Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce.

OBJECTIVE: Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce. METHODS: A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions. RESULTS: Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact. CONCLUSIONS: Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

The Early Effects of the Coronavirus Disease-19 Pandemic on Pediatric Resident Education: A National Assessment.

PURPOSE: Residency programs must ensure resident competence for independent practice. The coronavirus disease-19 (COVID-19) pandemic disrupted health care delivery, impacting pediatric residencies. This study examines the impact on pediatric resident education. METHODS: The authors conducted a mixed methods national survey of pediatric residency program directors (PDs) from May 2020 to July 2020. Data analysis included descriptive statistics, chi-square, and Wilcoxon rank sum tests. Multivariable modeling identified factors associated with resident preparation for more senior roles. Thematic analysis was performed on open-ended questions about PD COVID-19 pandemic recommendations to peers, Accreditation Council for Graduate Medical Education and American Board of Pediatrics. RESULTS: Response rate was 55% (110/199). PDs reported the COVID-19 pandemic negatively affected inpatient (n = 86, 78.2%), and outpatient education (n = 104, 94.5%), procedural competence (n = 64; 58.2%), and resident preparation for more senior roles (n = 50, 45.5%). In bivariate analyses, increasingly negative impacts on inpatient and outpatient education were associated with an increasingly negative impact on resident preparation for more senior roles (P = .03, P = .008), these relationships held true in multivariable analysis. Qualitative analysis identified 4 themes from PD recommendations: 1) Clear communication from governing bodies and other leaders; 2) Flexibility within programs and from governing bodies; 3) Clinical exposure is key for competency development; 4) Online platforms are important for education, communication, and support. CONCLUSIONS: The COVID-19 pandemic negatively impacted inpatient and outpatient education. When these were more negatively impacted, resident preparation for more senior roles was worse, highlighting the importance of competency based medical education to tailor experiences ensuring each resident is competent for independent practice.

Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic. Design: An observational, retrospective control study from January 2019 to October 2021. Setting: Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics. Patients: Children aged 0-19 years receiving care in an outpatient setting. Methods: Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline. Results: Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits. Conclusions: These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Serum periostin among infants with severe bronchiolitis and risk of developing asthma: A prospective multicenter cohort study.

BACKGROUND: Infants hospitalized for bronchiolitis (severe bronchiolitis) are at high risk for developing childhood asthma. However, the pathobiological link between these conditions remains unclear. We examined the longitudinal relationship of periostin (an extracellular matrix protein upregulated in response to type 2 inflammation) during bronchiolitis with the subsequent development of asthma. METHODS: In a 17-center prospective cohort study of infants (aged <1 year) with severe bronchiolitis, we measured the serum periostin level at hospitalization and grouped infants into 3 groups: low, intermediate, and high levels. We examined their association with asthma development by age 6 years and investigated effect modification by allergic predisposition (eg, infant's IgE sensitization). RESULTS: The analytic cohort consists of 847 infants with severe bronchiolitis (median age, 3 months). Overall, 28% developed asthma by age 6 years. In the multivariable model adjusting for nine patient-level factors, compared to the low periostin group, the asthma risk was significantly higher among infants in the intermediate group (23% vs. 32%, OR 1.68, 95%CI 1.12-2.51, p = .01) and non-significantly higher in the high-level group (28%, OR 1.29, 95%CI 0.86-1.95, p = .22). In the stratified analysis, infants with IgE sensitization had a significantly higher risk for developing asthma (intermediate group, OR 4.76, 95%CI 1.70-13.3, p = .002; high group, OR 3.19, 95%CI 1.08-9.36, p = .04). By contrast, infants without IgE sensitization did not have a significantly higher risk (p > .15). CONCLUSIONS: In infants with severe bronchiolitis, serum periostin level at bronchiolitis hospitalization was associated with asthma risk by age 6 years, particularly among infants with an allergic predisposition.

Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid.

OBJECTIVE: To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN: Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS: Population-based sample of pediatric Medicaid patients and providers. METHODS: Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS: Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS: Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.

Scholarly Activity During Pediatric Fellowship.

BACKGROUND AND OBJECTIVES: The educational requirements for pediatric fellows include at least 12 months of scholarly activity and generation of a work product. Yet there lacks detailed guidance on how programs can best integrate scholarly activity training into fellowships. Our objectives were to understand the resources and barriers to training and identify factors associated with productivity. METHODS: We surveyed pediatric fellowship program directors (FPDs) nationally in 2019. Data analysis included descriptive statistics, χ2 and Fisher's exact tests, and multivariable modeling to identify factors associated with high productivity (>75% of fellows in the past 5 years had an article from their fellowship accepted). RESULTS: A total of 499 of 770 FPDs responded (65%). A total of 174 programs (35%) were highly productive. The most frequent major barriers were a lack of funding for fellows to conduct scholarship (21%, n = 105) and lack of sufficient divisional faculty mentorship (16%, n = 79). The median number of months for scholarship with reduced clinical obligations scholarship was 17. A total of 40% (n = 202) of FPDs believed training should be shortened to 2 years for clinically oriented fellows. Programs with a T32 and a FPD with >5 publications in the past 3 years were twice as likely to be productive. Not endorsing lack of adequate Scholarship Oversight Committee expertise and a research curriculum as barriers was associated with increased productivity (odds ratio = 1.83-1.65). CONCLUSIONS: Despite significant protected fellow research time, most fellows do not publish. Ensuring a program culture of research may provide the support needed to take projects to publication. The fellowship community may consider reevaluating the fellowship duration, particularly for those pursing nonresearch focused careers.

Scholarly Activity Training During Pediatric Residency: How Well Aligned Are Program Directors and Residents?

OBJECTIVE: Training residents to be scholars is endorsed by leading medical education organizations. Our previous research suggests that the scholarly activity (SA) training experience is highly variable across pediatric residency programs, and residents and program directors (PDs) are generally dissatisfied. Understanding how PD and resident views align can help programs better guide resource allocation and improvement efforts. METHODS: We conducted cross-sectional surveys of second and third year pediatric residents and PDs at 22 diverse US categorical programs. We compared resident and PD responses to SA training beliefs, barriers, and satisfaction by 2-proportion z tests. We used descriptive statistics to describe resident responses in relation to same-institution PD responses. RESULTS: About 464 of 771 residents (60.2%) and 22 PDs (100%) responded. Across programs, PDs more strongly agreed that all residents should participate in SA (59% of PDs [n = 13] versus 27% of residents [n = 127], P = .002). Residents more strongly believed all residents should have protected SA time (91% of residents [n = 424] versus 68% of PDs [n = 15], P = .001). PDs more strongly perceived gaps in other resources as barriers, including lack of funding to conduct or present SA (P < .001, P = .02), lack of statistical support (P = .03), and lack of faculty mentorship (P < .001). Within program concordance was low. CONCLUSIONS: Discordance exists between PDs and residents with respect to SA participation and necessary resources, particularly, protected time. Programs must help residents identify when SA can be accomplished. Clearer national guidelines around SA training may also be necessary to reduce discordance and improve perceptions.

Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus.

OBJECTIVE: Magnesium sulfate (Mg) is one of several "second-tier" therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children. DESIGN: Single center, retrospective study. SETTING: Thirty-four-bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit. PATIENTS: Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN FINDINGS: A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6-74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check. CONCLUSION: Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.

Scholarly Collaboration, Mentorship, and Friendship: A New Model for Success in Academic Medicine.

Mentorship can be one of the most important factors in helping faculty members successfully advance academic careers. Finding effective mentorship, however, is extremely challenging and lack of mentorship may negatively impact productivity, promotion, and retention. Women, in particular, identify lack of mentorship as a major factor inhibiting career advancement, which in turn may be one element contributing to the significant gender gaps existing in academic medicine. Here, we describe a model of mentoring drawn from our personal experiences as 4 female faculty that has resulted in a successful collaboration spanning nearly a decade. This model combines different elements of mentoring models previously described in the literature into a single model of network mentoring. Our model aims to promote longitudinal, collaborative scholarship around a broad common research theme, provide long-term mentorship focused on successfully navigating personal and academic hurdles, and create a forum of mentorship for faculty at all academic ranks. Keys to the success of our model, The Accelerate Scholarship through Personal Engagement with a Collaborative Team (ASPECT) Model, are: 1) a shared overarching research goal that allows for multiple projects to be worked on over time; 2) regular, structured meetings; 3) a collaborative yet flexible arrangement with "group accountability"; and 4) a focus on the human connection. Our goal in writing this paper is to describe, in detail, lessons learned from our experiences and reflect on why and how this model may be effective in addressing mentoring gaps many faculty members, particularly women, experience.

Association of Serum Albumin With Apnea in Infants With Bronchiolitis: A Secondary Analysis of Data From the MARC-35 Study.

Importance: Apnea is a rare, life-threatening complication of bronchiolitis, the leading cause of infant hospitalization in the United States. Currently, no objective method exists for identifying which infants will become apneic. Objective: To investigate whether serum albumin levels are associated with apnea in infants with severe bronchiolitis. Design, Setting, and Participants: A secondary data analysis of the 35th Multicenter Airway Research Collaboration, an ongoing multicenter cohort study of infants hospitalized for bronchiolitis, was conducted from December 11, 2018, to May 30, 2019. Seventeen hospitals across the United States enrolled infants (n = 1016) during 3 consecutive bronchiolitis seasons (November 1 to April 30) between 2011 and 2014. Infants with heart-lung disease or a gestational age less than 32 weeks were excluded. Exposures: Serum albumin level was categorized as low (<3.8 g/dL) or normal (≥3.8 g/dL). Main Outcomes and Measures: Apnea during the hospitalization. Results: Of the 1016 infants hospitalized for bronchiolitis, the median (interquartile range [IQR]) age was 3 (2-6) months, 610 (60.0%) were male, and 186 (18.3%) were born preterm (32-37 weeks' gestation). Among the 25 infants (2.5%) with apnea while hospitalized, the median (IQR) serum albumin level was 3.5 (3.1-3.6) g/dL, and 22 (88.0%) had low serum albumin levels. The prevalence of apnea was 5.7% among all infants with low albumin levels, compared with 0.5% prevalence in infants with normal serum albumin levels. In unadjusted analyses, apnea was associated with younger age, preterm birth, weight-for-age z score, and low albumin (odds ratio [OR], 12.69; 95% CI, 3.23-49.82). After adjustment for age, preterm birth, and weight-for-age z score, low serum albumin levels remained statistically significantly associated with apnea (OR, 4.42; 95% CI, 1.21-16.18). Conclusions and Relevance: Low serum albumin levels appeared to be associated with increased risk of apnea after adjustment for known apnea risk factors. This finding provides a path to potentially identifying apnea, a life-threatening complication of bronchiolitis.

Parent Intent and Willingness to Immunize Children Against Influenza in the Pediatric Emergency Department.

OBJECTIVES: To determine rates of influenza immunization among children treated in a pediatric emergency department (ED) and to ascertain parent willingness for children to receive influenza vaccine (IV) in the ED. METHODS: Interviews were conducted with parents of children 6 months or older evaluated in the ED for minor illness or injury. Demographic data, IV history, and intent and willingness to receive future IV were recorded during the summer of 2013. Participants were contacted in March 2014 to assess IV status, barriers to obtaining IV, and willingness to obtain IV in the ED. Chart review determined number of patients who were at high risk. RESULTS: Of 457 families approached, 285 (62%) were enrolled. Two hundred forty-two (85%) intended to vaccinate; 83% reported willingness to receive IV at a future ED visit. Common reasons for not receiving IV were concerns about adverse effects (31%) and lack of time or interest (24%). Of the 224 participants (79%) reached in follow-up, 112 (50%) had received IV in the prior season. Among those who did not receive IV, 65 (66%) had intended to vaccinate, and 54 (55%) indicated they would have accepted IV in the ED. Fifty-three (54%) of unvaccinated patients at follow-up had high risk of influenza complications. CONCLUSIONS: Our data support an IV program in the pediatric ED as a means of increasing vaccination rates, particularly among high-risk patients. Parents are often concerned about adverse effects of IV, and providers should target education in this area.

Scholarly Activity Training During Residency: Are We Hitting the Mark? A National Assessment of Pediatric Residents.

OBJECTIVE: Participation in scholarly activity (SA) is an Accreditation Council for Graduate Medical Education requirement. Our previous research with program directors (PDs) suggests that pediatric SA training is variable and suboptimal. To help programs better meet requirements, our objective was to understand the resident perspective regarding SA training, including factors associated with satisfaction and productivity. METHODS: We conducted cross-sectional surveys of second- and third-year pediatric residents and PDs at 22 diverse programs in 2016. Surveys assessed resident demographics, career intentions, program characteristics, beliefs, barriers, satisfaction, and productivity, defined as SA accepted at a regional or national meeting, for publication, or grant funding. Data were analyzed using descriptive statistics and multivariable logistic regression. RESULTS: A total of 464 (60.2%) of 771 residents and 22 PDs (100%) responded. Most residents believed that residents should participate in SA (n = 380, 81.9%). However, only 37.9% (n = 175) were extremely or very satisfied with their training. Residents who reported that training to conduct research (adjusted odds ratio [AOR] = 1.9, 95% confidence interval [CI] 1.1-3.5), availability of a research curriculum (AOR = 1.9, 95% CI 1.2-3.1), and adequate faculty mentorship (AOR = 2.5, 95% CI 1.6-4.1) were not barriers were more satisfied. Protected time was associated with satisfaction (AOR = 1.7, 95% CI 1.1-2.7). A total of 43.8% of residents (n = 203) were productive. Productivity was associated with future plans to conduct research (AOR = 3.3, 95% CI 2.1-5.1). CONCLUSIONS: Residents believe SA training is important. Dedicated program infrastructure, protected time, and adequate mentorship appear to be crucial to improving quality perceptions.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis.

OBJECTIVE: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Cost-effectiveness of Strategies for Offering Influenza Vaccine in the Pediatric Emergency Department.

Importance: Influenza is a significant public health burden, causing morbidity and mortality in children, yet vaccination rates remain low. Vaccination in the pediatric emergency department (PED) setting may be beneficial but, to date, has not been proven to be cost-effective. Objective: To compare the cost-effectiveness of 4 strategies for PED-based influenza vaccine: offering vaccine to all patients, only to patients younger than 5 years, only to high-risk patients (all ages), or to no patients. Design, Setting, and Participants: Using commercial decision analysis software, a cost-effectiveness analysis was performed from January 1, 2016, to June 1, 2017, to compare influenza vaccine strategies at a tertiary, urban, freestanding PED with an estimated 60 000 visits per year among a hypothetical cohort of children visiting the above PED during influenza season. Sensitivity analyses estimated the effect of uncertainties across a variety of input variables (eg, influenza prevalence, vaccine price and effectiveness, and costs of complications). Main Outcomes and Measures: The primary outcomes were cost and incremental cost-effectiveness ratio in dollars per influenza case averted. Secondary outcomes included total societal costs, hospitalizations and deaths averted, and quality-adjusted life-years gained. Results: Offering influenza vaccine to all eligible patients has the lowest cost, at $114.45 (95% CI, $55.48-$245.45) per case of influenza averted. This strategy saves $33.51 (95% CI, $18-$62) per case averted compared with no vaccination, and averages 27 fewer cases of influenza per 1000 patients. Offering vaccine to all patients resulted in 0.72 days (95% CI, 0.18-1.78 days) of quality-adjusted life-years lost, whereas offering to none resulted in 0.91 days (95% CI, 0.25-2.2 days) of quality-adjusted life-years lost. In sensitivity analyses, this strategy remains robustly cost-effective across a wide range of assumptions. In addition to being the most cost-effective strategy regardless of age or risk status, routine vaccination in the PED results in a net societal monetary benefit under many circumstances. In Monte Carlo analysis, offering vaccine to all patients was superior to other strategies in at least 99.8% of cases. Conclusions and Relevance: Although few PEDs routinely offer influenza vaccination, doing so appears to be cost-effective, with the potential to significantly reduce the economic (and patient) burden of pediatric influenza.

Internet Usage by Parents Prior to Seeking Care at a Pediatric Emergency Department: Observational Study.

BACKGROUND: Little is known about how parents utilize medical information on the Internet prior to an emergency department (ED) visit. OBJECTIVE: The objective of the study was to determine the proportion of parents who accessed the Internet for medical information related to their child's illness in the 24 hours prior to an ED visit (IPED), to identify the websites used, and to understand how the content contributed to the decision to visit the ED. METHODS: A 40-question interview was conducted with parents presenting to an ED within a freestanding children's hospital. If parents reported IPED, the number and names of websites were documented. Parents indicated the helpfulness of Web-based content using a 100-mm visual analog scale and the degree to which it contributed to the decision to visit the ED using 5-point Likert-type responses. RESULTS: About 11.8 % (31/262) reported IPED (95% CI 7.3-5.3). Parents who reported IPED were more likely to have at least some college education (P=.04), higher annual household income (P=.001), and older children (P=.04) than those who did not report IPED. About 35% (11/31) could not name any websites used. Mean level of helpfulness of Web-based content was 62 mm (standard deviation, SD=25 mm). After Internet use, some parents (29%, 9/31) were more certain they needed to visit the ED, whereas 19% (6/31) were less certain. A majority (87%, 195/224) of parents who used the Internet stated that they would be somewhat likely or very likely to visit a website recommended by a physician. CONCLUSIONS: Nearly 1 out of 8 parents presenting to an urban pediatric ED reported using the Internet in the 24 hours prior to the ED visit. Among privately insured, at least one in 5 parents reported using the Internet prior to visiting the ED. Web-based medical information often influences decision making regarding ED utilization. Pediatric providers should provide parents with recommendations for high-quality sources of health information available on the Internet.