Identifying drivers of cost in pediatric liver transplantation.

Understanding the economics of pediatric liver transplantation (LT) is central to high-value care initiatives. We examined cost and resource utilization in pediatric LT nationally to identify drivers of cost and hospital factors associated with greater total cost of care. We reviewed 3295 children (<21 y) receiving an LT from 2010 to 2020 in the Pediatric Health Information System to study cost, both per LT and service line, and associated mortality, complications, and resource utilization. To facilitate comparisons, patients were stratified into high-cost, intermediate-cost, or low-cost tertiles based on LT cost. The median cost per LT was $150,836 [IQR $104,481-$250,129], with marked variance in cost within and between hospital tertiles. High-cost hospitals (HCHs) cared for more patients with the highest severity of illness and mortality risk levels (67% and 29%, respectively), compared to intermediate-cost (60%, 21%; p <0.001) and low-cost (51%, 16%; p <0.001) hospitals. Patients at HCHs experienced a higher prevalence of mechanical ventilation, total parental nutrition use, renal comorbidities, and surgical complications than other tertiles. Clinical (27.5%), laboratory (15.1%), and pharmacy (11.9%) service lines contributed most to the total cost. Renal comorbidities ($69,563) and total parental nutrition use ($33,192) were large, independent contributors to total cost, irrespective of the cost tertile ( p <0.001). There exists a significant variation in pediatric LT cost, with HCHs caring for more patients with higher illness acuity and resource needs. Studies are needed to examine drivers of cost and associated outcomes more granularly, with the goal of defining value and standardizing care. Such efforts may uniquely benefit the sicker patients requiring the strategic resources located within HCHs to achieve the best outcomes.

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.

Impact of a Pediatric-Focused Communication Course on Patient/Caregiver-Perceived Physician Communication Skills in a Pediatric Emergency Department.

OBJECTIVES: To evaluate the impact of a pediatric-focused, relationship-centered communication course on patient/caregiver assessment of emergency department (ED) physician communication skills. METHODS: This was a prospective study; a previously validated assessment tool (Pediatric Physician Interpersonal Communication Skills Assessment [P-PICSA]) was used to collect pediatric patient/caregiver evaluation of ED physician communication skills. Emergency department physicians were required to attend a 5.5-hour communication course. Differences in precourse/postcourse P-PICSA and top-box scores were analyzed to determine course impact on ED physician communication skills. RESULTS: From July 2016 to August 2017, 49 pediatric ED physicians participated in the course, and 24 physicians (49%) had 6-month precourse/postcourse P-PICSA data. Postcourse scores were higher for all 13 items, with 3 items achieving statistical significance: (1) the doctor used words I could understand; (2) the way the doctor involved me in making decisions about my child's care in the ED; (3) how the doctor discussed next steps and/or follow-up plans for my child's care after we leave the ED (P < 0.05). Additionally, postcourse, top-box score percentages were higher for 12 items, with 1 item achieving statistical significance (P = 0.0386). CONCLUSIONS: An organization-wide, pediatric-focused, relationship-centered communication course improved patient/caregiver-perceived ED physician communication. Further research is necessary to assess long-term sustainability.

Invasive Bacterial Infections in Infants Younger Than 60 Days With Skin and Soft Tissue Infections.

OBJECTIVE: The objective of this study was to describe the frequency of invasive bacterial infections (IBIs) in young infants with skin and soft tissue infections (SSTIs) and the impact of IBI evaluation on disposition, length of stay (LOS), and cost. METHODS: This retrospective (2009-2014) cohort study used data from 35 children's hospitals in the Pediatric Health Information System. We included infants younger than 60 days who presented to an emergency department (ED) with SSTI. Invasive bacterial infection was defined as bacteremia/sepsis, bone/joint infection, or bacterial meningitis. Readmission and return ED visits within 30 days were evaluated to identify missed IBIs for infants. RESULTS: A total of 2734 infants were included (median age, 33 days; interquartile range [IQR], 21-44); 62% were hospitalized. Invasive bacterial infection was identified in 2%: bacteremia (1.8%), osteomyelitis (0.1%), and bacterial meningitis (0.1%). Hospitalization occurred in 78% of infants with blood cultures, 95% with cerebrospinal fluid cultures, and 23% without cultures. Median hospitalization LOS was 2 days (IQR, 1-3). Median cost was US $4943 for infants with cerebrospinal fluid cultures (IQR, US $3475-6780) compared with US $419 (IQR, US $215-1149) for infants without IBI evaluations (P < 0.001). Five infants (0.2%) returned to the ED within 30 days with new IBI diagnoses (4 bacteremia, 1 meningitis). CONCLUSIONS: Invasive bacterial infection occurs infrequently in infants younger than 60 days who present to children's hospital EDs with SSTI. Bacteremia is the most common IBI. More extensive evaluation for IBI is associated with increased rate of admission, LOS, and cost. Further studies are needed to evaluate the safety of a limited IBI evaluation in young infants with SSTI.

Payer and race/ethnicity influence length and cost of childhood cancer hospitalizations.

BACKGROUND: Health disparities related to race, ethnicity, socioeconomic status, and insurance status impact quality, access, and health outcomes for children. Medicaid is a proxy for poverty and restricted access to health care. The goal of this study was to determine if there are discrepancies in the length and cost of hospitalizations between admissions covered by Medicaid or commercial insurance for pediatric patients with cancer. METHODS: Childhood cancer-related admissions were identified from the 2012 Kids Inpatient Database (KID) using the International Classification of Diseases, Ninth revision. Length of hospitalization and cost of hospitalization were compared among hospitalizations paid by Medicaid or commercial insurance. Total admission charges were converted to costs using cost-to-charge ratios, and survey weighting methods were used for all analyses. Linear multiple regression models for both length of hospitalization and cost were developed to include patient-level factors (race, sex, age, diagnosis, reason for admission). RESULTS: In 2012, there were 104 597 childhood cancer-related admissions. Hospitalizations paid by Medicaid were significantly longer than those paid by commercial insurance. Hispanic ethnicity was associated with higher cost of hospitalization regardless of payer, and black race was associated with higher costs within the Medicaid population. CONCLUSIONS: This analysis identifies differences in healthcare utilization for pediatric cancer-related admissions paid for by Medicaid compared with commercial insurance. Prolonged hospitalizations and increased costs create burdens on children and their families, medical delivery systems, and third-party payers. Further exploration into the causes of these disparities is warranted.

COVID-19 Vaccine Hesitancy in Caregivers of Hospitalized Children From 2020 Through 2023.

OBJECTIVES: Data on US caregiver perceptions on coronavirus disease 2019 (COVID-19) and COVID-19 vaccination are limited. We identified trends in and associations with COVID-19 vaccine hesitancy in caregivers of hospitalized children. METHODS: Cross-sectional surveys on pediatric COVID-19 disease and vaccine attitudes, behaviors, and beliefs were administered across study years (December 8, 2020-April 5, 2021, November 30, 2021-March 15, 2022, and October 26, 2022-March 15, 2023). English and Spanish-speaking caregivers of hospitalized children ages 6 months to 11 years were included. General vaccine hesitancy was assessed using the Parent Attitudes about Childhood Vaccines survey. RESULTS: Of 1268 caregivers from diverse backgrounds, one-third vaccinated or intended to vaccinate their child. Half endorsed fear of their child receiving the COVID-19 vaccine and were concerned the vaccine was new. Over time, more believed "the COVID-19 vaccine does not work" and fewer agreed "children who are otherwise healthy can die from COVID-19." Study season (2022-2023), older child age, higher income, child receipt of influenza vaccine, caregiver receipt of COVID-19 vaccine, and not being worried about vaccine novelty were positively associated with child vaccination. Intent to vaccinate was negatively associated with study season (2022-2023), Parent Attitudes about Childhood Vaccines score ≥50, lack of child influenza and caregiver COVID-19 vaccination, lack of fear of their child "getting COVID-19" and being "worried that the COVID-19 vaccine is new." The majority who intended to vaccinate were willing to immunize before discharge. CONCLUSIONS: Vaccine novelty and perceived lack of need were associated with refusal. Caregiver COVID-19 and child influenza vaccine acceptance were positively associated with COVID-19 vaccine acceptance. The inpatient setting offers the opportunity to improve vaccine uptake.

Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process.

BACKGROUND AND OBJECTIVES: Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones. METHODS: We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones. RESULTS: The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%). CONCLUSIONS: Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

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.

Social Needs Screening in Hospitalized Pediatric Patients: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVE: Addressing adverse social determinants of health is an upstream approach to potentially improve child health outcomes and health equity. We aimed to determine if systematically screening and referring for social needs in hospitalized pediatric patients increased families' enrollment in publicly available resources. METHODS: Randomized controlled trial at a large urban children's hospital enrolled English-speaking caregivers of patients 0 to 36 months of age on the general pediatrics service from June 2016 to July 2017. The intervention arm received the WE CARE Houston social needs intervention (screener and resource referrals based on screening results and receptiveness to help); the control arm received standard of care. Baseline social risk data were collected for all participants. Caregivers who screened positive for mental health need, substance abuse, or domestic violence received additional support, including from social workers. The primary outcome was enrollment in resources at 6 months postdischarge. Univariate and multivariable analysis was performed to identify associations. RESULTS: Our study sample consisted of 413 caregivers from diverse sociodemographic/socioeconomic backgrounds. Overall, 85% of study participants had ≥1 social risk (median 2, range 0-9). WE CARE Houston identified caregiver employment, health insurance, primary care physician, depression, childcare, smoking, and food resources as the most prevalent social needs. Among these, caregivers were most receptive to resources for childcare, mental health, health insurance, and primary care. There was no significant difference in enrollment in new resources by study arm. CONCLUSION: Screening for social needs in the hospital is feasible and can result in the identification of social needs, but further work is needed to successfully address these needs.

Viral Coinfections in Kawasaki Disease: A Meta-analysis.

CONTEXT: Viral infections are suspected triggers in Kawasaki disease (KD); however, a specific viral trigger has not been identified. OBJECTIVES: In children with KD, to identify (1) overall prevalence of viral infections; (2) prevalence of specific viruses; and (3) whether viral positivity was associated with coronary artery aneurysms (CAAs) or refractoriness to intravenous immunoglobin (IVIG). DATA SOURCES: We searched Embase, Medline, and Cochrane databases and gray literature. STUDY SELECTION: Eligible studies were conducted between 1999 and 2019, and included children diagnosed with KD who underwent viral testing. DATA EXTRACTION: Two investigators independently reviewed full-text articles to confirm eligibility, extract data, appraise for bias, and assess evidence quality for outcomes using the Grading of Recommendations Assessment Development and Evaluation criteria. We defined viral positivity as number of children with a positive viral test divided by total tested. Secondary outcomes were CAA (z score ≥2.5) and IVIG refractoriness (fever ≥36 hours after IVIG). RESULTS: Of 3189 unique articles identified, 54 full-text articles were reviewed, and 18 observational studies were included. Viral positivity weighted mean prevalence was 30% (95% confidence interval [CI], 14-51) and varied from 5% to 66%, with significant between-study heterogeneity. Individual virus positivity was highest for rhinovirus (19%), adenovirus (10%), and coronavirus (7%). Odds of CAA (odds ratio, 1.08; 95% CI, 0.75-1.56) or IVIG refractoriness (odds ratio, 0.88; 95% CI, 0.58-1.35) did not differ on the basis of viral status. LIMITATIONS: Low or very low evidence quality. CONCLUSIONS: Viral infection was common with KD but without a predominant virus. Viral positivity was not associated with CAAs or IVIG refractoriness.

Qualitative Study of Barriers and Facilitators to Care Among Children in Immigrant Families.

OBJECTIVES: Children in immigrant families comprise ∼25% of US children and live in families with high levels of poverty and food insecurity. Studies suggest a decline in public benefit enrollment among children in immigrant families. We aimed to explore perspectives on barriers and facilitators in accessing care among immigrant caregivers of hospitalized children. METHODS: With a general qualitative descriptive design, we developed a semistructured interview guide using an iterative process informed by literature and content expertise. Using purposive sampling, we recruited immigrant caregivers of hospitalized children in March 2020 and conducted interviews in English or Spanish. Interviews were recorded, transcribed, and translated to English. Three authors coded transcripts using Dedoose and identified themes via thematic analysis. RESULTS: Analysis of 12 caregiver interviews revealed barriers and facilitators in accessing healthcare and public benefit use. Barriers included healthcare system barriers, immigration-related fear, and racism and discrimination. Within healthcare system barriers, subthemes included language barriers, cost, complexity of resource application, and lack of guidance on available benefits. Within immigration-related fear, subthemes included fear of familial separation, fear of deportation, fear that benefit use affects immigration status, and provider distrust. Healthcare system facilitators of resource use included recruiting diverse workforces, utilizing language interpretation, guidance on benefit enrollment, legal services, and mental health services. Participants also recommended hospital partnership with trusted information sources, including media stations and low-cost clinics. CONCLUSIONS: Immigrant caregivers of hospitalized children identified barriers and facilitators in access to care. Further research is needed to assess the efficacy of caregiver-suggested interventions.

Neighborhood Child Opportunity and Emergency Department Utilization.

The Child Opportunity Index measures the structural neighborhood context that may influence a child's healthy development. We examined relationships between the Child Opportunity Index and emergency department utilization. BACKGROUND AND OBJECTIVES: The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample. METHODS: This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission. RESULTS: We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]). CONCLUSIONS: Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.

Public Benefit Use and Social Needs in Hospitalized Children With Undocumented Parents.

BACKGROUND AND OBJECTIVES: Studies supporta recent decline in public benefit enrollment among immigrant families. We aimed to describe health and resource use, barriers to use, and immigration-related fear in families with undocumented parents compared with families without undocumented parents. We also aimed to assess associations with discontinuation of public benefits and fear of deportation. METHODS: We assessed immigration concerns and enrollment in Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with an 89-item anonymous, cross-sectional survey of English- and Spanish-speaking caregivers of hospitalized children. Multivariable logistic regression was used to assess associations with discontinuation of public benefits and fear of deportation. RESULTS: Of 527 families approached, 399 enrolled (105 with 1 or more undocumented parent, 275 with no undocumented parent, and 19 with undisclosed immigration status). Compared with families without undocumented parents, families with undocumented parents had higher levels of poverty and food insecurity. Controlling for perceived eligibility, public benefit use was similar across groups. Of families with undocumented parents, 29% reported public benefit discontinuation because of immigration concerns, and 71% reported fear of deportation. Having an undocumented parent was associated with public benefit disenrollment (odds ratio: 46.7; 95% confidence interval: 5.9-370.4) and fear of deportation (odds ratio: 24.3; 95% confidence interval: 9.6-61.9). CONCLUSIONS: Although families with undocumented parents had higher levels of poverty and food insecurity compared with families without undocumented parents, public benefit use was similar between groups. Immigration-related fear may be a barrier to public benefit use in this population.

Inpatient Food Insecurity in Caregivers of Hospitalized Pediatric Patients: A Mixed Methods Study.

BACKGROUND AND OBJECTIVE: Among US households with children, 14% are food insecure. Household food insecurity (FI) is associated with poorer health outcomes and increased hospital admissions. There is less known about caregivers' ability to obtain adequate food during hospitalization (inpatient FI). METHODS: We conducted a mixed methods study of primary caregivers of hospitalized children 0 to 18 years. A modified US Household Food Security Survey was used to identify inpatient FI. Associated factors were identified using logistic regression adjusted for covariables. Caregiver semistructured interviews were conducted to elicit perceptions on food accessibility and effects of and solutions for inpatient FI. RESULTS: The prevalence of inpatient FI was 43%. Household FI was present in 38% of families. Inpatient FI was associated with household FI (P < .01). In multivariable analysis, odds of inpatient FI were increased among caregivers with annual household income <$30,000 (adjusted odds ratio [aOR] 2.14), public transportation use (aOR 6.33), living >30 miles from the hospital (aOR 2.80), self-rated fair/poor health (aOR 3.31), maternity leave (aOR 4.75), and past/current Supplemental Nutrition Assistance Program benefit utilization (aOR 2.52). Qualitative analysis identified barriers to food access, such as lack of affordable options, and found that caregivers made sacrifices for their hospitalized child, including skipping meals. Caregivers viewed their presence at their child's bedside and personal nourishment as important factors affecting their child's care. CONCLUSIONS: Inpatient FI may affect a significant proportion of hospitalized children's caregivers. Pediatric hospitals should ensure that caregivers have access to food in order to fully engage in their child's care.

Effectiveness of Modalities to Teach Evidence Based Medicine to Pediatric Clerkship Students: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of a traditional didactic session (TDS) as compared to a self-paced, interactive, multimedia module (SPM) on the application of evidence-based medicine (EBM) skills among medical students during their inpatient pediatric rotation. METHODS: We conducted a randomized controlled trial from June, 2017 to June, 2018 at a quaternary care children's hospital. Students were randomized to TDS or SPM during each 2-week block. All students completed a critical appraisal tool (CAT) of evidence related to a clinical question in a standardized appraisal form and self-reflected about the EBM process. The primary outcome was the numeric score of the CAT derived by using the validated Fresno tool. Secondary outcomes of knowledge, attitudes, confidence, and self-reported behaviors related to EBM were measured using validated surveys. Statistical analysis was performed using Student's t test for CAT scores and mixed-model procedure (PROC MIXED), with subject as random effect and time as repeated measure for the secondary outcomes. RESULTS: One hundred twenty-seven clerkship students were included. Overall, there was no significant difference in mean CAT scores for TDS (n = 59) versus SPM (n = 66) groups (90.3 vs 92.0, P = .65). There were no significant differences between SPM and TDS groups for knowledge (P = .66), attitudes (P = .97), confidence (P  = .55), and accessing evidence (P = .27). Both groups showed significant gains in knowledge, attitudes, confidence, and accessing evidence from baseline to postcourse. Improvements in knowledge and confidence were sustained at 3-months. CONCLUSION: A SPM learning module is as effective as a TDS module for application of EBM concepts and knowledge to patient care.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions.

BACKGROUND: Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. METHODS: This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. RESULTS: There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CONCLUSIONS: CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

A Quality Improvement Initiative To Improve Postdischarge Antimicrobial Adherence.

OBJECTIVES: Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program. METHODS: Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis. RESULTS: Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% (P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001). CONCLUSIONS: The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence.

Antibiotic Regimens and Associated Outcomes in Children Hospitalized With Staphylococcal Scalded Skin Syndrome.

BACKGROUND: Controversy exists regarding the optimal antibiotic regimen for use in hospitalized children with staphylococcal scalded skin syndrome (SSSS). Various regimens may confer toxin suppression and/or additional coverage for methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S aureus (MRSA). OBJECTIVES: To describe antibiotic regimens in hospitalized children with SSSS and examine the association between antistaphylococcal antibiotic regimens and patient outcomes. DESIGN/METHODS: Retrospective cohort study of children hospitalized with SSSS using the Pediatric Health Information System database (2011-2016). Children who received clindamycin monotherapy, clindamycin plus MSSA coverage (eg, nafcillin), or clindamycin plus MRSA coverage (eg, vancomycin) were included. The primary outcome was hospital length of stay (LOS); secondary outcomes were treatment failure and cost. Generalized linear mixed-effects models were used to compare outcomes among antibiotic groups. RESULTS: Of 1,259 children included, 828 children received the most common antistaphylococcal antibiotic regimens: clindamycin monotherapy (47%), clindamycin plus MSSA coverage (33%), and clindamycin plus MRSA coverage (20%). Children receiving clindamycin plus MRSA coverage had higher illness severity (44%) compared with clindamycin monotherapy (28%) and clindamycin plus MSSA (32%) (P =.001). In adjusted analyses, LOS and treatment failure did not differ among the 3 regimens (P =.42 and P =.26, respectively). Cost was significantly lower for children receiving clindamycin monotherapy and highest in those receiving clindamycin plus MRSA coverage (mean, $4,839 vs $5,348, respectively; P <.001). CONCLUSIONS: In children with SSSS, the addition of MSSA or MRSA coverage to clindamycin monotherapy was associated with increased cost and no incremental difference in clinical outcomes.

Developing a communication curriculum for primary and consulting services.

Communication skills are fundamental to effective patient care, and inter-subspecialty communication is frequently identified as a key component of medical education curriculums globally. The team primarily responsible for a patient, the 'primary service', may often request a consult from a specialist, the 'consulting service', for questions of diagnosis, management, or assistance in arranging or performing a procedure or test. Few resources exist to support the development and growth of communication curriculums across primary and consulting services. We provide tips to improve communication across services in patient care and enhance learning for multiple levels of providers. This article provides a guide for the planning and implementation of a communication curriculum and highlights key components for success, based on our experience as teaching faculty on primary and consulting services, at a large academic institution. With the proper collaborations, teaching touch points, specialist consult communication tool, peer coaches, and timely feedback, this course can meet numerous educational and institutional priorities.