Analysis of Hospital Operating Margins and Provision of Safety Net Services.

Importance: Safety net hospitals (SNH) provide many community services. The cost of providing these services is unknown. Objective: To determine what safety net criteria are associated with differences in hospital operating margin. Design, Setting, and Participants: This cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports. Exposures: Five domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index. Main Outcomes and Measures: Operating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates. Results: A total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin. Conclusions and Relevance: In this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline.

BACKGROUND: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019. METHODS: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System. RESULTS: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time. CONCLUSIONS: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

Hypokalemia-Induced Rhabdomyolysis in a Child with Autism Affected by the COVID-19 Pandemic.

OBJECTIVE: Pediatric patients with autism spectrum disorder (ASD) often have coexisting feeding disorders. We hope to emphasize the significant implications that these feeding disorders can have on this patient population through a unique case of hypokalemia-induced rhabdomyolysis. METHOD: We present a unique case of a 3-year-old boy with ASD and a longstanding history of food selectivity whose routine was disrupted during the COVID-19 pandemic resulting in avoidant/restrictive food intake disorder and severe undernutrition, who presented with profound hypokalemia and was subsequently found to have elevated muscle enzymes consistent with rhabdomyolysis despite only subtle complaints of difficulty walking. RESULTS: The patient was treated with aggressive hydration, electrolyte therapy, and nasogastric tube feeds, which resulted in clinical and biochemical evidence of improvement. He was also reconnected to ASD-related care services that had lapsed during the COVID-19 pandemic. CONCLUSION: This case exemplifies the adverse impact that feeding disorders can have on patients with ASD, particularly in the setting of stressors such as a global pandemic, and is also the first documented pediatric case of rhabdomyolysis secondary to hypokalemia from severe undernutrition. It demonstrates that physicians should have a low threshold to assess for clinical and laboratory evidence of rhabdomyolysis in patients with profound hypokalemia because symptoms of hypokalemia-induced rhabdomyolysis can often be subtle, which can delay diagnosis and thereby increase the risk for life-threatening complications from extensive muscle damage.

The Implementation of a National Physical Activity Intervention in Colombia.

Background: In 2011, the Colombian government started a nationwide program, Hábitos y Estilos de Vida Saludable (HEVS; Healthy Life Habits), providing free, community-based physical activity classes for individuals across Colombia. This study describes the HEVS program, participant characteristics, and changes in anthropomorphic and health measures following the program. Methods: In this observational study, demographic information, current health status, lifestyle habits, and anthropomorphic measures were collected from adult HEVS participants at baseline and after program completion 11 months later. Changes in anthropomorphic and health measurements after the HEVS program were compared in the same participants using a paired t test and McNemar test, respectively. Results: A total of 56,472 adult participants (86.5% female) enrolled in the HEVS program. The greatest proportion of participants was between the ages of 18 and 34 years. Prior to participating in HEVS, mean body mass index and waist circumference were 26.3 kg/m2 and 85.7 cm, respectively. Postprogram data from 17,145 individuals showed statistically significant decreases in body mass index, waist circumference, and the proportion of patients with self-reported hypertension. Conclusions: The HEVS program successfully engaged a large number of Colombians in physical activity and resulted in significant improvements in their health, demonstrating the effectiveness of a government-supported, community-based physical activity program.