ($363,554) compared to staged repair ($428,109). For ductal-dependent TOF, there is no difference in postoperative mortality following the initial surgery (6%) whether management involves primary repair or palliative shunt. Although delaying complete repair by performing a palliative shunt is associated with a shift of much of the morbidity burden to outside of the newborn period, there is greater total postoperative morbidity and resource utilization associated with the staged approach.

Hospitalized Children With Encephalitis in the United States: A Pediatric Health Information System Database Study.

OBJECTIVES: Given the paucity of data on resource utilization among children with encephalitis, the objective of this study was to describe the epidemiology and evaluate resource utilization and discharge data of children with encephalitis admitted to US hospitals from 2004 to 2013. METHODS: We conducted a retrospective cohort study utilizing the Pediatric Health Information System database of children aged 0 to 18 years with the International Classification of Diseases, Ninth Revision codes for encephalitis from 2004 to 2013. Only the initial admissions were included, and the age group analyzed was 0 to 18 years. RESULTS: Among 7298 children with encephalitis, 2933 (40%) were admitted to a pediatric intensive care unit. The median age was nine years, the overall median length of stay was 16 days, and children requiring critical care had a median length of stay of 25 days. Children in the pediatric intensive care unit were more likely to have seizures (P <0.001) and head magnetic resonance imaging (P <0.001) than children on the floor. Similarly, children requiring critical care were more likely to have a broad diagnostic evaluation sent including cerebrospinal fluid cultures, blood bacterial and fungal cultures, western equine encephalitis antibody, St. Louis equine encephalitis antibody, varicella-zoster serology, human immunodeficiency virus 1 antibody, human immunodeficiency virus DNA polymerase chain reaction, acid-fast stain, and Lyme disease serology. Seventeen percent of children were treated with intravenous immunoglobulin, and 4% underwent plasmapheresis. There was a trend of increasing use of intravenous immunoglobulin and plasmapheresis in children with encephalitis over the study period. A total of 5944 (81%) children were discharged home, and the mortality in this cohort was 3% (230). The mean charges for hospitalization for a child with encephalitis was $64,604 and for those requiring critical care was $260,012. CONCLUSIONS: Encephalitis is a significant cause of morbidity and mortality in children. Children with encephalitis admitted to the pediatric intensive care unit are more likely to have seizures and to undergo a more extensive evaluation to determine the cause of encephalitis. Use of plasmapheresis and intravenous immunoglobulin is on the rise in hospitalized children. Prospective studies are necessary to better understand treatment and intervention strategies for children with encephalitis and their impact on outcomes.

Outcomes associated with preoperative use of extracorporeal membrane oxygenation in children undergoing heart operation for congenital heart disease: a multi-institutional analysis.

BACKGROUND: There are very sparse data on patient outcomes related to the use of extracorporeal membrane oxygenation (ECMO) prior to heart operation in children with congenital heart disease. This study was designed to evaluate this association using the Pediatric Health Information System (PHIS) database. HYPOTHESIS: We hypothesize that patients receiving ECMO prior to heart operation will have worse outcomes, including mortality, compared with patients receiving ECMO after heart operation. METHODS: Patients age ≤18 years receiving ECMO before or after pediatric heart operation (with or without cardiopulmonary bypass) at a PHIS-participating hospital from 2004 to 2013 were included. Multivariable logistic regression or Cox proportional-hazards models were fitted to study the effect of timing of ECMO initiation in relation to cardiac surgery on study outcomes. RESULTS: A total of 3498 patients from 42 hospitals qualified for inclusion. Of these, 494 (14%) received ECMO prior to heart operation (presurgery ECMO) and 3004 (86%) received ECMO after heart operation (postsurgery ECMO). Unadjusted mortality was significantly lower in the presurgery ECMO group compared with the postsurgery ECMO group (30% vs 45%; P < 0.0001). After adjusting for patient and center characteristics, odds of mortality were significantly lower in the presurgery ECMO group (odds ratio: 0.46, 95% confidence interval: 0.36-0.59, P < 0.0001). There were no significant differences in ECMO duration, length of hospital stay, and hospital charges between the 2 groups in adjusted models. CONCLUSIONS: This study suggests that ECMO can be used with satisfactory outcomes prior to heart operation in children with congenital heart disease.

Impact of preoperative location on outcomes in congenital heart surgery.

BACKGROUND: Little is known about the impact of preoperative location on outcomes in infants undergoing cardiac surgery for congenital heart disease. This study was designed to evaluate the morbidity and mortality among infants who were cared for in a neonatal ICU (NICU) versus dedicated cardiovascular intensive care unit (CVICU) prior to cardiac surgery in a multi-institutional population. METHODS: Data were obtained from a multicenter, administrative, national dataset, Pediatric Health Information System (PHIS). Patients 0 to 45 days undergoing surgery for congenital heart disease (with or without cardiopulmonary bypass) at a PHIS-participating hospital (2004 to 2013) were included. Propensity score matching was performed to match the NICU and the CVICU patients with similar demographic and preoperative clinical characteristics. RESULTS: A total of 5,376 patients from 20 hospitals met inclusion criteria. By propensity score matching, 2,456 patients matched 1 to 1 between the NICU and the CVICU groups. Outcomes including mortality (NICU vs CVICU, 11.9% vs 8.8%, p < 0.001), preoperative and total hospital length of stay (LOS), and total length of mechanical ventilation were significantly greater among the NICU patients compared with the CVICU patients. There was no significant difference in mortality among the patients undergoing "low" complexity operations (NICU vs CVICU, 8.4% vs 6.7%, p = 0.22), and patients undergoing treatment at high volume hospitals (NICU vs CVICU, 9.6% vs 9.5%, p = 0.95). CONCLUSIONS: This study demonstrates that preoperative location might impact outcomes in children undergoing operation for congenital heart disease. It is possible that preoperative location may be surrogate for other factors that may bias the results. Further study is warranted.