Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City.

OBJECTIVES: To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions. METHODS: We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index. RESULTS: Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index. CONCLUSIONS: The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Variability in pediatric appendectomy: The association between disposable supply cost and procedure duration.

BACKGROUND: Pediatric appendicitis accounts for a notable proportion of health care use and cost in the United States. To identify opportunities for cost savings during pediatric laparoscopic appendectomy, this study assessed whether surgeons' use of costlier disposable supplies correlated with procedure duration and patient outcomes. METHODS: This retrospective cross-sectional study assessed laparoscopic appendectomy for uncomplicated pediatric appendicitis at 2 tertiary-care academic hospitals. The cost of disposable surgical supplies, procedure duration, and patient outcomes were obtained from medical records. The correlation between average supply cost and procedure duration among surgeons was assessed using Pearson's correlation coefficient. Associations between use of specific disposable supplies and supply cost or procedure duration were assessed using Student's t tests. RESULTS: A total of 380 laparoscopic appendectomies were performed by 11 surgeons. Mean normalized supply cost varied between surgeons (range: 60.6%-151.1%) and was not correlated with procedure duration (R = 0.2951, P = .378). The use of energy-based sealing devices (76.7% increase, P < .001), staplers (38.4% increase, P < .001), endoscopic specimen pouches (45.3% increase, P < .001), and disposable ports (43.6% increase, P < .001) increased overall disposable supply cost. None of the disposable supplies in this analysis were associated with shorter procedures. Based on Medicaid reimbursement, the interquartile range of supply cost was 9.2% and 6.0% of hospital revenue at each site. CONCLUSION: Surgeons varied in their use of disposable supplies for pediatric laparoscopic appendectomy, but the cost of supplies used did not influence outcomes. Incentivizing more judicious supply use may reduce costs related to pediatric appendicitis.

Secondary review reduced inpatient MRI orders and avoidable hospital days.

INTRODUCTION: Medical centers have dramatically increased the use of magnetic resonance imaging (MRI). At 2 large academic tertiary care centers in New York City, nearly half of inpatient MRI orders took more than 12 h to complete, delaying patient discharge and increasing avoidable hospital days. We posited that transitioning inpatient MRIs to outpatient facilities, when safe and appropriate, could reduce inpatient MRI orders and avoidable hospital days. METHODS: We manually reviewed 59 inpatient MRI orders delayed on the estimated date of discharge (EDD). These orders were often delayed due to no standard process to escalate orders for medical reasons or no system to coordinate outpatient orders. We developed a revised workflow involving an automation platform that flagged inpatient MRI orders requested within 24 h of the EDD and emailed the care team to request a second review of the order. The care team reconsidered whether the order was (1) required for discharge, (2) non-urgent and could be converted to an outpatient order, or (3) unnecessary and could be canceled. RESULTS: Over 9 months, the automation platform flagged 618 inpatient MRI orders, of which 53.9% (333/618) were reviewed by the care team. Among the orders, 24.0% (80/333) of reviewed orders and 12.9% (80/618) of all orders were transitioned to either outpatient or canceled orders. These transitioned orders were associated with 267 fewer avoidable hospital days and a cost savings of $199,194. CONCLUSION: A standardized process and second review of inpatient MRI orders on the EDD can reduce inappropriate orders and more effectively use inpatient imaging resources. PRECIS: A standardized workflow and automation platform encouraged a second review of inpatient MRI orders to reduce inappropriate orders, avoidable hospital days, and hospital costs.

Early versus late surgical management of complicated appendicitis in children: A statewide database analysis with one-year follow-up.

BACKGROUND: Complicated appendicitis is common in children, yet the timing of surgical management remains controversial. Some support initial antibiotics with delayed operation whereas others support immediate operation. While a few randomized trials have evaluated this question, they have been small, single-center trials with limited follow-up. We present a database analysis of outcomes in early versus late surgical management of complicated appendicitis with one-year follow-up. METHODS: We conducted a retrospective review of children with complicated appendicitis presenting between 2000 and 2013, utilizing a New York State database. We compare children undergoing later versus early appendectomy with a primary outcome measure of any complication within one year as determined from ICD-9 codes. RESULTS: 8840 children were included in the analysis, 7708 of whom underwent early appendectomy. Patients with late appendectomy were significantly more likely to have at least one complication when compared to those undergoing early appendectomy (34.6% vs 26.7%, p<0.01). CONCLUSIONS: We present the first population-level study evaluating early versus late appendectomy in children with complicated appendicitis with a one-year follow-up period. Children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data corroborated previous studies supporting early operative management. LEVEL OF EVIDENCE: This study provides level III evidence of a treatment study.