Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department.

OBJECTIVE: Evaluate a nurse-initiated quality improvement (QI) intervention aimed at enhancing asthma treatment in a pediatric emergency department (ED), utilizing outcomes and workflow. METHODS: We evaluated the impact of QI interventions for pediatric patients presenting to the ED with asthma with pre-post analysis. A pediatric asthma score (PAS) of >8 indicated moderate to severe asthma. This secondary analysis of the electronic health record (EHR), evaluated on 1) patient outcomes (time to clinical treatment, ED length of stay [EDLOS], admissions and discharges home), 2) clinical workflow. RESULTS: We compared 886 visits occurring between 01/01/2015 and 09/27/2015 (pre-implementation period) with 752 visits between 01/01/2016 and 09/27/2016 (post-implementation). Time to first documentation of PAS was decreased post-intervention (p<.001) by >30 min (75 ± 57 to 39 ± 54 min). There were significant decreases in time to treatment with both steroid and bronchodilator administration (both p<.001). EDLOS did not significantly change. Based on acuity level, those discharged home from the ED with high acuity (PAS score ≥8), had a significant decrease in time to initial PAS, steroid and bronchodilator use and EDLOS. Of those with high acuity who were admitted to the hospital, there was a difference pre- to post-implementation, in time to first PAS (p<.05), but not to treatment. Workflow visualization provided additional insights and detailed (task level) comparisons of the timing of ED activities. CONCLUSIONS: Nurse-initiated ED interventions, can significantly improve the timeliness of pediatric asthma evaluation and treatment. Examining workflow along with the outcomes, can better inform QI evaluations and clinical management.

Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma.

OBJECTIVES: To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept. STUDY DESIGN: This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18 years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range = 0-100) when there was statistical evidence that the percentages were different. RESULTS: Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P = .46). CONCLUSIONS: The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.

Analysis of medication patterns for pediatric asthma patients in emergency department: Does the sequence placement of glucocorticoids administration matter?

Objectives: Timely glucocorticoid administration is associated with decreased admission rate and is thus a common quality metric for ED asthma care; less is known about the impact of the timing of glucocorticoids in the context of the sequence of asthma medications administered. Therefore, we investigated the distribution of asthma medication sequences in one ED and analyzed the effect of the sequence placement of glucocorticoids administration on treatment outcomes.Methods: A retrospective study using five-year electronic health record data obtained from an academic urban children's hospital ED was conducted. We clustered the sequences of medication administration using an exact string-matching algorithm to identify the most frequently used asthma medication sequences. Then, we used the identified patterns to perform statistical tests to examine the effect of the sequence placement of glucocorticoids administration on the outcomes length-of-stay and ED disposition.Results: A total of 4,844 encounters were included in our study. The ten most common treatment sequences accounted for 43% of all encounters. Stratified analyses confirmed that treatment sequences pattern was correlated with patient severity, but ED crowding does not impact treatment sequences. In multivariable models, glucocorticoids administration earlier in the treatment sequence was associated with shorter length of stay and lower hospital admission rates.Conclusions: By analyzing medication sequence patterns for the ED encounter of pediatric asthma, we found that the earlier sequence placement of glucocorticoids administration is associated with improved outcomes. Our findings can help inform quality improvement and clinical guideline development related to ED asthma care for children.

Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma.

OBJECTIVES: Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS: This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS: Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS: Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.

Association between Postdischarge Oral Corticosteroid Prescription Fills and Readmission in Children with Asthma.

OBJECTIVES: To assess the relationships between postdischarge emergency department visits, oral corticosteroid (OCS) use, and 15- to 90-day asthma readmission in children. STUDY DESIGN: Retrospective study of 9288 children from 12 states in the Truven MarketScan Database, ages 2-18 years, hospitalized between January 1, 2009, and June 30, 2011, with asthma, and continuously enrolled in Medicaid for 6 months prior and 3 months after hospitalization. The primary outcome was 15- to 90-day readmission for asthma. Secondary outcomes were postdischarge emergency department visits (within 28 days) and outpatient OCS prescription fills (6-28 days postdischarge or earlier if coinciding with an outpatient asthma visit). Logistic regression was used to assess the relationship of hospital readmission with patient characteristics and asthma health services surrounding the index admission. RESULTS: Median age at index admission was 6 years (IQR, 3-9); 62% were male and 49% were black; 2.8% had a 15- to 90-day readmission (median, 50 days; IQR, 32-70). After index discharge, 4% had an emergency department visit (median, 17 days; IQR, 12-24) and 11% had an outpatient OCS fill (median, 14 days; IQR, 6-21). In multivariable analysis, children with a postdischarge outpatient OCS fill (OR, 3.2; 95% CI, 2.4-4.6) or hospitalization within 6 months preceding the index admission (OR, 2.9; 95% CI, 2.0-4.0) had the greatest likelihood for hospital readmission. CONCLUSIONS: OCS fill within 28 days of hospital discharge was most strongly associated with 15- to 90-day hospital readmission. This finding may inform evolving strategies to reduce asthma readmissions in children.

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

OBJECTIVES: To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models. STUDY DESIGN: We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy. RESULTS: For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals. CONCLUSIONS: We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.

ICD Social Codes: An Underutilized Resource for Tracking Social Needs.

BACKGROUND: Social determinants of health (SDH) data collected in health care settings could have important applications for clinical decision-making, population health strategies, and the design of performance-based incentives and penalties. One source for cataloging SDH data is the International Statistical Classification of Diseases and Related Health Problems (ICD). OBJECTIVE: To explore how SDH are captured with ICD Ninth revision SDH V codes in a national inpatient discharge database. MATERIALS AND METHODS: Data come from the 2013 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, a national stratified sample of discharges from 4363 hospitals from 44 US states. We estimate the rate of ICD-9 SDH V code utilization overall and by patient demographics and payer categories. We additionally estimate the rate of SDH V code utilization for: (a) the 5 most common reasons for hospitalization; and (b) the 5 conditions with the highest rates of SDH V code utilization. RESULTS: Fewer than 2% of overall discharges in the National Inpatient Sample were assigned an SDH V code. There were statistically significant differences in the rate of overall SDH V code utilization by age categories, race/ethnicity, sex, and payer (all P<0.001). Nevertheless, SDH V codes were assigned to <7% of discharges in any demographic or payer subgroup. SDH V code utilization was highest for major diagnostic categories related to mental health and alcohol/substance use-related discharges. CONCLUSIONS: SDH V codes are infrequently utilized in inpatient settings for discharges other than those related to mental health and alcohol/substance use. Utilization incentives will likely need to be developed to realize the potential benefits of cataloging SDH information.

Intranasal Fentanyl and Quality of Pediatric Acute Care.

BACKGROUND: Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting. OBJECTIVE: The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia. METHODS: This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of < 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes. RESULTS: During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p < 0.05) and shorter ED length of stay (168 vs. 267 min; p < 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes. CONCLUSIONS: INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury.

OBJECTIVE: To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN: Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS: There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS: Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Outpatient follow-up visits and readmission in medically complex children enrolled in Medicaid.

OBJECTIVE: To examine the association between postdischarge outpatient follow-up and 30-day readmissions in Medicaid enrolled children with complex, chronic conditions. STUDY DESIGN: This was a retrospective cohort analysis of Colorado Medicaid recipients with complex, chronic conditions who were discharged from the hospital between 2006 and 2008. The primary outcome was readmission between 4 and 30 days after index hospital discharge. Using multivariable logistic regression, we examined the association between early postdischarge outpatient visits (≤ 3 days postdischarge) and readmission. We secondarily analyzed the relationship between any outpatient visit from 4 to 29 days of index discharge and readmission. RESULTS: For the 2415 patients with complex, chronic conditions included in the analysis, the 4- to 30-day readmission rate was 6.3%. The odds of readmission was significantly greater for patients with ≥ 1 outpatient visit ≤ 3 days after discharge compared with patients without a visit ≤ 3 days after discharge (aOR 1.7 [1.1-2.4]). The odds of readmission were significantly lower for patients with ≥ 1 outpatient visit from 4 to 29 days after discharge compared with patients without such visits (aOR 0.5 [0.3-0.7]). Other factors associated with readmission included index hospital length of stay and number of complex, chronic conditions. CONCLUSIONS: In medically complex children, there is a positive association between early postdischarge outpatient follow-up and readmission. There is an inverse association between later postdischarge outpatient follow-up and readmission. Outpatient follow-up occurring within 4-29 days after discharge may help to prevent 30-day readmissions. Additional research is needed to inform guidelines regarding longer term postdischarge outpatient follow-up in these children.

A framework for describing health care delivery organizations and systems.

Describing, evaluating, and conducting research on the questions raised by comparative effectiveness research and characterizing care delivery organizations of all kinds, from independent individual provider units to large integrated health systems, has become imperative. Recognizing this challenge, the Delivery Systems Committee, a subgroup of the Agency for Healthcare Research and Quality's Effective Health Care Stakeholders Group, which represents a wide diversity of perspectives on health care, created a draft framework with domains and elements that may be useful in characterizing various sizes and types of care delivery organizations and may contribute to key outcomes of interest. The framework may serve as the door to further studies in areas in which clear definitions and descriptions are lacking.

Racial and ethnic disparities in diagnostic imaging for child physical abuse.

IMPORTANCE: Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES: To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN: In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING: The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS: We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES: For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS: In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE: We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.

Post-Acute Cardiovascular Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Project.

Background: The risk of cardiovascular outcomes in the post-acute phase of SARS-CoV-2 infection has been quantified among adults and children. This paper aimed to assess a multitude of cardiac signs, symptoms, and conditions, as well as focused on patients with and without congenital heart defects (CHDs), to provide a more comprehensive assessment of the post-acute cardiovascular outcomes among children and adolescents after COVID-19. Methods: This retrospective cohort study used data from the RECOVER consortium comprising 19 US children's hospitals and health institutions between March 2020 and September 2023. Every participant had at least a six-month follow-up after cohort entry. Absolute risks of incident post-acute COVID-19 sequelae were reported. Relative risks (RRs) were calculated by contrasting COVID-19-positive with COVID-19-negative groups using a Poisson regression model, adjusting for demographic, clinical, and healthcare utilization factors through propensity scoring stratification. Results: A total of 1,213,322 individuals under 21 years old (mean[SD] age, 7.75[6.11] years; 623,806 male [51.4%]) were included. The absolute rate of any post-acute cardiovascular outcome in this study was 2.32% in COVID-19 positive and 1.38% in negative groups. Patients with CHD post-SARS-CoV-2 infection showed increased risks of any cardiovascular outcome (RR, 1.63; 95% confidence interval (CI), 1.47-1.80), including increased risks of 11 of 18 post-acute sequelae in hypertension, arrhythmias (atrial fibrillation and ventricular arrhythmias), myocarditis, other cardiac disorders (heart failure, cardiomyopathy, and cardiac arrest), thrombotic disorders (thrombophlebitis and thromboembolism), and cardiovascular-related symptoms (chest pain and palpitations). Those without CHDs also experienced heightened cardiovascular risks after SARS-CoV-2 infection (RR, 1.63; 95% CI, 1.57-1.69), covering 14 of 18 conditions in hypertension, arrhythmias (ventricular arrhythmias and premature atrial or ventricular contractions), inflammatory heart disease (pericarditis and myocarditis), other cardiac disorders (heart failure, cardiomyopathy, cardiac arrest, and cardiogenic shock), thrombotic disorders (pulmonary embolism and thromboembolism), and cardiovascular-related symptoms (chest pain, palpitations, and syncope). Conclusions: Both children with and without CHDs showed increased risks for a variety of cardiovascular outcomes after SARS-CoV-2 infection, underscoring the need for targeted monitoring and management in the post-acute phase.

Pediatric Gastrointestinal Outcomes During the Post-Acute Phase of COVID-19: Findings from RECOVER Initiative from 29 Hospitals in the US.

Importance: The profile of gastrointestinal (GI) outcomes that may affect children in post-acute and chronic phases of COVID-19 remains unclear. Objective: To investigate the risks of GI symptoms and disorders during the post-acute phase (28 days to 179 days after SARS-CoV-2 infection) and the chronic phase (180 days to 729 days after SARS-CoV-2 infection) in the pediatric population. Design: We used a retrospective cohort design from March 2020 to Sept 2023. Setting: twenty-nine healthcare institutions. Participants: A total of 413,455 patients aged not above 18 with SARS-CoV-2 infection and 1,163,478 patients without SARS-CoV-2 infection. Exposures: Documented SARS-CoV-2 infection, including positive polymerase chain reaction (PCR), serology, or antigen tests for SARS-CoV-2, or diagnoses of COVID-19 and COVID-related conditions. Main Outcomes and Measures: Prespecified GI symptoms and disorders during two intervals: post-acute phase and chronic phase following the documented SARS-CoV-2 infection. The adjusted risk ratio (aRR) was determined using a stratified Poisson regression model, with strata computed based on the propensity score. Results: Our cohort comprised 1,576,933 patients, with females representing 48.0% of the sample. The analysis revealed that children with SARS-CoV-2 infection had an increased risk of developing at least one GI symptom or disorder in both the post-acute (8.64% vs. 6.85%; aRR 1.25, 95% CI 1.24-1.27) and chronic phases (12.60% vs. 9.47%; aRR 1.28, 95% CI 1.26-1.30) compared to uninfected peers. Specifically, the risk of abdominal pain was higher in COVID-19 positive patients during the post-acute phase (2.54% vs. 2.06%; aRR 1.14, 95% CI 1.11-1.17) and chronic phase (4.57% vs. 3.40%; aRR 1.24, 95% CI 1.22-1.27). Conclusions and Relevance: In the post-acute phase or chronic phase of COVID-19, the risk of GI symptoms and disorders was increased for COVID-positive patients in the pediatric population. Key Points: Question: Does COVID-19 increase the risk of gastrointestinal (GI) symptoms and diseases during the post-acute phase in children and adolescents?Findings: Newly diagnosed GI symptoms and disorders such as diarrhea, constipation, and vomiting are seen more commonly in children and adolescents with SARS-CoV-2 infection.Meaning: Clinicians need to be mindful that after SARS-CoV-2 infection in children, lingering GI symptoms without a unifying diagnosis may be more common than among uninfected children.

Vaccine Effectiveness Against Long COVID in Children.

OBJECTIVES: Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years. METHODS: This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination. RESULTS: The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months. CONCLUSIONS: This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data.

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.

Epidemiology of hyperglycemic hyperosmolar syndrome in children hospitalized in USA.

BACKGROUND: Previous studies of hyperglycemic hyperosmolar syndrome (HHS) in children are limited to case series or single-institution reviews, which describe HHS primarily in children with type 2 diabetes mellitus. OBJECTIVE: To estimate the incidence and describe the epidemiologic characteristics of HHS among children in USA. SUBJECTS: All discharges in the Kids' Inpatient Database - a triennial, nationwide, stratified probability sample of hospital discharges for years 1997-2009 - with age 0-18 yr and a diagnosis of HHS. METHODS: Using sample weights, we calculated the incidence and population rate of hospitalization with a diagnosis of HHS. RESULTS: Our sample included 1074 HHS hospitalizations; of these, 42.9% were 16-18 yr, 70.6% had type 1 diabetes (T1D), and 53.0% had major or extreme severity of illness. The median length of stay was 2.6 d, 2.7% of hospitalizations ended in death, and median hospital charge was $10 882. When comparing HHS hospitalizations by diabetes type, the proportion with T1D fell steadily with age, from 89.1% among children 0-9 yr, to 65.1% in 16-18 yr olds. Patients with T1D had a shorter length of stay by 0.9 d, and had a lower median charge by $5311. There was no difference in mortality by diabetes type. Population rates for HHS hospitalization rose 52.4% from 2.1 to 3.2 per 1 000 000 children from 1997 to 2009. CONCLUSION: Hospitalizations for a diagnosis of HHS have high morbidity and are increasing in incidence since 1997. In contrast to prior reports, we found a substantial percentage of HHS hospitalizations occurred among children with T1D.

Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older.

PURPOSE: Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups. BASIC PROCEDURES: Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older. MAIN FINDINGS: The primary analysis included 33906 subjects (101837 weighted) 10 years and older. The secondary analysis included 13393 subjects (37983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years. CONCLUSIONS: This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.

Child Opportunity Index and Rehospitalization for Ambulatory Care Sensitive Conditions at US Children's Hospitals.

OBJECTIVE: Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations. METHODS: Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions. RESULTS: The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75]). CONCLUSIONS: Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations.