Exploring home fall events among infants and toddlers using social media information: an infodemiology study in China.

BACKGROUND: Practical interventions of fall prevention are challenging for infants and toddlers. This study aimed to explore specific details of falls that occurred at home for kids 0-3 years old using key information from social media platforms, which provided abundant data sources for fall events. METHODS: We used internet-based search techniques to collect fall events information from 2013 to 2023. The search was restricted and implemented between 1 and 12 April 2023. Online platforms included Baidu, Weibo, WeChat, TikTok, Toutiao and Little Red Book. A qualitative descriptive approach was used to analyse the fall events and major factors, including the fall event time, child age, environmental factors and behavioural characteristics of children and caregivers. RESULTS: We identified 1005 fall injury cases among infants and toddlers. Fall mechanisms included falls from household furniture (71.2%), falls from height (21.4%) and falls on the same level (7.4%). Environmental risk factors mainly consisted of not using or installing bed rails incorrectly, a gap between beds, unstable furniture, slippery ground and windows without guardrails. Behavioural factors included caregivers leaving a child alone, lapsed attention, turning around to retrieve something, misusing baby products, inadequately holding the child and falling asleep with children. Child behavioural factors included walking or running while holding an object in hand or mouth and underdeveloped walking skills. CONCLUSION: Interventions for preventing falls should be designed specifically for Chinese families, especially considering family function in the context of Chinese culture. Social media reports could provide rich information for researchers.

U.S. Leading Causes of Death and Years of Potential Life Lost, 1981-2019: Implications for Surgical Research.

INTRODUCTION: Examining burden of diseases could shed light on priorities of public health interventions and research funding. This study examined trends of the U.S. top leading causes of death from 1981 to 2019 using the total number of deaths, age-adjusted death rate, and years of potential life lost (YPLLs). METHODS: Data were from the Web-based Injury Statistics Query and Reporting System. This study gathered total number of deaths, age-adjusted death rates per 100,000 people, and YPLLs under 70 y of age (YPLL-70) from 1981 to 2019 for the top 10 leading causes of death and human immunodeficiency virus/acquired immunodeficiency syndrome (AIDS) for each year. The 39 y from 1981 to 2019 were evenly divided into three study periods: 1981-1993, 1994-2006, and 2007-2019. The percent change of YPLL-70 over three time periods for the top ten leading causes of death and AIDS was calculated. Trends of age-adjusted death rates and YPLL-70 of the top five leading causes of death based on the 2018-2019 death data were also reported by graphing them against time from 1981 to 2019 to highlight major mortality causes. Age-adjusted death rates for the top five leading causes of deaths and the National Institutes of Health (NIH) annual funding level in 2019 were graphed together to illustrate funding discrepancy in injury research and prevention. RESULTS: The total number of deaths caused by malignant neoplasms in 2019 was 244,994, followed by 183,442 deaths of heart diseases, 121,476 deaths of unintentional injuries, and 41,051 suicide deaths. Despite an initial -22.20% drop of YPPL-70 during 1981-1993, unintentional injuries experienced significant increases of 19.38% and 18.59% of YPLL-70 in 1994-2006 and 2007-2019, respectively. The age-adjusted death rate for unintentional injuries was 1182 per 100,000 people in 2019, and the NIH funding in the same year was $897 million. In comparison, the age-adjusted death rate for cancer, heart disease, and human immunodeficiency virus/AIDS was 786, 649, and 30 per 100,000 people while the NIH funding was $2,560, $2,394, and $3037 million, respectively. CONCLUSIONS: Unintentional injuries, suicide, and homicide were consistently among the top leading causes of death and YPLL-70, so they should be prioritized in public health planning, research, and federal funding allocation. Injury and trauma research is severely underfunded by the U.S. premier funding agency.

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients.

BACKGROUND: Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. METHODS: Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. RESULTS: Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. CONCLUSIONS: In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

A Population-Based Study of the Incidence, Medical Care, and Medical Expenditures for Pediatric Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is one of the leading causes of pediatric trauma morbidity and mortality around the world. However, limited research exists regarding disparities in the incidence of TBI and medical care seeking behaviors and medical expenditures for TBI, particularly using population-based and nationally-representative data. MATERIALS AND METHODS: The present study used the Medical Expenditure Panel Survey (MEPS) Panels 9-19 (2004-2015) to provide nationally-representative estimates for the civilian, non-institutionalized U.S. POPULATION: We examined differences in TBI incidence and associated medical care seeking behaviors and expenditures in relation to individual and family sociodemographic characteristics. RESULTS: From a total of 50,563 children in the MEPS Panels 9-19, we identified 449 children with TBI. For 82% of these children, medical treatment was sought. The estimated annual total expenditure associated with pediatric TBIs nationally was approximately $667 million, with mean expenditures per TBI being $1,532 and family out of pocket expenditures accounting for 8.3% of total expenditures. Race/ethnicity was the only significant factor associated with both medical care seeking behavior and total expenditures. CONCLUSIONS: The present study is among the first to compare pediatric TBI-related medical expenditures among different sociodemographic groups in the U.S. Our findings can inform future intervention research and policy-making from the perspectives of both epidemiological and behavioral sciences.

The association between traumatic dental and brain injuries in American children.

BACKGROUND/AIM: It is crucial that dentists who treat traumatic dental injuries rule out concomitant brain injuries. Despite anatomic proximity, controversy exists regarding association between facial trauma and head injury. The aim of this study was to examine the association between dento-alveolar trauma (DAT) and traumatic brain injuries (TBI) using a national dataset of emergency department (ED) visits. MATERIAL AND METHODS: Nationwide Emergency Department Sample (NEDS) data, one of the Healthcare Cost and Utilization Project (HCUP) datasets, were analyzed. Encounters of patients age 0-18 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with DAT and TBI in the 2010-2014 NEDS were identified. Data were analyzed using descriptive statistics, chi-square test, and logistic regression models to investigate the association between DAT and TBI and factors associated with TBI in DAT-positive patients. RESULTS: During the study period, 6 281 658 ED visits were associated with traumatic injuries. DAT was recorded in 93 408 (1.5%) and TBI was recorded in 996 334 (15.9%) of these traumatic injury visits. Within the group of DAT-positive encounters, 7035 (7.5%) had codes associated with TBI. Of trauma encounters where a DAT was not involved (6 188 250 encounters), 989 299 (16%) had an associated TBI code. Patients with DAT had 0.20 odds of having TBI (95% CI, 0.19-0.20, P < .0001) compared with patients who did not have DAT when all other confounding variables were kept constant. Having multiple injuries, being involved in motor vehicle crashes, and injuries due to assault were associated with higher odds of concomitant TBI in patients who sustained DAT. CONCLUSIONS: There was an inverse association between DAT and TBI in this study population.

Comparison of manual and computer assigned injury severity scores.

BACKGROUND: The study objective was to compare the ISS manually assigned by hospital personnel and those generated by the ICDPIC software for value agreement and predictive power of length of stay (LOS) and mortality. METHODS: We used data from the 2010-2016 trauma registry of a paediatric trauma centre (PTC) and 2014 National Trauma Data Bank (NTDB) hospitals that reported manually coded ISS. Agreement analysis was performed between manually and computer assigned ISS with severity groupings of 1-8, 9-15, 16-25 and 25-75. The prediction of LOS was compared using coefficients of determination (R2) from linear regression models. Mortality predictive power was compared using receiver operating characteristic (ROC) curves from logistic regression models. RESULTS: The proportion of agreement between manually and computer assigned ISS in PTC data was 0.84 and for NTDB was 0.75. Analysing predictive power for LOS in the PTC sample, the R2=0.19 for manually assigned scores, and the R2=0.15 for computer assigned scores (p=0.0009). The areas under the ROC curve indicated a mortality predictive power of 0.95 for manually assigned scores and 0.86 for computer assigned scores in the PTC data (p=0.0011). CONCLUSIONS: Manually and computer assigned ISS had strong comparative agreement for minor injuries but did not correlate well for critical injuries (ISS=25-75). The LOS and mortality predictive power were significantly higher for manually assigned ISS when compared with computer assigned ISS in both PTC and NTDB data sets. Thus, hospitals should be cautious about transitioning to computer assigned ISS, specifically for patients who are critically injured.

Radiographic timelines for pediatric healing fractures: a systematic review.

Skeletal fractures, a common injury in physically abused children, often go undetected and untreated for significant lengths of time and are sometimes incidentally discovered radiographically. Our objective was to review current literature for scientific studies of pediatric fracture healing with associated timelines. We conducted a search of Embase, EBSCOhost, MEDLINE (PubMed), and Web of Science for literature published from the earliest available up to August 2018. We evaluated the included articles for quality, with consideration for use in clinical and forensic settings. Of a total of 313 full-text articles evaluated, 10 met study inclusion criteria. The patient age range among studies was 0-17 years, with children younger than 1 year included in the majority of studies. The fracture locations included in studies were primarily fractures of the upper limb and pectoral girdle, followed by fractures of the lower limb. The radiographic features of healing varied greatly among the studies. Timelines of common fracture healing variables differed significantly among studies. Scientific, radiographic studies of pediatric fracture healing are limited. Gaps in knowledge regarding fracture healing highlight the need for future research and validation studies. Fracture healing timelines derived from existing timelines should be used with caution.

Perceived health after adult traumatic brain injury: a Group-Based Trajectory Modeling (GBTM) analysis.

OBJECTIVE: To provide nationally representative estimates of adults with traumatic brain injury (TBI) and identify clusters of individuals with TBI who follow similar perceived health trajectories using group-based trajectory modeling. PARTICIPANTS: Adults (≥18 years old) from panels 9-19 (2004-2015) of the Medical Expenditure Panel Survey (MEPS) who experienced a TBI (n = 949). DESIGN: Data from MEPS, a nationally representative database of noninstitutionalized individuals in the USA, were used to 1) produce a national annual estimate of adults with TBI and 2) identify subgroups of patients with TBI who followed different general and mental health trajectories. MAIN MEASURES: Perceived general health (PGH), perceived mental health (PMH). RESULTS: On average, 502 adults per 100,000 noninstitutionalized US adults experienced a TBI annually, and about one million adults are living with a TBI. Three distinct trajectory groups were identified in models of both perceived general health (PGH) and perceived mental health (PMH). TBI type, sex, and persistent disability predicted assignment to a group in the PGH model. TBI type, sex, age, insurance status, family poverty status, and persistent disability predicted assignment to a PMH trajectory. CONCLUSION: Referrals and early-intervention resources should be distributed to individuals with increased risk of following low PGH and/or PMH trajectories.

The impact of driving time on pediatric TBI follow-up visit attendance.

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

Impact of a Dedicated Advanced Practice Provider Model for Pediatric Trauma and Burn Patients.

BACKGROUND: A free-standing, academic Level 1 pediatric trauma and verified pediatric burn center created a dedicated trauma and burn service advanced practice provider role, and restructured rounds. The changes were implemented to improve patient care. METHODS: A pre and postintervention study using historical controls was performed to compare 18 months prior (preintervention) and 18 months following (postintervention) practice changes. Data collection included demographics, injury characteristics, length of stay (LOS), complications, and patient satisfaction results. RESULTS: When compared with the preintervention period, the postintervention period had a higher patient volume and an increased number of severely injured patients. Mean LOS was stable for all patients and trauma patients, as were the complication rates related to trauma and burns. However, the mean LOS/total body surface area (TBSA) burned decreased from 1.36 to 1.04 days/TBSA (p = .160) in burn patients and from 0.84 to 0.62 days/TBSA (p = .060) in those with more than 5% TBSA. Patient satisfaction scores were stable in the categories of nursing care and the child's physician. Despite an increase in the volume and severity of patients, there was a clinically meaningful decrease in burn patient LOS/TBSA. CONCLUSION: The addition of a dedicated advanced practice provider and restructured trauma service appears to provide a benefit to pediatric burn patients.

Deliberate self-harm among children with disabilities in China: a matched case-control study.

BACKGROUND: Study about deliberate self-harm (DSH) in children with different types of disabilities was scarce. This study compared the incidence and patterns of DSH between children with and without disabilities aged 6-17 years using a matched case-control study in Beijing. METHODS: A total of 650 pairs of children with and without disabilities were surveyed. Characteristics of latest episode of self-harm within the 12 months were compared. Associations between disability status, sociodemographic factors, smoking, drinking, sleep problems, and self-harm were examined. RESULTS: Children with disabilities showed significant higher incidence of DSH than children without disabilities. Two groups differed significantly in terms of self-harm methods, body parts injured, premeditation, wishing to be known by others and help-seeking behavior. The adjusted OR for self-harm was 4.76 (2.99-7.55) for children with disabilities compared with children without disabilities. Children who slept fewer than 6 h per night, had difficulty falling asleep at night sometimes/often, and went to sleep after midnight 1 to 3 nights per month or at least once a week were at elevated risk of self-harm. CONCLUSION: This study highlights a strong relationship between disability, sleep problems, and DSH. Interventions to reduce self-harm should target disability and sleep problems as important risk factors.

Alcohol and drug screening of adolescent trauma alert patients at a level 1 pediatric trauma center.

BACKGROUND: Adolescent trauma patients are reported to have increased incidence of alcohol and other drug (AOD) use, but previous studies have included inadequate screening of the intended populations. A Level 1 Pediatric Trauma Center achieved a 94% rate of AOD screening. We hypothesized that a positive AOD screening result is associated with males, increasing age, lower socioeconomic status, violent injury mechanism, higher Injury Severity Score (ISS), lower GCS, need for operation and increased hospital length of stay. METHODS: After achieving high rates of screening among admitted trauma alert patients 12-17 years old, we evaluated patients presenting during 2014-2015. Chi-square tests were used to compare the percentage of patients with positive test results across sociodemographic, injury severity measures and patient outcomes. RESULTS: Three hundred and one patients met criteria for AOD screening during the study period. Ninety-four percent of these patients received screening and 18% were positive. Males (21.4%) were more often positive than females (11.6%). Increasing age was directly correlated with AOD use. Race was associated with a positive screen. Black patients more often had positive screens (40.9%), as compared with White patients (13.8%) and other races (23.5%). Patients with commercial insurance (6.6%) were less likely to be positive than those with no insurance (19.0%) or Medicaid (30.9%). Lower median household income was associated with positive AOD screening. Patients with violent injury mechanisms were more likely to screen positive (36.2%) than those with non-violent mechanisms (18.0%). No statistical differences were found with injury severity scores, the need for operation, or hospital length of stay. CONCLUSIONS: With near universal screening of adolescent trauma alert admissions, positive AOD results were more often found with males, increasing age, lower socioeconomic status, and violent injury mechanism. LEVEL OF EVIDENCE: Level III, Retrospective comparative study without negative criteria. STUDY TYPE: Prognostic.

Attending Follow-up Appointments After Pediatric Traumatic Brain Injury: Caregiver-Perceived Barriers and Facilitators.

OBJECTIVE: To examine barriers and facilitators for follow-up care of children with traumatic brain injury (TBI). SETTING: Urban children's hospital. PARTICIPANTS: Caregivers of children (aged 2-18 years) discharged from an inpatient unit with a TBI diagnosis in 2014-2015. DESIGN: Survey of caregivers. MAIN MEASURES: Caregiver-reported barriers and facilitators to follow-up appointment attendance. RESULTS: The sample included 159 caregivers who completed the survey. The top 3 barriers were "no need" (38.5%), "schedule conflicts" (14.1%), and "lack of resources" (10.3%). The top 5 identified facilitators were "good hospital experience" (68.6%), "need" (37.8%), "sufficient resources" (35.8%), "well-coordinated appointments" (31.1%), and "provision of counseling and support" (27.6%). Caregivers with higher income were more likely to report "no need" as a barrier; females were less likely to do so. Nonwhite caregivers and those without private insurance were more likely to report "lack of resources" as a barrier. Females were more likely to report "good hospital experience" and "provision of counseling and support" as a facilitator. Nonwhite caregivers were more likely to report "need" but less likely to report "sufficient resources" as facilitators. CONCLUSIONS: Care coordination, assistance with resources, and improvements in communication and the hospital experience are ways that adherence might be enhanced.

Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults.

BACKGROUND: Racial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. MATERIALS AND METHODS: We used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. RESULTS: In the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. CONCLUSIONS: Medicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.

Featured Article: Evaluating Smartphone-Based Virtual Reality to Improve Chinese Schoolchildren's Pedestrian Safety: A Nonrandomized Trial.

Objective: This nonrandomized trial evaluated whether classroom-based training in a smartphone-based virtual reality (VR) pedestrian environment (a) teaches schoolchildren to cross streets safely, and (b) increases their self-efficacy for street-crossing. Methods: Fifty-six children, aged 8-10 years, attending primary school in Changsha, China participated. Baseline pedestrian safety assessment occurred in the VR environment and through unobtrusive observation of a subsample crossing a street for 11 days outside school. Self-efficacy was assessed through both self-report and observation. Following baseline, children engaged in the VR for 12 days in their classrooms, honing complex cognitive-perceptual skills required to engage safely in traffic. Follow-up assessment replicated baseline. Results: Probability of crash in the VR decreased posttraining (0.40 vs. 0.09), and observational data found the odds of looking at oncoming traffic while crossing the first lane of traffic increased (odds ratio [OR] = 2.4). Self-efficacy increases occurred in self-report (proportional OR = 4.7 crossing busy streets) and observation of following crossing-guard signals (OR = 0.2, first lane). Conclusions: Pedestrian safety training via smartphone-based VR provides children the repeated practice needed to learn the complex skills required to cross streets safely, and also helps them improve self-efficacy to cross streets. Given rapid motorization and global smartphone penetration, plus epidemiological findings that about 75,000 children die annually worldwide in pedestrian crashes, smartphone-based VR could supplement existing policy and prevention efforts to improve global child pedestrian safety.

Follow-Up Care Adherence After Hospital Discharge in Children With Traumatic Brain Injury.

OBJECTIVE: To investigate factors associated with follow-up care adherence in children hospitalized because of traumatic brain injury (TBI). DESIGN: An urban level 1 children's hospital trauma registry was queried to identify patients (2-18 years) hospitalized with a TBI in 2013 to 2014. Chart reviewers assessed discharge summaries and follow-up instructions in 4 departments. MAIN MEASURES: Three levels of adherence-nonadherence, partial adherence, and full adherence-and their associations with care delivery, patient, and injury factors. RESULTS: In our population, 80% were instructed to follow up within the hospital network. These children were older and had more severe TBIs than those without follow-up instructions and those referred to outside providers. Of the 352 eligible patients, 19.9% were nonadherent, 27.3% were partially adherent, and 52.8% were fully adherent. Those recommended to follow up with more than 1 department had higher odds of partial adherence over nonadherence (adjusted odds ratio [AOR] = 5.8, 95% CI: 1.9-17.9); however, these patients were less likely to be fully adherent (AOR = 0.1; 95% CI: 0.1-0.3). Privately insured patients had a higher AOR of full adherence. CONCLUSIONS: Nearly 20% of children hospitalized for TBI never returned for outpatient follow-up and 27% missed appointments. Care providers need to educate families, coordinate service provision, and promote long-term monitoring.

Emergency Care for Children in the United States: Epidemiology and Trends Over Time.

BACKGROUND: The emergency care system for children in the United States is fragmented. A description of epidemiological trends based on emergency department (ED) volume over time could help focus efforts to improve emergency care for children. OBJECTIVES: To describe the trends of emergency care for children in the United States from 2006-2014 in EDs across different pediatric volumes. METHODS: We analyzed pediatric visits to EDs using the Health Care Utilization Project Nationwide Emergency Department Sample in a representative sample of 1,000 EDs annually from 2006-2014. We report trends in disease severity, mortality, and transfers based on strata by pediatric volume and other hospital characteristics. RESULTS: From 2006-2014, there were 318,114,990 pediatric ED visits. Pediatric visits remained steady but declined as a percentage of total visits (-3.91%, p = 0.0007). The majority (92.7%) of children were cared for in lower-volume EDs (<50,000 pediatric visits/year), where mortality was higher vs. the highest-volume EDs. Mortality decreased over time (0.34/1,000 to 0.27, p = 0.0099), whereas interhospital transfers increased (p = 0.0020). ED visits increased for children with Medicaid insurance (40.7% to 56.7%, p < 0.0001), whereas rates of self-pay insurance decreased (13.6% to 9.45%, p = 0.0006). The most common reasons for pediatric ED visits were trauma (25.6%); ear, nose, and throat; dental/mouth disorders (21.8%); gastrointestinal diseases (17.0%); and respiratory diseases (15.6%). CONCLUSIONS: Overall, pediatric ED visits have remained stable, with lower mortality rates, whereas Medicaid-funded pediatric visits have increased over time. Most children still seek care in lower-volume EDs. Efforts to improve pediatric care could be best focused on lower-volume EDs and interhospital transfers.